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Recognition of compartment syndrome | Signal

Reference number
1140 C
Issue date27 November 2009
TypeSignal

This Signal relates to problems in delayed diagnosis and treatment of compartment syndrome (especially post-surgery) which have led to amputation.

 

Compartment syndrome is a rare problem which happens due to increased pressure within a confined space (compartment) and occurs most commonly below the knee or elbow. This can be caused by inflammation and swelling or bleeding after surgery, injury or repetitive muscle use. It also may occur following prolonged abnormal positioning, such as lithiotomy.

 

Without prompt surgical treatment by fasciotomy, it may lead to neurovascular damage and muscle death and has resulted in amputations.

 

Extract from a typical incident report reads:

 

"The patient was admitted under the care of consultant surgeon for left total knee replacement. This procedure was carried out on [Day 1]. Following this procedure the patient was complaining of loss of sensation and a vascular review was requested on [Day 3]. The vascular registrar reviewed the patient on [Day 3] and felt that nothing needed to be done urgently as pulses could be felt. The patient had also had a nerve block during surgery and this could have been another explanation for the loss of sensation. The consultant reviewed the patient again on [Day 5] and asked for an urgent vascular consultation. An arterial duplex showed an occlusion and the patient was taken to theatre immediately for a fasciotomy due to compartment syndrome under the care of vascular consultant on [Day 5]. This lady was taken back to theatre on [Day 8] for wound inspection and it was felt that there was no improvement. This lady was brought back to [name] Ward following this procedure and was informed that she required an above knee amputation procedure which was done on [Day 9]."


 
After reviewing a trigger incident following knee replacement surgery, the incident database was scanned.

 

Fifty-nine relevant incidents were identified over four years. Four patients suffered severe harm: mid-arm amputation; above knee amputation; significant necrosis of anterior thigh muscles; and foot drop due to nerve damage. Two patients needed further surgery. Incidents were reported from surgical specialties, medical specialties and A&E.

 

Learning from these incidents included:

 

  • problems in delayed diagnosis, which included missed symptoms by nursing and junior medical staff
  • problems in accessing diagnostic equipment such as Doppler scans
  • wrong diagnosis, for example deep vein thrombosis (DVT) or sprained ankle
  • delay in treatment and inappropriate management, for example patients transferred to general wards post-operatively for general nursing care without specialist skills or awareness of warning signs
  • lack of clarity regrading best treatment, such as conservative or surgical.  

 

This is a rare syndrome which evidence suggests can be difficult to detect. Organisations may want to remind staff of potential signs and consider appropriate pressure relieving devices, where appropriate, as well as the need for careful positioning of patients to minimise harm. 

 

Relevant to:  Emergency medicine, surgery, general medicine.

 


 

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