28 year old male presents to an ED with complaints of severe distal forearm and wrist pain and swelling after a fall. On exam, patient is found to have severe swelling of the forearm and wrist, diminished sensation to 2nd and 3rd digits and minimal motion of fingers. No palpable radial pulse, but pulses obtained by doppler. X-rays were negative for a fracture. Patient was in the ED for approximately 6 hours with approximately 8 pain assessments of 10/10 pain despite 3 administrations of Dilaudid, 1mg , via IV along with administration of 10 mg of Oxycodone, 1,000 mg of acetaminophen and 600 mg. of ibuprofen.
Given degree of swelling, disproportionate pain complaints, and persistent paresthesia, the ED consults the plastics service. On exam, plastics found compartments compressible with normal cap refill and 2 point discrimination intact. Patient was placed in a spica splint and advised to keep arm elevated. No measurement of compartment pressures taken. Patient discharged with dx of arm contusion.
36 hours later, patient is returned to ED by EMS, hypotensive, tachycardic and tachypnea with absent pulses of the extremity with diminished sensation and the extremity cold, pale and with skln breakdown. Patient diagnosed with acute compartment syndrome, sepsis with distal emboli and necrotizing fasiciitis. Patient undergoes emergent fasciotomy and thrombolectomies. However, left arm was unable to be salvaged and paitent underwent amputation at the shoulder. , .
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Do you believe there might have been medical error?
Signs and symptoms of compartment syndrome was present on the first ED visit. The first error was a delay in care. This was a true emergency and the patient should've been evaluated by CT scan of the arm to r/o necrotizing fasciitis, and also arterial doppler to evaluate for arterial blood flow. These two evaluations should've been done stat by the ED physician. None of these diagnostic tests were done by the consultant (plastic surgery). I'm not sure why plastic surgery was consulted instead of orthopedic surgery and/or vascular surgery. The consultant cannot rule out compartment syndrome just by "normal cap refill and 2 point discrimination intact" as both of these evaluations are not sensitive and also very subjective. In this case, compartment pressure should've been checked. Also, with all these symptoms, including severe pain, no palpable pulse, and diminished sensation, patient should've been admitted and not discharged. Here is how I manage this type of patient: 1- Stat CT scan of the arm 2- Stat arm arterial doppler 3- Stat orthopedic surgery and vascular surgery consult. 4- If any sign of subcutaneous air noted on exam, x-ray or CT, stat broad-spectrum antibiotic for presumed necrotizing fascitis. 5- Admission to ICU. I demand the surgeon to take the patient to OR immediately from the ED if CT or doppler is positive to prevent any delays.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was a significant delay in care and also missed-diagnosis. There was a possibility of saving the patient's limb if all diagnostic tests were done properly and the patient was managed accordingly.
What makes you a good expert for this case?
I'm a board-certified internal medicine and critical care physician that deals with all critical conditions including compartment syndrome and necrotizing fasciitis. I have managed multiple similar cases in throughout my carrier.
How often do you encounter cases similar to this one in your practice?
I see at least 1-2 compartment syndrome and/or necrotizing fasciitis a month.
Do you believe there might have been medical error?
Patient clearly had compartment syndrome which is a medical emergency. There was an error by both the ER staff and the plastic surgeon. This was an error that should have been avoided. Not the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
undiagnosed compartment syndrome resulted in amputation. Improper evaluation and in the least compartment pressures should have been measured.
What makes you a good expert for this case?
I am a hand and upper extremity surgeon who has had extensive experience in evaluating, treating and operating on compartment syndrome.
How often do you encounter cases similar to this one in your practice?
Up to 5 times a year if not more.
Do you believe there might have been medical error?
Compartment syndrome is a clinical diagnosis. Although we are lacking a few important details, (duration of the swelling and pain prior to ED presentation), the clinical examiantion performed by plastic service in the ED doesn't appear to be consistent with classic compartment syndrome. Acute compartment syndrome usually maniests within 8-12 hours after the initial injury. The patient returning to ED with the diagosis of acute compartment syndrome 36 hours after the initial evaluation does not fit classic natural history of compartment syndrome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As long as the plastic service did the proper physical examiantion (compressible compartment, good cap refill, intact 2pt), it is not likely the medical error that cause this patient's unfortunate outcome. It would be helpful to know other parts of physical examination is documented. (hand in resting position (intrinsic minus position), pain with passive stretching)
What makes you a good expert for this case?
I have evaluated and treated multiple patients with hand compartment syndrome in both emergency room and operative room. In addition, I performed multiple hand compartment checks in the past. Checking hand compartment pressure is very painful to patients, and I don't personally perform the compartment pressure check unless I have a very strong suspicion of the compartment syndrome based on history and the clinical examination.
How often do you encounter cases similar to this one in your practice?
I will get consulted a dozen times a year for suspected hand compartment syndrome, but usually only 1-2 cases turn out to be the true compartment syndrome.
Do you believe there might have been medical error?
