MEDICAL MALPRACTICE: FAILURE TO DIAGNOSE COMPARTMENT SYNDROME
The human body contains forty six osteofacial compartments. Within these compartments are muscles, veins, arteries and nerves surrounded by tissue called fascia which is dense and unyielding.
The most common orthopedic setting for compartment syndrome is the closed tibia fracture for which the incidence is 3% to 17% 1. This discussion will be limited to compartment syndrome following tibia fractures.
The foreleg consists of four compartments known as the anterior, lateral, posterior and deep posterior compartments 2. Located within the anterior compartment are the motors for dorsiflexion of the foot and toes; the tibialis anterior, extensor halluces longus and extensor digitorum longus muscles. These muscles are innervated by the deep peroneal nerve which enters the anterior compartment after winding around the outer surface of the neck of the fibula. Located within the posterior compartment are the gastrocnemius, soleus and plantaris muscles which plantar flex the foot and flex the leg. These muscles are invervated by the tibia] nerve. The deep posterior compartment contains the flexor halluces longus, flexor digitorum longus, tibialis posterior and. popliteus muscles. These muscles plantar flex the foot (tibialis posterior), flex the leg and rotate it medially (popliteus), flex the big toe and flex and supinate the foot (flexor halluces longus) and flex the four small toes and plantar flex and supinate the foot (flexor digitorum longus). These muscles are innervated by the tibial nerve. Finally, the lateral compartment contains the peroneus longus muscle and the peroneus brevis muscle which pronate and flex the foot. These muscles are supplied by the superficial peroneal nerve 3.
Following high-energy injury to the tibia resulting in fracture such as that sustained by a pedestrian struck by an automobile, fluid may accumulate in one or more of the compartments. Since the fascia will not yield the intracompartmental pressure rises and continues to rise, compressing the arterioles and eventually stopping the arterial inflow to the muscles within the compartment. If ischemia is unrelieved, necrosis of the muscles and loss of function of the nerves will occur 4. It has been demonstrated that nerve involvement is caused by the isehemia itself and not to muscle compression of the nerves 5.
Compartment syndrome is a surgical emergency. Depending upon the compartments affected, failure to diagnose and promptly treat compartment syndrome may result in irreversible yschemia of the extrinsic muscles of the leg and even require amputation 6. Plantar hypesthesia, claw toes and weakness or contracture of the affected muscles may also result 7.
Infection due to tissue necrosis as well as renal failure resulting from excessive myoglobin clogging the renal tubule has also been documented 8. The only effective treatment for compartment syndrome is decompressive surgery by fasciotomy. A fasciotomy simply entails making an incision through the skin and fascia into the compartment thus allowing the distended tissues to expand through the incision thereby relieving pressure on the capillaries and restoring circulation 9.
The clinical signs of compartmental syndromes include pain out of proportion to the clinical situation, weakness and pain on passive stretch of the muscles of the compartment involved and tenseness of the fascial boundaries of the compartment. Patients at risk for compartment syndrome should be examined at frequent intervals. The goal of the physician is early diagnosis and prompt decompression 10. If the patient’s clinical history and examination are indicative of compartment syndrome but not conclusive, compartment pressures should be measured. If pressures are higher than 40 mm Hg or within 30mm Hg of the patient’s mean arterial pressure, a fasciotomy is indicated 11.
In the case of a patient who has sustained a high energy tibial fracture followed by compartment syndrome resulting in permanent neuromuscular deficits such as foot drop or even amputation, the attorney in deciding whether to accept a malpractice case based on a failure to timely diagnose and treat the compartment syndrome must carefully review the hospital record in order to determine when the signs and symptoms of compartment syndrome were first documented and how long thereafter a fasciomoty was performed. It is suggested that if the delay from the onset of signs and symptoms until surgical decompression is less than twelve (12) hours the attorney should be hesitant to accept the case. The defense to these cases is usually that the patient’s end result was caused by the initial trauma and not any delay in diagnosing and treating compartment syndrome. Further, it will be argued that decompressive surgery was performed within a reasonable time following diagnosis of elevated pressures. Obviously, the longer the delay from onset of symptoms until surgery, the more meritorious the case.
