EXECUTIVE SUMMARY

Missed compartment syndrome presents a high risk for ED litigation. To reduce risks:

  • remember that compartment syndrome is a clinical diagnosis, and is made based on exam;
  • be very suspicious when the patient is in pain that seems out of proportion to the injury;
  • ensure the involved extremity is iced, elevated, and immobilized and seek prompt surgical consultation.

Compartment syndrome is one of the few true orthopedic emergencies seen in the ED, and the consequences can be dire.

“Thus, it presents a high risk for litigation,” says J. Mason DePasse, MD, an orthopaedic surgery fellow at Brown University’s Warren Alpert Medical School in Providence, RI. Researchers reviewed 139 malpractice claims involving missed acute compartment syndrome.1 Of this group, 37 were settled, 33 resulted in a plaintiff ruling, and the rest resulted in a defendant ruling.

“We wanted to better characterize the factors that affect the outcomes of malpractice claims related to compartment syndrome,” says DePasse, the study’s lead author. Key findings:

  • Women and children were more likely to win suits, but indemnity payments were not affected.

“These findings are likely the result of the jury reactions,” DePasse offers. “Juries may be more sympathetic to women and children.”

  • Seventy-two percent of cases involved the lower extremity.
  • Plaintiffs who developed compartment syndrome because of an elective surgical procedure, such as calf enhancement or total joint replacement, were more likely to win suits when compared to plaintiffs who were diagnosed with compartment syndrome after trauma.

Jurors may be less likely to assign blame to a physician in cases of compartment syndrome caused by trauma, DePasse suggests.

  • There was no difference in litigation outcome for plaintiffs who required amputation compared to plaintiffs who did not.

This was an unexpected finding for the researchers. “It could be that adverse neurologic outcome is perceived as equal in severity to amputation, which may be true in many cases,” DePasse offers.

  • Plaintiffs who developed compartment syndrome as a surgical complication were more likely to win suits.

However, the most common etiology of compartment syndrome across all malpractice claims was acute trauma.

  • Delay in diagnosis was present in almost 90% of cases.

Surprisingly, delay in diagnosis did not affect the outcome of litigation. DePasse says this might be because almost every ED malpractice claim involves delay in diagnosis.

“The few that do not involve factors that juries find equally compelling, such as compartment syndrome as a result of erroneous intravenous catheter placement,” he says.

DePasse says that the most important thing emergency physicians can do to limit legal risk is to be aware of risk factors and injury patterns associated with compartment syndrome, as well as signs and symptoms suggestive of compartment syndrome.

Although compartment syndrome can occur in the thigh and foot, it is far more likely to occur in the lower leg. “It is usually associated with high-energy trauma or crush injuries,” says DePasse, adding that high-energy, bicondylar tibial plateau fractures and segmental tibial shaft fractures are particularly worrisome.

“While measuring compartment pressures is a useful adjunct to diagnosis, it is important to remember that compartment syndrome is a clinical diagnosis and is made based on exam,” DePasse stresses.

Physicians should be very suspicious when the patient is in pain that seems out of proportion to the injury, and when there is pain with gentle, passive stretching of the toes or fingers. “Furthermore, if the leg or forearm feels very firm or ‘rock hard,’ compartment syndrome is likely developing,” DePasse warns.

The classically taught “Ps” — pain, paresthesia, pallor, paralysis, pulselessness, and poikilothermia — often are not as helpful as EPs might assume. Most of these symptoms, especially loss of pulse, occur after significant damage has occurred, according to DePasse.

Compartment syndrome in children may be difficult to recognize, DePasse notes. “Keeping the three ‘As’ [agitation, anxiety, and increasing analgesic requirement] in mind is useful.”

If the EP is concerned about the possibility of developing compartment syndrome, DePasse says “ensure the involved extremity is iced, elevated, and immobilized, and seek prompt surgical consultation.”

REFERENCE

  1. DePasse JM, Sargent R, Fantry AJ, et al. Assessment of malpractice claims associated with acute compartment syndrome. J Am Acad Orthop Surg 2017;25:e109-e113.

SOURCE

  • J. Mason DePasse, MD, Orthopaedic Surgery Fellow, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI. Email: jmdepasse@gmail.com.