Open Tib/Fib Fracture [Compartment Syndrome]
Case #191
A 40-year-old pregnant woman at 32 weeks gestation was walking in her neighborhood.
A car suddenly jumped the curb and she was pinned underneath the vehicle.
EMS responded and she was taken to a nearby trauma center.
X-rays confirmed an open tib/fib fracture.
Ortho took her to the OR for intramedullary fixation of the left tibia, and irrigation/debridement of the gaping soft tissue wound.
Fasciotomies of the anterior and lateral compartments were performed.
On day 6 of hospitalization, ortho was rounding and took down her splint.
Dr. L (ortho attending) inspected the leg, was satisfied with her progress, and she was re-splinted.
Over the next few hours, her pain steadily increased.
By midnight, she was in 10/10 pain, and neither her scheduled nor PRN pain medications were helping.
Around 2am, Dr. C (ortho resident) came to the bedside to assess her.
He ordered a DVT US, which was completed and read as negative within 2 hours.
Dr. C went back and assessed her at 4am.
She still had severe pain.
He took off her splint. She had normal pulses and capillary refill.
Given the obvious concern for compartment syndrome, he called Dr. L.
Dr. L recommended giving additional pain medication.
During the day, the patient was seen by multiple ortho residents.
By afternoon they decided she had compartment syndrome.
Her compartments were tense and measured pressures were reportedly elevated.
She was taken to the OR for fasciotomies.
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The patient had a long recovery and required skin and muscle grafts.
Her left leg is permanently disabled and she had a poor cosmetic outcome.
She filed a lawsuit alleging that a four compartment fasciotomy should have been done initially, and that ortho was too slow taking her back to the OR once she developed compartment syndrome.
They sued the ortho attending (Dr. L), the ortho resident who was caring for her when she developed compartment syndrome (Dr. C), and the hospital.
An expert witness was hired:
The plaintiffs also hired a plastic surgeon:
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The defense hired multiple experts including this orthopedic surgeon:
The plaintiff offered to settle the lawsuit for $12,000,000.
The defense refused this offer.
The two sides were unable to reach a settlement before trial.
As the trial approached, the defense asked the judge to block any mention of Dr. L’s other legal issues.
He faced criminal charges for accidentally shooting and killing an ortho rep.
They had gotten drinks at a restaurant and gone back to Dr. L’s house, where they were handling several handguns for fun.
Dr. L did not realize one of the guns was loaded, and shot the ortho rep in the chest, killing him.
Dr. L’s criminal charges (and not guilty verdict) were not mentioned during the malpractice trial.
Before trial, the plaintiffs decided to drop Dr. C and the hospital from the lawsuit.
Dr. L was left as the sole defendant.
After a multi-day trial, the jury returned a verdict for the defense.
MedMalReviewer Analysis:
The plaintiff never had a strong case. Her disabling injuries were clearly caused by the car accident itself. It was a huge stretch to ask the jury to differentiate between the injury from the accident and disability caused by the alleged negligence. Even if Dr. L had done a 4-compartment fasciotomy initially, she still would have had an undesirable outcome.
The first plaintiff witness made sure to announce in his expert opinion that he is “known as a premier provider for orthopedic care” and went to a “premiere medical school”. Stating your credential is appropriate in an expert opinion letter, but doing so in such a pompous manner is a dead giveaway for a massive ego problem. The fact that he misspelled “premier” as “premiere” while flaunting his education and intelligence is ironic.
This case illustrates the challenges in diagnosing compartment syndrome. The key finding is severe pain that is uncontrolled by analgesics. If you wait for the classic findings of pulselessness, palor and paralysis, it’s probably too late.
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This was an interesting read because it's one of the few cases that made it to trial (but I suppose I can see why given the plaintiff's weak case and ridiculous ask).
Have to say, your second analysis point was my first thought. I'm sure the plaintiff's expert is a qualified and well-regarded orthopedic surgeon, but his opinion's preamble makes him sound like a pompous blowhard (sorry to borrow your word, but "pompous" was literally my first thought). I wonder if that attitude came out at trial and alienated the jury from any strained argument the plaintiff might otherwise have.
Unknown to me is if the fasciotomies were sub cutaneous or was the skin left open. In high energy trauma the skin itself can limit tissue perfusion at the arteriolar level. and with continued swelling, tissue pressure will be elevated. Why a 4 compartment procedure was not performed as well is unknown. Unknown to me was why the resident/attending did not perform tissue pressure assessment with a device such as the QuickStick or its equivalent as described historically by Whitesides.