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Delay in Diagnosing and Treating Compartment Syndromes

By Gene Moen

If you handle personal injury or medical negligence cases, you have probably encountered a condition called “compartment syndrome.” It can be a result of an injury received in an accident or it can result from a medical procedure. In either case, prompt diagnosis and intervention is crucial to avoid much more serious injury and disability. This article will describe the condition and will emphasize the medical negligence claims that arise from delays in diagnosis and treatment.

The body contains many closed spaces (compartments). They consist of a group of muscles, nerves, and vessels bound by relatively rigid walls of bone and a tough membrane (fascia). Compartments can be found in the arms and other parts of the body, including the abdomen and buttocks. Compartment syndrome most commonly occurs in the legs (often in the front part of the calf) but occasionally can occur in the arms and, more rarely, in other parts of the body.A compartment syndrome (CS) occurs when there is excessive pressure in a compartment; this can result in tissue, nerve, and muscle death. The problem arises when swelling or bleeding occurs in a compartment. Because it is in a closed space, damage to muscles and nerves can occur from cutting off the blood supply to the cells. The keys to successful treatment are early diagnosis and prompt decompression of the compartment through a fasciotomy (cutting open the compartment to relieve pressure). A compartment syndrome is a true medical emergency.This article will focus on the lower extremity compartments, particularly those in the calf, because that is where CS is most commonly encountered.

CAUSES

There are many potential causes of CS. For those in the leg, about 45 percent are caused by fractures of the tibia. Other causes can be vascular injury, burns, crush injuries, penetrating injuries, overexertion, IV-drug use, and a too-tight cast or dressing. There is also literature describing bilateral leg CS after a lengthy surgery in the lithotomy position.CS can be chronic or acute. Most chronic CS occurs with repetitive stress, such as experienced by competitive athletes (e.g., runners or bicyclists), and is commonly bilateral. It causes pain, which usually subsides within 1-2 hours of stopping the activity, but can return when the activity is resumed. The use of anabolic steroids can contribute to CS development. In some cases, there can be “acute on chronic” CS where the pain does not subside and the compartment pressures increase over hours or days.

Acute CS presents the most serious risk and usually requires emergent medical treatment because there is a relatively short window in which diagnosis and treatment must occur to avoid muscle or nerve damage.

DIAGNOSIS

Traditionally, the five P’s have been considered diagnostic: Pain, Parathesia, Pallor, Pulselessness, and Paralysis. However, the last four of these signs and symptoms are not clinically reliable and usually manifest themselves only in the late stages of CS. The only consistent symptom that is always present is pain that is greater than expected for the injury or condition. Thus, if a vascular surgery occurs at 4:00 p.m. and the patient begins to experience increasing leg pain at midnight, CS must be suspected. Similarly if a post-op patient after a long surgery in the lithotomy position develops bilateral leg pain hours after the surgery, CS must be considered. Usually, in post-trauma patients leg pain subsides over time and with administration of pain medications. CS must be considered if pain persists or increases instead.

Physical examination may reveal few signs of CS. The affected limb may be swollen or tight. Because sensory nerves are often affected before motor nerves, sensory findings on testing may be an early finding. Inability to dorsiflex the foot is almost always a late finding. If a major sensory deficit or loss of peripheral pulses are found, the CS is also likely to be advanced. Because CS can cause muscle necrosis, it may result in high levels of creatine kinase (CK) in the blood and even be evidence that rhabdomyolysis is developing. This would indicate a late-stage CS where significant muscle necrosis has already occurred. In a few cases, rhabdomyolysis can be diagnosed before CS occurs, but CS may then develop hours or days later.

Plain film x-rays will not disclose CS. If CS is suspected, however, there are hand-held, pressure-testing devices that can detect high pressures in a compartment. These devices are seldom utilized by admitting physicians, who are often untrained in using them, which means that an orthopedic consult is the most significant first step when CS is suspected. The orthopedic surgeon is also the physician who would perform a fasciotomy to relieve pressure in a compartment if CS is diagnosed.

TREATMENT

The only effective treatment for CS is an urgent fasciotomy to relieve pressure in the compartment and restore muscle perfusion. Medical therapy is rarely useful in treating CS. Muscles tolerate four hours of isehemia, but by eight hours the damage is usually irreversible. However, ischemia may be a late development even when symptoms are present, and fasciotomies performed within 24-36 hours following onset of acute CS often have a good prognosis.

