Leading Trauma Surgeon Discusses Inappropriate Treatment of Compartment Syndrome

Trauma Surgery Expert WitnessThis case involves complications from a foreign body penetration in the patient’s left leg. The penetrating trauma was a result of a fall from his unfinished deck, which resulted in abrasions and bleeding of his left leg. There were also two puncture wounds in the man’s leg, which were suspicious for foreign body penetration. The patient complained of severe pain and thought his leg may have been broken. According to the emergency department medical records, the man’s left leg was swollen and his pain intensity on a 1-10 scale was a 10. The only diagnostic study ordered was an x-ray of the patient’s leg. The x-ray discovered a small focus of potential subcutaneous gas, with no foreign body apparent and no fracture identified. Nevertheless, pieces of wood were eventually found in the patient’s left leg and removed after he developed an infection with associated compartment syndrome.

Question(s) For Expert Witness

  • 1. Do you routinely treat patients similar to the one described in the case?
  • 2. Have you ever had a patient develop the outcome described in the case? What could have been done for the patient to avoid such an outcome?
  • 3. Are findings of "Small focus of potential subcutaneous gas" indicative of any underlying issues given the patient's pain during his initial presentation?

Expert Witness Response E-001709

Although the treatment of these patients can not be described as routine, it is something I have a great deal of familiarity with. Compartment syndrome is a medical emergency that all physicians encountering this patient population need to be able to recognize and either treat or refer on immediately. I have had patients present with this problem and treated them. I have not done an operation that caused compartment syndrome. To avoid compartment syndrome, the compartments need to be released (fasciotomies). I have seen and treated compartment syndrome following fractures, ischemia repercussion injuries in vascular surgery patients, electrical burns, and severe puncture infections like this patient, extravasation injuries, and metabolic disorders like McArdles disease (I treated and have submitted an article on a patient with compartment syndrome to a medical journal in the last month in fact and it is being revised for possible publication). The gas is a finding that may be indicative of many underlying issues, but even in the absence of gas, before that x-ray was done, the 10/10 pain and swollen leg with that mechanism should have led to emergent operative exploration. The gas is additional information but even in its absence I would have taken that patient to the OR for exploration and likely fasciotomy. I know that a “gas gangrene” or a clostridial infection (and other bacteria) can cause this.

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