Once the case is accepted, the focus should be two-fold, proving an unreasonable delay and proving the end result was not caused by the initial trauma.
In proving the end result was not caused by the initial trauma, the hospital record must be carefully scrutinized with regard to neurological and vascular findings regarding the injured leg or legs on admission to the hospital. Findings on admission of positive dorsiflexion and plantar flexion of the toes and ankles, positive sensation of the extremities and feet and intact neurovascular status of the legs and feet will go a long way toward proving that it was the delay in diagnosis and treatment of compartment syndrome and not the initial injury which caused the patient’s bad result. Further, if surgery was performed for the tibial fracture, the recovery room records must be reviewed with an eye towards the same findings.
In proving the delay, the depositions of the attending orthopedic surgeon and nurses are critical. The goal should be to obtain admissions from the physician as to the signs and symptoms of compartment syndrome, the fact that a patient presenting with a high energy tibial fracture is at risk for developing compartment syndrome and the fact that it is a surgical emergency. Any candid orthopedic surgeon will acknowledge the basic principles set forth above. The deposition of the nurse or nurses is an opportunity to have positive findings within the nursing notes explained and whether the nurses considered compartment syndrome and notified any physician about it.
The following is an example of a portion of a deposition of an orthopedic surgeon in a case involving the failure to diagnose and promptly decompress bilateral compartment syndrome following the patients sustaining bilateral tibial fractures when he was truck by an automobile. The patient was left with bilateral foot drop as a result of nerve and muscle injury. It was plaintiff’s contention these injuries resulted from the failure to diagnose compartment syndrome and not the initial trauma.
Q. Are patients who have suffered fractures of the tibia at risk for developing compartment syndrome?
Q. What is your understanding, generally speaking, of what compartment syndrome is?
A. Compartment syndrome is a process by which, though injuries to an extremity -- the way the muscles are arranged, they’re arranged in what we call fascial compartments, which basically are like a sausage.
Muscles and the vessels and the nerves go though a compartment that has a tight covering.
So when there’s a soft tissue injury and/or fracture, sometimes the pressure in this compartment goes up above the normal pressure. And if it reaches a threshold, it can stop the circulation to the small vessels that supply the muscles and nerves.
Q. If that happens, what can happen to the muscles?
A. The muscles can necrose, that is, die; and the nerves similarly become nonfunctional.
Q. Doctor, does a leg or lower extremity contain four compartments?
A. Yes it does.
Q. Are those compartments known as anterior, posterior, deep posterior and lateral compartments?
A. Yes they are.
Q. What are the signs or symptoms of compartment syndrome of the lower extremity?
A. The symptoms are increase in pain and numbness. The signs are swelling and tenseness of the compartment. Those are the early signs. And plus pain on passive stretch of the toes, that’s another sign. The pulses are usually maintained, unless there’s an injury to the artery or other pre-existing diseases. Pulses are only lost as a late phenomenon, if at all.
Q. One could have positive pulses and still be suffering from compartment syndrome?
A. That’s correct.
Q. Is plantar hypesthesia a sign of compartment syndrome as well?
A. It can be.
Q. Given a patient such as the plaintiff, who presents to the hospital with bilateral fractures of the tibia how often should such a patient be examined by a physician?
A. I think he has to be monitored closely, but I don’t think he necessarily has to be seen by a physician.
Q. A nurse would do?
A. If the nurse is trained in recognizing those signs, she’ll do.
Q. When you say trained in recognizing those signs, you mean signs of developing compartment syndrome; true?
* * *
Q. Doctor, is the earliest sign of impending anterior compartment syndrome, pain referred to the anterior compartment on passive flexion of the toes?
