Compartment Syndrome is a serious medical condition that requires immediate recognition and a high degree of suspicion by nurses, ER doctors, internists, and orthopedic specialists alike to prevent catastrophic injury to patients.
Missed diagnosis of compartment syndrome can result in permanent nerve damage, amputation, chronic pain from complex regional pain syndrome (CRPS) renal failure and even death.
Compartment syndrome often occurs after trauma — such as after falls or motor vehicle accidents — and most often impacts one of the four “compartments” of the tibia or lower leg, upper arm, forearm, wrist or hand. Technically, it can occur in any of the over 300 muscle compartments of the body, but the areas mentioned above are the most common.
Even minor trauma, such as a routine fracture, may result in compartment syndrome if the symptoms are not monitored closely, addressed and treated promptly by medical professionals. Once the symptoms have presented themselves, there is a narrow window in which to take action and prevent catastrophic injury.
Symptoms of Compartment Syndrome: The Five P’s
The symptoms of compartment syndrome are remembered, and taught to medical professionals, as the “5 P’s” :
1).Pain. Pain out of proportion to what one may expect from an injury, such as a fracture or pain with passive stretch of the (hand, flexion of the toes, flexion of the wrist) are signs of compartment syndrome.
4) Pulse: The lack of palpable pulses is a sign of compartment syndrome, and may often be tested by a handheld Doppler ultrasound.
3.) Pallor: This refers to the pale color of the extremity that is being robbed of its blood supply, and is an ominous sign of compartment syndrome.
4.) Paresthesia: this refers to the numbness and tingling one feels when the nerve has been deprived of oxygen and is now damaged; and may or may not be reversible. Neurovascular examinations need to be done at regular intervals in a hospital setting. The best way to check for this is checking for what is known as “2 point discrimination,” and nursing or house staff should check this regularly as part of their assessment. The test will be performed by checking with a tool that has two pointed prongs and a single prong and asks the patient (with closed eyes) what he or she is feeling, essentially to discriminate between the two sensations. If the patient fails this test, compartment pressures should be immediately checked, often using a device called a Stryker Tonometer to see if the compartmental pressure is over 30 mmHg. If it is, will the patient will require and emergency fasciotomy surgery.
5.) Paralysis. This refers to the inability to move a limb or area of body impacted, and is another ominous sign of compartment syndrome.
Nurses, doctors and other medical professionals are trained to timely diagnose compartment syndrome by looking for the 5 P’s on examination. Timely diagnosis is key.
On physical exam the limb may appear and feel hard and “wooden” like. It may be covered in bullae or large blisters. If left untreated; or inadequately treated, the muscles within the muscle compartment undergo ischemic necrosis (death due to lack of oxygen) or at times in the upper extremity a limb contracture may occur. This is termed Volkmann’s ischemic contracture, and is manifested by an arm which is permanently bent or flexed into a “claw hand”, the wrist and the elbow, rigidly flexed owing to an overlooked compartment syndrome, ignored for longer than 24 hours. The muscles deprived of oxygen undergo fibrotic changes, scarring and then shortening, causing these changes. The individual has difficulty with even basic activities such as combing their hair or feeding themselves, driving and even picking up items.
How Compartment Syndrome Develops
What happens in compartment syndrome is that the initial injury causes swelling to the affected area, usually a limb, which leads initially to venous swelling and congestion with waste products. This compromises arterial blood flow with all important oxygen to nourish the muscles and nerves.
Without oxygen nerves begin to feel the effects within as little as 45 minutes. Muscles begin to die or become “necrotic” within 4-6 hours. A vicious cycle ensues, the more cellular death the more swelling and pressure on the arterioles that feed the muscle and thusly the further lack of oxygen. The condition rapidly deteriorates.
If the patient is not timely diagnosed with compartment syndrome and taken to the operating room to have a surgical decompression — meaning a long surgical incision made along the entire length of all involved muscle bellies to alleviate the swelling decreasing the pressure on the arteries and nerves — they will not survive. The muscles and nerves will become necrotic “die” and suffer irreversible damage, and need to be surgically “debrided” or, removed. This process can occur if you have just had a fracture treated conservatively with a splint or cast, or it can occur post-operatively.
Timely Diagnosis of Compartment Syndrome is Critical
Clinicians need to remain extremely vigilant when dealing with any fracture or trauma, considering compartment syndrome until proven otherwise. Time is of the essence with compartment syndrome.
If a patient is having extraordinary pain with their fracture or after orthopedic surgery, doctors should not attribute it to a flaw or lack of bravado on the part of the patient. They must consider compartment syndrome, because the potential consequences for failing to do so are disastrous for the patient.
With timely recognition, compartment syndrome is entirely preventable. It does not occur at the time of trauma, but rather develops afterwards over time. And there are clear, red flag signs that compartment syndrome is developing.
Compartment Syndrome Malpractice Attorneys
Attorneys who specialize in medical malpractice with experience in cases involving compartment syndrome should be able to review the patient’s medical records to determine whether there is a viable cause of action for negligence.
Sometimes, the operative report may be telling, such as in cases where the surgeon doesn’t release the tourniquet prior to suturing the wound, or sutures the fascia, which should be avoided altogether due to the expected swelling and or blood clot formation. Wound closure should only include subcutaneous tissue and skin alone as to avoid compressing arteries and nerves. Other times, the nurses charting may clearly show signs of compartment syndrome (see the 5 P’s above), which went ignored.
If you have had a traumatic injury and developed compartment syndrome and maybe felt as though you were not heard by your medical team and now you live with the consequences of compartment syndrome such as chronic pain, chronic regional pain syndrome, difficulty walking, damage to nerves and muscles or Volkmann’s Contracture or are unable to work due to these medical issues, contact one of the attorneys at the Passen & Powell at 312-527-4500 for free a consultation.