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Tomorrow is too late

01 May 2011

Six-year-old FM underwent a left Salter’s osteotomy to treat the developmental dysplasia of his hip. Mr R, consultant orthopaedic surgeon, performed the procedure. Prior to it, he discussed the risks and benefits of this operation with FM’s parents and recorded it all in the clinical notes.

Following the surgery, FM’s left leg was set on a Thomas splint. The initial postoperative period was uneventful and with good pain control. However, three days after the surgery Mr R’s specialist trainee, Mr F, noticed some numbness of the toes as well as a foot drop on examination of FM’s limb. Mr F removed both the Thomas splint and the leg bandage. Since the symptoms persisted 24 hours later, Mr F asked his consultant to review the child. At this point, the anterior compartment was tense and there was no active extension of toes or ankle. Passive plantar flexion of the ankle was painful.

After explaining the situation to FM’s parents, Mr R took him to theatre to measure compartment pressures; the diagnosis of compartment syndrome was confirmed and a fasciotomy performed. Mr R did a surgical release of all compartments of the leg with debridement of all non-viable tissues, including the whole tibialis anterior muscle. During the following weeks, FM had to return to theatre three more times for further debridement and sequential secondary closure of the wound.

FM was eventually discharged home to attend long-term rehabilitation. He was left with a permanent long scar and some weakness of the lower leg. Although his gait was normal, he was unable to take part in some sports. FM’s parents made a claim against Mr R and his team for causing and then failing to promptly diagnose compartment syndrome.

Expert opinion stated that compartment syndrome following a Salter’s osteotomy was an extremely unusual complication. However, they believed the case to be indefensible in court, due to the unusual decision to use a Thomas splint, and also in view of the difficulty in defending compartment syndromes not diagnosed at an early stage. The case was settled out of court for a moderate amount.

The claim was brought seven years after the operation took place, by which time Mr R had retired. This highlights the importance of occurrence-based indemnity, where a doctor is eligible for assistance if indemnity arrangements were in place at the time of the incident, regardless of when the claim is made.

Learning points

  • Compartment syndrome should be suspected following any surgery on the limbs, particularly if a tight bandage is applied.
  • Failure to identify and treat a compartment syndrome urgently can lead to severe and permanent disabilities. In addition, it is very unlikely to be successfully defended.
  • Compartment syndrome is a dynamic process. If it is considered but clinically excluded, a detailed documentation should be entered in the notes. A description of the signs and symptoms present at the time should be documented. Close clinical monitoring is necessary and measurement of intracompartmental pressures should be contemplated at an early stage.
  • There is conflicting evidence supporting fasciotomies in delayed diagnosed compartment syndrome, as these may be associated with severe infection and even death.

Further reading

  1. Frink M et al, Compartment syndrome of the lower leg and foot, Clin Orthop Relat Res 468(4): 940-50 (2010)
  2. Shadgan B et al, Diagnostic techniques in acute compartment syndrome of the leg, J Orthop Trauma 22(8): 581-7 (2008)
  3. Gourgiotis S et al, Acute limb compartment syndrome: a review, J Surg Educ 64(3): 178-86 (2007)
  4. http://emedicine.medscape.com/article/1270542-overview