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An orthopaedic emergency

01 May 2007

Mrs A, a 31-year-old dental nurse, sustained a complex fracture of her dominant right distal humerus after falling from her bike. She attended the local A&E Department, where other injuries were excluded, and she was admitted to the orthopaedic unit. She was reviewed by the orthopaedic team on call. The clinical notes mention normal neurovascular status and good pain control. She was scheduled to undergo open reduction and internal fixation on the next morning’s trauma list. Surgery was performed as planned by Mr D, an orthopaedic consultant.

Soon after being transferred to the ward from theatre, Mrs A complained of severe pain in her arm and forearm. The nursing staff documented this in the notes and she was given simple oral analgesia. Eight hours after surgery, Mrs A was seen by the orthopaedic registrar, Mr E, who had assisted during the operation. He recorded in the notes that the pain was severe, there was marked swelling and decreased sensation on the hand, but that distal pulses were normal. The back slab provided in theatre was removed. Mrs A’s pain in the arm worsened and Dr V, a junior doctor cross-covering surgical specialties, and with no previous experience in orthopaedics, reviewed Mrs A at 2am. He prescribed opioid analgesics and advised review by the orthopaedic team in the morning.

Mrs A was seen during the next morning ward round. At this point she had no active movement in her hand or wrist. Any passive movement was extremely painful and the forearm compartments were clinically under tension. Compartment syndrome of the forearm was diagnosed and she was taken to theatre within the next hour for surgical fasciotomies. During surgery moderate muscle necrosis was found and surgical debridement was performed. She returned to theatre 48 hours later for wound exploration. No further debridement was necessary; the wound edges were approximated and finally, on a third visit to theatre two days later, the wounds were closed. Mrs A developed a mild Volkmann’s contracture and she underwent intensive, prolonged physiotherapy with a suboptimal result.

A claim was brought against Dr E and Dr V alleging a failure to identify compartment syndrome.

Expert opinion

Our orthopaedic expert was critical of the postoperative care. He said that compartment syndrome should have been suspected earlier and action taken promptly. If compartment syndrome was not clinically evident when Dr E saw Mrs A, it was clear that she was at high risk of developing it and she should have been closely monitored. Dr V failed to recognise an established compartment syndrome, delaying its treatment, with permanent consequences for the claimant.

The claim was settled for a moderate amount.

Learning points

  • Compartment syndrome is a true orthopaedic emergency. Failure to identify it and treat it urgently can lead to severe and permanent disabilities. As it is relatively uncommon, less experienced staff may not be familiar with its clinical presentation. Adequate training and awareness amongst the medical and nursing staff looking after a trauma patient is essential.
  • Compartment syndrome is a dynamic process. If it is considered but clinically excluded, detailed documentation should be entered in the notes. A description of the signs and symptoms present at the time, together with instructions for nursing staff should be documented. Close clinical monitoring is necessary.
  • It is important that doctors act within the limits of their competence and expertise, particularly for junior doctors who are asked to “act up”.
  • In recent years working hours in the UK and Ireland have tended to decrease, but this has increased the number of handovers between doctors. Robust systems are important for these handovers so that a consistent standard of documentation is maintained.
  • There is conflicting evidence supporting fasciotomies in late-diagnosed compartment syndrome, as these may be associated with severe infection and even death.

Further information

Elliott KGB and Johnstone AJ, Diagnosing Acute Compartment Syndrome, J Bone Joint Surg Br 85-B: 625–32 (2003).

Finkelstein JA, Hunter GA, Hu RW, Lower Limb Compartment Syndrome: Course after Delayed Fasciotomy, J Trauma 40:342–4 (1996).

Pearse MF, Harry L, Nanchahal J, Acute Compartment Syndrome of the Leg Fasciotomies Must be Performed Early, but Good Surgical Technique is Important,BMJ 325(7364): 557–8 (2002).

Cascio BM, Pateder DB, Wilckens JH, Frassica FJ, Compartment Syndrome: Time from Diagnosis to Fasciotomy, J Surg Orthop Adv 14(3):117–21 (2005).