1. Non-palpable radial pulse is abnormal in a 28 year old male, even if there are doppler signals. In conjunction with decreased sensation and decreased motor function, this likely should have prompted further workup for compartment syndrome with direct compartment pressure measurements with a Stryker needle and CK level. Was CK level done at the initial ED visit? 2. Unless patient had a history of opioid abuse, unremitting pain 10/10 despite high dose narcotics (dilaudid 3 mg IV and oxycodone 10 mg) should prompted further workup for more serious conditions such as compartment syndrome or necrotizing fasciitis. 3. It is likely that compartment syndrome was secondary to necrotizing fasciitis. Reference: Leechavengvongs S1, Jidpugdeebodin S, Milindankura S. "Necrotising fasciitis causing compartment syndrome of the forearm and septic shock due to Vibrio vulnificus: a case report." Hand Surg. 2006;11(1-2):77-82. The article states: "Compartment syndrome caused by necrotising fasciitis has rarely been described. We report a case of systemic Vibrio vulnificus necrotising fasciitis presented with compartmental syndrome of the forearm and septic shock. The patient was treated with systemic antibiotic treatment and urgent surgical decompression followed by multiple necrotic tissue debridements. The patient recovered with some limited motion of the hand function. Prompt recognition and immediate treatment with antibiotics and surgical intervention are essential." Was there a CBC with differential drawn at the initial visit? If there was elevated WBC and bandemia, that would strongly suggest necrotizing fasciitis in conjunction with the described physical exam.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
1. Based on the information provided above, I would hypothesize that the primary inciting event may have been necrotizing fasciitis due to a break in the skin from trauma. This then caused a secondary compartment syndrome. 2. The patient presented a second time to the ED with "absent pulses of the extremity with diminished sensation and the extremity cold, pale and with skln breakdown." These are very late findings in compartment syndrome. Loss of arterial pulse is a late finding because compartment pressures are so high that they have exceeded systolic blood pressure (~100-140 mmHg). Even when compartment pressures exceed diastolic blood pressure (~40-60 mmHg), the limb is already threatened. Systemic findings such as "hypotensive, tachycardic and tachypnea" are very late findings due to release of toxic metabolites from either sepsis due to necrotizing fasciitis or compartment syndrome. Therefore, it is likely there was delay in diagnosis. If necrotizing fasciitis or compartment syndrome were diagnosed at the initial ED visit, immediate decompressive fasciotomy and/or debridement may have saved the patient's arm. 3. Given the constellation of clinical findings at the initial visit (pain out of proportion, inability to control pain despite high dose narcotics, decreased sensory and motor function), one should have a low index of suspicion for compartment syndrome and necrotizing fasciitis. I would be curious to know whether WBC was elevated, bandemia was present, and CK was elevated at the initial ED visit.
What makes you a good expert for this case?
I am a board-certified vascular surgeon. We commonly are asked to assess for compartment syndrome. Compartment pressure measurements using a Stryker needle should be done if there is pain out of proportion to exam. I have also assisted or been involved in surgery for necrotizing fasciitis, including emergency radical circumferential debridement of the skin of the upper extremity from the wrist to the shoulder.
How often do you encounter cases similar to this one in your practice?
This specific case involving upper extremity compartment syndrome in conjunction with, and possibly due to necrotizing fasciitis, is uncommon. However, compartment syndrome is a common issue that vascular surgeons treat. Necrotizing fasciitis is also common. I have also been involved in cases of necrotizing fasciitis and understand the principles of managing necrotizing fasciitis, which include second-look operations to ensure adequacy of debridement.
Do you believe there might have been medical error?
The information is insufficient to be certain. On the initial examination, it seems likely he was heading towards compartment syndrome. However, intact two point discrimination and soft compartments does seem to argue against a compartment syndrome. An exam should have documented the specific finding of 'pain on passive extension' of the digits or lack of this to better ascertain whether the clinician was thinking of compartment syndrome and if they had ruled it out clinically. On return to the ER, there is some very confusing information. He either had a compartment syndrome or not. The findings of emboli and necrotizing fasciitis are either erroneous (and all this was caused by a compartment syndrome) OR they are correct (and are the primary diagnosis and he never had a compartment syndrome). I would be very surprised if he had both a compartment syndrome AND a life threatening infection. I believe there is more to the story than a simple contusion causing compartment syndrome and examination of the notes may show this more clearly.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I believe EITHER a compartment syndrome was missed resulting in necrosis of the limb; OR there was another diagnosis (such as nec fasc) which was missed causing the injury. Other cases like this which I have seen have also involved complete 'red herrings' including IV drug use, burns, lying on the arm for extended periods, etc, which sometimes complicate the situation and completely exonerate the clinicians. Knowing the full circumstances and back story is essential to being able to assign causation.
What makes you a good expert for this case?
I am an academic plastic and hand surgeon. I am a sub-specialist in surgery of the hand and see this type of case routinely in my regular practice. I am an Associate Professor of Surgery at Harvard Medical School.
How often do you encounter cases similar to this one in your practice?
Several times per year. I take call 9 full weeks each year and would see compartment syndrome about half of the weeks I am on call.
Do you believe there might have been medical error?
No steps were taken to do further assessment on this patient : ie this patient should have had a pulse oximeter placed on the finger, gotten admitted and then checked for compartment pressures. Since none of this was done , the standard of care was not followed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In a compartment syndrome , a limb can be salvaged if tissue necrosis has not occurred yet . If measures had been taken it is quite possible that the limb could have been saved.
What makes you a good expert for this case?
I am a medical reviewer for the medical board of California. I board certified in plastic surgery and hand surgery and already do independent reviews.
How often do you encounter cases similar to this one in your practice?
Once or twice a month . I am on call at multiple medical centers and deal with trauma call quite often
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