Case Study: Compartment Syndrome, the Sequelae of a Delayed Diagnosis

The Case

An orthopedic surgeon evaluated a man in the emergency department who had sustained a severely painful injury to his left calf earlier that day. The patient was playing softball when another player slid into him.

The patient complained to the surgeon that his pain was 10/10. He could not bear weight on his leg, and his left calf measured at 19 inches compared with a right calf measurement of 16 inches. He had strong pedal pulses with a positive Homan’s sign, and a large bruise over the left calf at the point of impact. After DVT was ruled out by ultrasound, the surgeon released the patient with a diagnosis of “large hematoma.” He was given a prescription for Percocet and discharge instructions to return in two days for an office visit.

The patient returned to the surgeon’s office as directed. At this visit his left calf was edematous with ecchymosis. He experienced pain with dorsiflexion of the left foot. A repeat ultrasound showed no evidence of DVT, but did show evidence of a residual large hematoma.

Four days later, on Saturday, the patient contacted the on-call orthopedic surgeon, requesting an additional prescription for Percocet. The on-call surgeon instructed the patient to go to the emergency department for reevaluation. The patient did go to the emergency department, but to one at a different hospital (hospital #2).

The ED physician at hospital #2 consulted an orthopedic surgeon at that hospital. The surgeon’s clinical impression included left calf hematoma, with possible compartment syndrome. The patient was discharged with a Percocet refill, instructions to keep his left leg in an ace wrap, apply a heating pad, and to return to his regular orthopedic surgeon on Monday. Bothered by the possible diagnosis of compartment syndrome, the ED physician called the on-call orthopedic surgeon at hospital #1. That surgeon asked that the ED physician call the patient at home, directing him to report to the ED at hospital #1, as he had instructed the patient that morning. Upon the patient’s return to ED #1, the on-call orthopedic surgeon, with the assistance of a manometer system for monitoring compartment pressures, did diagnose anterior compartment syndrome and admitted him for immediate surgery.

The patient underwent fasciotomies with subsequent necrotic muscle debridement and evacuation of the large hematoma. Seven days later he was discharged home.

After discharge the patient continued to have some problems with cellulitis; he was not taking his oral antibiotic as prescribed. He subsequently required a flap and skin grafts. He now has permanent, marked decrease in muscle function in his left leg. He also has permanent foot drop, walks with an impaired gait and has work restrictions.

The Allegations

The Plaintiff alleged that the first orthopedic surgeon deviated from the standard of care by failing to consider the possibility of compartment syndrome during the ED visit and subsequent office visit, failed to order the necessary test to rule in or rule out compartment syndrome, failed to respond to the plaintiff’s continuous phone calls regarding his pain and failed to perform tests that would have recognized compartment syndrome.

Defense

Experts provided only “thin” support, in part due to lack of documentation by the first orthopedic surgeon, and some classic findings signaling the development of compartment syndrome.

Disposition

The case was settled after mediation for a moderate to large amount.

This classic case emphasizes that compartment syndrome should be thought of early and often in any injury to an arm or leg, with or without fracture, particularly when pain is out of portion to the injury. A provider has approximately six hours to make the diagnosis and treat the condition before unfortunate complications such as tissue necrosis occur, leading to severe functional impairment and/or amputation.

• Fasciotomy in the upper and lower extremities, if done early, can usually be a minor procedure with a small incision; the incision often can be closed loosely by skin alone with a low risk of developing an infection.
• Late closure is very difficult and late fasciotomy generally does not serve to preserve muscle function after tissue necrosis has occurred.
• By the time pulselessness, paresthesia or paralysis has resulted, musculature in the extremity has been destroyed, and normal function preservation often is not possible.
• Compartment syndrome should be ruled out in an arm or leg injury evaluation; do not hesitate to obtain a consultation to confirm or to discount the diagnosis.
• Document your rationale if you do not believe that compartment syndrome is apparent.
• Remember, the one “P “that must be dealt with decisively is pain out of proportion to the injury.

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