54yo male arrived to Hospital #1 by way of a walk-in clinic referral (this is a Level 2 Trauma Center) at 2PM.
A large steel beam fell on the mid right foot (surface was packed dirt). IP was wearing steel toed boots and impingement approximately one minute. Significant swelling to midfoot. X-ray shows multiple displaced fractures and subluxations of the midfoot.
Severe soft tissue swelling. Unable to palpate pulses, however they are present per doppler. Delayed capillary refill noted. ER doc recognizes possible development of compartment syndrome.
XR resulted around 3pm confirming above.
Some time between 3-4PM: ER DOC NOTE ”I have reached out and have called our on-call orthopedic physician due to my concerns for crush injury and compartment syndrome given that he does have pain with dorsiflexion of his toes his foot is tense and swollen any does have loss of 2 point discrimination pulses are however present this does not exclude compartment syndrome. I have attempted to reach out multiple times however did not hear back despite this at and have since spoken to our on-call trauma surgeon. He spoke with orthopedics in the operating room who stated that this is a fracture pattern that is concerning and does need podiatry evaluation. Given we do not have on-call podiatry here they have recommended I transfer the patient out.
PLEASE NOTE: HOSPITAL #1 shows it does have both level 2 trauma, ortho and podiatry available. Unsure why they claimed no podiatry.
4PM ER doc requests transport to Hospital #2. (Later there are claims they attempted multiple other facilities) No call back.
5PM: The ER doctor is relieved by the new provider and told about the case. He was still waiting on a call back.
545pm: Hospital 2 calls back. New ER doc note ”I assumed care of the patient at 1700 pending transfer phone call/acceptance. Discussed case with orthopedic surgeon at (hospital #2) Accepted patient for transfer and discussed case as well with ER physician. I assessed the patient after sign-out still having significant pain after 1 dose of morphine. Ordered IV Dilaudid. Patient has no significant skin changes in comparison to the previous but does have significant swelling. Relatively soft swelling. Reported dopplerable pulses by previous provider. Multiple phone calls made to transfer center to attempt to expedite the patient's transfer/evaluation. Requested med flight to expedite. Patient stable throughout ER stay. Per transfer center, pending shih change with medflight at 2000 for potential flight.”
Note: Only 2 sets of VS done during stay at Hospital #1 (2pm and 8pm).
850pm TXP to Hospital #2 (almost 9 hours post injury)
Hospitalist from Hospital #2: “They called several hospitals in order to try and find someone to evaluate him for a compartment syndrome and apparently they were turned down by many hospitals, which were only 15 minutes away declined to pick up the phone. He reached out to us for this emergent concern here 8 hours after the initial injury and we accepted to evaluate him for compartment syndrome, so he was life-flighted here essentially 12 hours later from the injury and scheduled for surgery as he has significant swelling of his foot and enough pain and pressure to warrant an emergent fasciotomy of the right foot as the medial and dorsal side of his foot has exquisite pain more so than the lateral side.”
Emergent right foot compartment fasciotomies by Ortho surgeon at 2am.
Ortho Surgeon note: “I had a long discussion with him concerning the delayed surgery as it was between 12-13 hours prior to the injury that the surgery was performed, and if he has a significant compartment syndrome early on at, there may already be irreversible damage, but as he has significant pain, intense pressure he was feeling in his foot, the decision to release the compartments seemed to be the best decision”
His post-op was unremarkable.
Since then, ortho follow-up. Multiple complications: Nerve damage to foot, cannot walk without cane/walked/orthopedic boot, cannot work, continuous pain and swelling, still doing PT.
You have multiple aspects of this case that we'll be exploring. In concern to this review, we believe that orthopedic surgery at hospital #1 should have taken a more proactive and aggressive role in the management of this patient and not delayed treatment/intervention. Was podiatry necessary prior to ortho eval/intervention?
There's also a concern that the patient should never have been transported to a different facility.
We have attached screenshots of multiple XRs just after the injury.
Thank you in advance.
Files:
No questions yet!
Do you believe there might have been medical error?
The Emergency Department physician documents an exam which is concerning for active compartment syndrome. This is a surgical emergency. The on-call orthopedic surgeon should either have evaluated the patient personally or confirmed that another capable surgeon was going to do this in a timely fashion. Call at a Level 2 Trauma center involves seeing an evaluating acute surgical problems such as compartment syndrome. The mechanism of injury and associated fractures are highly concerning for compartment syndrome, and the documentation looks rather clear that it was occurring, and was appropriately recognized by the ED physician.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient would likely have had a mediocre outcome at best, regardless, as this is a severe injury, but the outcome was likely worsened by the delayed treatment of compartment syndrome. It will be difficult to prove exactly how much of the injury was due to delay in treatment versus the initial traumatic injury. However, there is clearly some element of damage from the delay in fasciotomy.
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon with experience encompassing working at Level 1 trauma centers for multiple years and caring for acute compartment syndrome cases.
How often do you encounter cases similar to this one in your practice?
I see acute compartment syndrome and complications from it at least several times per year.
Do you believe there might have been medical error?
it is possible there was a delay in treatment of a compartment syndrome. however, the treatment of the latter is controversial. In fact, some surgeons argue that the fasciotomy of a foot compartment syndrome will result in more issues than to let the compartment syndrome run its course. It may be easier to treat the sequelae of a compartment syndrome than to treat it acutely
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
acute treatment of the compartment syndrome would likely result in more foot issues than if left untreated
What makes you a good expert for this case?
chief of orthopedic surgery director of foot and ankle surgery associate professor at Columbia university I specialize in severe deformities, including those resulting from compartment syndromes
How often do you encounter cases similar to this one in your practice?
these are rare injuries. I see 1-2/year
Do you believe there might have been medical error?
If compartment syndrome is even suspected pressures should have been taken of the compartments ASAP. Compartment syndrome is one of the few orthopedic emergencies.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Diagnosis and Management of Acute Compartment Syndrome Osborn, Patrick M. MD; Schmidt, Andrew H. MD Author Information Journal of the American Academy of Orthopaedic Surgeons 29(5):p 183-188, March 1, 2021. | DOI: 10.5435/JAAOS-D-19-00858 In this case there is causation for a medical error that has resulted in permanent injury to the patient's foot
What makes you a good expert for this case?
I have been practicing general orthopedics for over 25 years. I have seen and treated compartment syndrome over the years.
How often do you encounter cases similar to this one in your practice?
This is not a common complication and or diagnosis. But when it is even suspected compartment pressures and frequent physical exams must be performed to avoid permanent complications.
Do you believe there might have been medical error?
Timing of response and ultimate fasciotomy with sequela. The X-rays are unimpressive but there is a clinical suspicion requiring examination and response. No obvious intervention in ER (Ice, toradol)
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The role of foot fasciotomy is somewhat controversial and nuanced so it would depend somewhat on the symptoms and severity. more often than not, with a foot compartment in the presence or absence of fasciotomy, there may be long term residual symptoms. The findings and management of the fasciotomy will be important
What makes you a good expert for this case?
I am an orthopedic lower extremity trauma surgeon...I see this frequently
How often do you encounter cases similar to this one in your practice?
Frequently. I am the ortho chair and have been in charge of trauma and trauma call over 15 years.
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