Intravenous antibiotics are usually given prior to the procedure, because necrotic muscles can be a nidus for infection. If the CS is advanced, decompression may not be helpful if a post-fasciotomy infection develops; in those cases, the patient may require life-saving amputation.

DAMAGES

The consequences of untreated CS is muscle and nerve death in the affected limb, and potentially amputation or even death. Cellular destruction and alterations in muscle cell membranes lead to the release of myoglobin into the circulation, which can lead to kidney damage. Advanced CS may result in rhabdomyolysis. This can cause renal failure, which in turn can be complicated by sepsis, which can be fatal.

More commonly, the major complication from a late-diagnosed CS is a foot drop, because the anterior tibialis muscle is affected. Postoperative motor deficits from CS are usually treated with orthotic braces to compensate for the loss of ankle/foot extension. In some cases the nerve damage caused by CS may result in chronic limb pain or other sensory changes such as tingling or numbness. The end result of even a timely fasciotomy will be a scar where the compartment was opened. If damaged muscle tissue must be removed, however, the incision and resulting scar will be much larger.

MEDICAL/LEGAL ISSUES

As noted earlier, the key to successful treatment of CS is early diagnosis and pressure-releasing surgery. Physicians who treat patients for an injury that may lead to CS are often under-trained and inexperienced in this condition. This applies to nurses and other providers who see the patient. Thus, any suspicion of CS should lead to a prompt orthopedic consult since those physicians are better trained to diagnose CS and are, ultimately, the ones who would treat it by a fasciotomy. Orthopedists can also utilize pressure-testing devices to confirm a diagnosis. In discovery one should find out if a hospital has such devices on-site and which physicians are authorized to use them. Failure to conduct pressure testing when there are findings suspicious for CS may be a basis for a claim.

In the past, when hospitalists were less common, the admitting physician or surgeon relied on the eyes, ears, and hands of the nursing staff. This is still the case in rural and smaller hospitals where on-site physicians are seldom present, especially during the evening or night. Even when calls are made by a nurse to a physician, disputes can arise over what the physician was told about the signs and symptoms of CS. If the nurse tells the physician that the patient has 4 out of 10 leg pain, it is crucial to know whether and to what extent the patient is receiving pain medication such as morphine or Dilaudid that may dull the pain perception. In evaluating a potential late-diagnosis case, the attorney must obtain all medication records, including the PCA (patient-controlled analgesia) records and PYXIS or other computer or pharmacy records of medication administration.

If a physician is told by a nurse about crescendo or increasing leg pain in a patient who has risk factors for CS, it is incumbent on the physician to urgently see and assess the patient. It is not within the standard of care to wait until morning rounds if a patient is called during the night about such pain symptoms.

The concept of the differential diagnosis is often key to CS cases. Since out-of-proportion pain is the hallmark symptom, the physician (or the nurse) must consider what may be causing the pain. There may be other and more benign explanations that would be in the differential diagnosis, but one of the most serious would be CS. If so, CS must be presumed until proven otherwise because this is an emergent condition and delay in treatment can result in permanent disability.

Keep in mind that under the WACs nurses have an independent duty to make a nursing diagnosis and plan regarding a patient. Thus, a nurse who records increasing or severe post-operative leg pain must call the physician to report the findings. If a treating physicians is ignoring the reports of persistent leg pain, nurses have an independent duty to go up the nursing chain of command to seek an orthopedic consult.

As in all cases involving a delay in diagnosis, claims alleging untimely treatment of CS will often focus on causation. If the diagnosis and fasciotomy occurs when there are some signs of muscle or nerve damage already, the question is: how much better would it have been if the treatment had occurred earlier? The key is determining the time when symptoms were initially suggestive of CS and required intervention. If those symptoms do not reflect serious nerve or muscle damage already, then prompt treatment would likely produce a good outcome. The recent case of -Mohr v. Grantham, _Wn.d2d _ (2011), 262 P.3d 490 may help since it holds that damages are recoverable for the “loss of chance” of a better outcome. Left unanswered by that opinion is how one quantifies the percentage chance lost and the amount of damages that would have been avoided.

Gene Moen is a partner in the Seattle firm of Chemnick Moen Greenstreet. The firm limits its practice to medical negligence claims. This article was first published in Trial News, January 2012.

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