A. That’s an early sign. It may not be the earliest, but, it’s an early sign.
Q. In a patient at risk for compartment syndrome such as this patient, should the toes
be passively flexed at regular intervals?
A. I would think that they should be as part of a routine examination of his vital
Q. That would be one thing that you would want to have done; correct?
A. Correct. If he was complaining of increasing pain, in that setting you don’t have
to passive-flex his toes every minute.
But if he’s complaining of increasing pain or paresthesia or some other complaint that is referable to the compartment syndrome, you certainly would passively extend his toes to try to determine the etiology of his complaints.
Q. Can compartment syndrome in patient such as this lead to irreversible ischemia of the intrinsic and extrinsic muscles of the leg?
Q. Did that happen to this patient?
A. Yes. This patient did sustain permanent injury to the muscles in the anterior compartment.
Q. Would you agree that the most common cause of compartment syndrome of the lower extremities is a fracture of the tibia?
A. I would think it is the most common cause, yes.
Q. Would you consider compartment syndrome to be a surgical emergency?
A. Because of the time frame needed to prevent those irreversible changes.
Q. What is the time frame needed to prevent those irreversible changes?
A. You would like to decompress him within six to eight hours.
Q. Does the extent of muscle damage caused by compartmental syndrome depend upon the length of time from its first developing until decompression is achieved?
Q. The longer one waits to decompress, the more neuromuscular damage there will be, correct?
Q. Is it fair to say that the longer one waits from development of compartment syndrome to decompression by fasciotomy, the more chance of permanent neuromuscular deficits?
Q. Would you agree that if the arterioles remain in spasm for more than eight hours, muscle function will not recover?
A. Everything’s relative to other blood supply; but in general the longer the muscle or the nerves are deprived of their nutrition, the more damage there could be.
The doctor was then questioned as to the treatment of the plaintiff with particular regard to his developing compartment syndrome.
Q. Going to the nurse’s note for 1:00 a.m., it being, Patient awake, complaint of numbness, tingling and some pain anterior left foot; correct?
Q. Given this patient’s injuries, would you consider this finding a sign that the patient may be developing compartmental syndrome?
A. It’s possible.
(The reason the above are symptomatic of compartment syndrome, is they are indicative of ischemic injury to the deep and/or superficial peroneal nerves.)
Q. Should a physician have been made aware, given this patient’s injuries, of this finding?
Q. Was a physician made aware of these findings?
A. An attempt was made to contact a physician.
Q. Is there any indication that a resident responded?
A. I don’t see any.
Q. Is there any indication in this note that the compartmental pressures were measured?
Q. Should they have been?
A. Again, it depends on the examination of the patient.
Q. Given this patient’s injuries the findings as indicated in the 1:00 AM note, should this patient’s compartmental pressures have been measured?
A. It depends on the examination by the person who has to measure the pressures.
Q. Who would that person be in this situation?
A. The resident or myself, if I’m notified.
Q. Were you notified?
Q. Did the resident measure the pressures?
Q. At 1:00 AM.
The doctor was then questioned with regard to his own note 9 2 hours later.
Q. I have just a few questions about your note. With reference to the statement that the patient had increasing numbness in both legs, when did the numbness first start?
A. I can’t give you an exact time because I didn’t write it down, and I don’t know.
Q. Is it fair to say that it started at lest at 1:00 AM.
A. Well, it was noted by the nurse at 1:00 AM.
Q. But she at least, notes numbness in the foot?
A. I would think that it is probably part of the same numbness.
Q. Does that indicate to you that this patient started developing compartmental syndrome at 1:00 AM?
A. Around that time, I would think, yes.
In this case, fasciotomy was not done until 1:00 p.m. The doctor, by his own testimony, thus established at least a twelve hour interval between onset of compartment syndrome and the requisite surgery. He was then questioned as to his findings on
Q. Doctor, based on the findings that you made on fasciotomy, do you have an opinion as to when the patient first developed compartmental syndrome of his left lower extremity.
