Compartment Syndrome in Open Tibial Fractures
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Compartment Syndrome in Open Tibial Fractures, S. Blick, R. Burmback, A. Poka, A. Burgess, N. Ebraheim, The Journal of Bone and Joint Surgery 68A:1348-53 (1986)
The physician must maintain a high index of suspicion to detect a compartment syndrome in the patient who has multiple trauma, as its clinical signs and symptoms may be masked by closed injury of the head or the need for ventilatory support or prolonged anesthesia for other surgical procedures. Compartment syndrome will slow and eventually halt the microvascular delivery of blood to that compartment. The earliest clinical syndrome is the complaint of pain that is out of proportion to the circumstances or injury. Clinical diagnostic signs include tenseness and swelling of the portion of the involved limb, pain when the muscles within the compartment are passively stretched, and decreasing sensory and motor function of the nerves that pass through the involved compartment. The peripheral pulses are usually normal. In a compartment syndrome a total loss of the flow of blood distal to the involved compartment occurs only when the interstitial pressure equals or exceeds the patient’s systolic blood pressure; this usually occurs after the onset of other clinical signs of compartment syndrome.
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Subjective clinical findings depend on a responsive, cooperative patient. Measurements of the pressure in the compartment, which are a useful adjunct to clinical diagnosis in the cooperative patient, assume an even greater importance when the physician is investigating a compartment syndrome in a patient who has sustained multiple trauma. Such a patient may be unable to participate in the subjective clinical diagnosis of compartment syndrome because of prolonged duration of anesthesia that is required for surgical repair of injuries, because of pulmonary insufficiency necessitating extended sedation and ventilatory support, or because of closed intracranial injury. Only tenseness and swelling can be useful for diagnosis of the unconscious patient.
The fact that compartment syndrome occurs after both high energy and low energy fractures supports Matsen’s concept that a compartment syndrome can develop after any injury regardless of its etiology. According to Matsen and Clawson, it is important to measure or re-measure after the fracture has been reduced as restoration of the length of the bone may further increase the pressure in the compartment. Hypotension (either systemic or local, caused by elevation of the limb) can lower the threshold for irreversible injury. The high incidence of hypotension of patients who have sustained multiple trauma also justifies the use of a lower threshold for fasciotomy (30 mm. of mercury).
It is important to risk overtreatment of a borderline compartment syndrome. The risk of complications from fasciotomy is far less than that of the devastating functional loss caused by an undiagnosed, untreated compartment syndrome. Difficulties in management of the wound that are presented by open fractures that require fasciotomy necessitate the use of internal or external fixation. External fixation provides excellent stabilization of bone and soft tissue as well as easy access to the wounds that were caused by the injury and fasciotomy.
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