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Compartment Syndrome

Compartment Syndrome an Example!

As related to a court of law, that could be considered typical for the development, diagnosis, and ultimate treatment of compartment syndrome following a pediatric elbow fracture.  This narrative is excerpted from a publicly accessible case law file and it is instructive for a number of reasons.

Number 1 — There was a delay in transferring the child to an orthopedic surgeon who could have definitively managed the fracture.

Number 2 — The child was cared for overnight by someone who did not personally discuss the possibility of a compartment syndrome with a physician, and in our experience, the further you stray from a one-on-one conversation with the doctor, the more likely the details are going to be “lost in translation.”

In many training programs, it is taught that it is important at every step of the care process to diagnosis and prevent the worst possible outcome from occurring during the care of a trauma patient.  In this instance, it seems like there were a few opportunities to get this child in the hands of someone who was able to diagnose and treat a possible compartment syndrome earlier rather than later.  The reason why this case is presented here is because it is typical of the chain of events that leads to a poor outcome, and if you are a parent and any of these events seem to be transpiring, it would be advisable to get your child in the hands of a qualified orthopedic surgeon with expertise or experience in the management of pediatric fractures who could intervene early.

The summary of the facts is as follows….

On a morning in March, six-year-old appellant fell off the monkey bars at school (all further dates are in the same year). After complaining of pain in his left elbow, he was taken to XXX Medical Center by ambulance. Emergency room personnel noted that there was swelling and tenderness around the elbow, but that his neurovascular status was normal. They found he had a pulse in his left arm and good capillary refill (“good blood flow into the extremity, and . . . adequate blood flow back out”). Appellant’s X-ray revealed that he had a displaced supracondylar fracture of the distal humerus, or a “severely broken elbow.” Appellant’s condition required surgery.

Emergency room personnel called respondent Dr. A to authorize treatment. She was appellant’s pediatrician at this time. Dr. A told the caller to send appellant to her office. Emergency room personnel then called back to authorize “definitive immobilization,” which requires “an orthopedic surgeon to either reduce [the] fracture without surgery, without opening up the arm, or to open up the arm and then stabilize [the] fracture.” Dr. A did not authorize the treatment and informed the caller that she would make arrangements for appellant to see an orthopedic surgeon.

When appellant and his mother arrived at Dr. A’s office, appellant’s left arm was in an air splint. Appellant’s pain was not out of proportion to his injury. After checking for a radial pulse and observing that his hand was warm and pink, that he could move his fingers, and that he had good capillary refill, Dr. A concluded that appellant had no neurological or vascular compromise. Dr. A made an appointment for appellant to see Dr. B, an orthopedic surgeon, at 1:00 p.m. the following day.

In the meantime, Dr. A instructed appellant’s mother to monitor his pulse by checking on the color and temperature of his hand, and to call her immediately if there was any change. Appellant’s mother never observed a change in the color or temperature of his hand. At approximately 5:00 p.m. or 6:00 p.m., appellant left his mother’s house with his father. Appellant’s mother believes she told his father to monitor the color and temperature of his hand, but does not remember if she told him what to do if in fact there was any change.

The next day, appellant saw Dr. B. After observing that appellant’s left arm was pulseless, Dr. B referred him to Orthopaedic Hospital of ZZZ. Appellant arrived at Orthopaedic Hospital’s emergency room at approximately 3:00 p.m. Dr. C, an emergency room physician, observed that although appellant had normal capillary refill, he had no palpable radial pulse. A doppler machine indicated that a radial pulse was present, but that blood flow through the radial artery was diminished. Dr. C noted that appellant was unable to extend or flex all of his fingers, and that appellant was experiencing some tingling. Based on this evaluation, Dr. C concluded that there was potential for vascular injury.

Appellant was transferred to Children’s Hospital of ZZZ for surgery. Because of a delay with the ambulance transportation service, appellant did not arrive at ZZZ until after 8:00 p.m. There, Dr. D, a pediatric orthopedic surgeon, reduced and stabilized the fracture by removing a blood clot, realigning appellant’s bones and inserting metal pins to hold the bones in position. Once that was done, Dr. D could feel a weak radial pulse in appellant’s left arm, where there had been no palpable pulse before. The doppler test confirmed that there was blood flowing through the radial artery. After surgery, appellant had very little swelling and the muscles in his left arm were soft. For those reasons, Dr. D ruled out compartment syndrome.

According to Dr. D, “[c]ompartment syndrome is a diagnosis that describes a condition where there’s an extreme amount of swelling in a given compartment. A compartment is a space that is encased in heavy tissue, similar to a sausage being encased in an outer wrapping. And the inner portion of that wrapping is the muscle. So when you have a compartment syndrome, you have swelling in the muscle that is so great that the flow of blood to the muscle is being restricted, similar to standing on a garden hose, and so you jeopardize . . . blood flow to the muscle.” Dr. E, appellant’s expert orthopedic surgeon, testified that once the pressure inside a given compartment reaches a certain level, a fasciotomy (cutting of the fascia, the tissue that encases the muscle) must be performed to release the pressure within six hours or permanent damage will occur.

On March 28, at 8:00 a.m., Dr. D noticed increased swelling in appellant’s left arm and forearm. Dr. D loosened the dressings and advised continued elevation of the arm. An hour later, the swelling had decreased. At about noon, Dr. D measured the pressure in appellant’s arm. An uninjured muscle usually measures between zero and 10 millimeters of mercury. Compartment syndrome becomes a concern when the pressure is above 30 millimeters. Dr. Early diagnosed appellant with compartment syndrome of the left forearm after learning that one of his measurements was 38 millimeters.

Dr. D performed a fasciotomy on appellant’s left forearm. He noticed that some of the muscles were light brown, instead of a healthy bright red. The muscles also were of a fragile consistency and did not contract normally. However, he did not remove the unhealthy muscles because he was not sure that they were dead, and he wanted to give them a chance to survive. He also knew that appellant would be undergoing surgery again in a couple of days to close the wound, so he planned to remove any necrotic, or dead, muscle at that time.

On March 30, Dr. D found necrotic muscle tissue in appellant’s left forearm, which he removed. Dr. D took appellant into surgery several more times to remove more necrotic tissue, treat the wound and attempt to close the wound. On April 8, the wound was completely closed. Although appellant later underwent a muscle transplant surgery, he was left with an “unsightly, minimally functional hand.”  Appellant, through his guardian ad litem, sued Dr. A, Dr. D and others for medical malpractice.

1 ping

  1. Immediate versus delayed treatment for supracondylar fractures | pediatric fractures, broken bones, cast care, & fracture healing says:

    [...] This was a really important study because prior to this study, the orthopedic community used to believe that there was a principle that you should never “let the sun set on a supracondylar fracture”, which obligated the vast majority of cases to be treated in the middle of the night.  With this study, there was at least some scientific basis to waiting throughout the night and treating the fracture in the morning.  However, this treatment option is not without its risks.  The child has to be under the care of someone who is cognizant of the risks of a vascular injury in the setting of a supracondylar elbow fracture, and in one of our case law examples, we present the narrative of a child who ended up developing a catastrophic complication as the result of a delay in treatment.  For full details of this narrative, read the entire story here. [...]

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