A. I would say he developed it over eight hours prior to decompression fasciotomy.
Q. When you say over eight hours, you mean more than eight yours before; correct?
Q. Doctor, going to the next operative report for the right lower extremity, do you have it?
Q. You assisted on this surgery; is that correct?
Q. What was the significance of the finding of the loss of contractility of the muscles of the anterior compartment?
A. That it may be necrotic.
Q, What would have caused it to become necrotic?
A. Loss of blood supply.
Q. Would the loss of the blood supply have been caused by the elevated pressures within the compartment?
Q. Going to the second page, do you see where it says, the musculature of the lateral?
Q. What significance, if any, was there to you of the findings of areas of hemorrhage within the muscle bellies?
A. The significance is the same in all the compartments, that the lack of contractility and the discoloration indicate -- can indicate necrosis of the muscle.
Q. As a result of loss of blood supply; correct?
Q. As a result of the compartment syndrome; yes?
Q. How long would it take for all of the muscle of the anterior compartment to become nonviable?
A. It’s my understanding it would take over eight hours.
Q. Doctor, directing your attention to the pathology report that indicates the specimen was debridement, necrotic muscle, lateral, does it?
A. That’s what it says.
Q. The diagnosis is skeletal muscle with acute inflammation, interstitial and perivascular amyotrophic change of myocytes.
Do you see where it says that?
Q. What is the significance to you, if any, of amyotrophic change of the myocytes?
A. I think it means that muscle was dead.
Q. It indicates that the patient sustained myonecrosis; correct?
Q. Is the result of myonecrosis residual soft tissue contractures, among other things?
Q. What, if anything, did the findings on the path report indicate to you about the length of time that elapsed between the patient’s first developing compartmental syndrome and the time the decompressions by fasciotomy were performed?
A. It just indicates to me that it was over eight hours.
Q. Doctor, what caused his loss of active dorsiflexion?
A. I think injuries to the peroneal nerve, as well as debridement of the necrotic muscle in the anterior compartment.
Q. The necrosis of the muscle in the anterior compartment was caused by compartmental syndrome was it?
A. Certainly, in part.
The physician in this New York Medical Malpractice case conceded the general principles regarding the cause of diagnosis and treatment of compartment syndrome. He was then forced to concede that the patient had suffered from compartment syndrome for at least over eight hours prior to surgery and in fact admitted the onset was at least 12 hours prior. Finally, his testimony regarding findings on decompression surgery and post decompression surgery eliminated the initial trauma as a cause of the patient’s muscle and nerve injury which were admittedly caused by prolonged ischemia resulting from elevated intracompartment pressures.
1.Guill B. Templeman D: Compartment Syndrome of the Lower Extremity. Ortho, Clincs NA. 25: r: 677-684, 1994.
2. Halpern A., Nagel D: Anterior Compartment Pressures in Patients with tibia fractures. J. Trauma 20:9: 786-790, 1980.
3. Gray’s Anatomy, Edited by Charles M. Goss: 27th ed., Pub. Leu & Febigeru 1959.
4. Rorabeck C. H., Macnab I: Anterior Tibial Compartment Syndrome Complicating Fractures of the Shaft of the tibia. J. Bone and Joint Surg. 48-B: 4:627-636, 1966.
5. Seddon H. I: Volkmann’s Ischemia in the Lower Limb. J. Bone and Joint Surg. 48B:4:627-636, 1966.
6. Rorabech C.H. Macnab I: supra.
7. Matsen FA., Clawson D. Kay: The Deep Posterior Compartmental Syndrome of the Leg. J. Bone and Joint Surg. 57-A: 1:35-39, 1975.
8. Gamron R.B.: Taking the Pressure Out of Compartment Syndrome. Amer. J. of Nursing, Aug. 1988, 1076-1080.
10. Matsen F.A. Winquist R.A.; et al.; Diagnosis and Management of Compartmental Syndromes. J. Bone and Joint Surg. 62-A: 2:286-291, 1980.
11. Guli B. Templeman D: Supra.