A Case Example
Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. It develops when swelling or bleeding occurs within a compartment as the fascia does not stretch, and so this causes increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to the muscle and nerve cells is then disrupted which can lead to permanent nerve and muscle damage. Surgery (fasciotomy) is the only treatment for acute compartment syndrome. This involves the muscle compartment being cut open to allow muscle tissue to swell, decrease pressure and restore blood flow.
In this case the patient attended A&E with severe calf pain but without any obvious signs of injury. The pain had suddenly occurred whilst horse riding the day before. The patient could weight bear and move the ankle and toes and did not have ‘pins and needles’. Although various tests were performed and the leg was examined, they were not seen by an orthopaedic specialist but were advised to monitor the situation and see their GP or return to A&E if symptoms got any worse.
Six days later, the patient returned to A&E with considerably worsening symptoms. This time, they were unable to move their ankle and toes, there was considerable swelling on one side of the calf and they were in a lot of pain. They also presented with ‘foot drop’ (where a person drags the foot because muscle weakness means they cannot lift it). These are symptoms that would indicate a strong possibility of compartment syndrome and would need immediate surgery to prevent further deterioration of the nerves and muscles.
Main Learning Points
This was an unusual presentation of compartment syndrome with no obvious sign of injury.
Junior doctors may not be as aware of this condition, but senior A&E doctors certainly should be and able to recognise the signs. It requires immediate surgery to decompress the area before further deterioration of the nerves and muscles occurs.
At the first attendance at A&E, the patient did not display many of the main symptoms of compartment syndrome but if they had been warned of the symptoms to look out for, they would have returned earlier and not waited 6 days, in which time the condition had worsened considerably. It is not a condition that goes away of its own accord.
Whilst symptoms and signs were not those usually found with compartment syndrome, the condition requires a high index of suspicion. A lack of injury would be unusual but any cardinal signs of pain (out of proportion to that expected), pallor, paraesthesia, and paralysis should alert a clinician to the diagnosis. Often the most sensitive early indicator is pain experienced that is out of proportion to an index event. Any additional signs encountered occur with a delayed presentation and are late emerging signs. The patient needs to be made aware of these so they can look out for them.
If there is any index of suspicion patient referral to the orthopaedic team would be mandatory for consideration of urgent fasciotomy. Patients should also be safety netted and advised to return urgently for further review if it is felt compartment syndrome is unlikely as symptoms and signs can emerge over hours.
- At the second attendance, the worsening symptoms strongly indicated compartment syndrome and timely surgical intervention should have taken place.
Reducing the Risk of Litigation
By not referring to an orthopaedics team and marking the case as urgent when clear symptoms of compartment syndrome were indicated, the A&E clinicians fell short of expected standards which leads to enhanced risk of litigation.
TMLEP recommends the following:
In cases of severe muscle pain when engaging in a sport, the possibility of compartment syndrome should be considered, even when there is no obvious sign of injury.
When discharging patients from A&E, advice should be given of the signs and symptoms of compartment syndrome and clear directions to return if symptoms worsen.
- If compartment syndrome is suspected, further review by an orthopaedic specialist, with a view to urgent surgical decompression should be undertaken and marked as urgent.
The possibility of compartment syndrome as a diagnosis should be taken into consideration in patients who have severe muscle pain after partaking in sports. Patients who have suspected compartment syndrome should be made aware of the signs and symptoms to look out for if their symptoms begin to worsen.