Escalating Postsurgical Pain Not Addressed

OUTCOME
A $14,891,123.02 verdict was returned.

COMMENT
Many clinical situations can lead to compartment syndrome, including sources inside the limb (fractures) or outside the limb (burns), as well as patient factors in the setting of seemingly trivial trauma (bleeding diathesis/anticoagulation therapy). In any practice setting where limbs are crushed, fractured, surgically manipulated, splinted, burned, or compressed, compartment syndrome may occur. Clinicians working in ambulatory or surgical settings should routinely alert patients to the possibility of this complication, and they must remain vigilant for patient reports of intense or escalating limb pain.

In a typical case of compartment syndrome, blood accumulates in a closed space (compartment) of an extremity, raising pressure sufficient to cause ischemia, followed by nerve damage and muscle necrosis. The classic diagnostic findings include pain, pallor, “pulselessness,” and paralysis (the “four Ps”). Disproportional pain (at times refractory to narcotic analgesia) is the earliest indicator of compartment syndrome. Pain is often described as deep, unremitting, and poorly localized; stretching of the muscle group within the compartment also worsens pain. 

Malpractice cases involving missed compartment syndrome often result in a substantial verdict. This is so because patients are often young, and limb damage is severe—possibly including muscle loss, paralysis, or debilitating ischemic contracture. Fasciotomy is a relatively straightforward, curative treatment, but by the time it is performed, substantial damage may have been done.

To make matters worse, many causes of compartment syndrome are iatrogenic (eg, casting, surgery, instrumentation of a limb in an anticoagulated patient), which can compound the jury’s wrath. Lastly, the plaintiff’s lawyer can paint a vivid picture in which the limb is filling, time is ticking, the patient is screaming, damage is mounting—yet nothing is done. The jury is easily able to understand the elevating pressure in the limb, see the connection between the pressure and the damage, and recognize that a surgical release would have cured the problem. So guided, the jury can become incensed that the limb was allowed to “implode,” seriously degrading a patient’s life—as exemplified by the substantial verdict in favor of this unfortunate 19-year-old woman.

In any injury or intervention involving a limb, instruct the patient to return in the event of intense escalating pain. Exercise caution when the demand for analgesics seems high, escalating, or unduly urgent, or when pain is difficult to control. If compartment syndrome is suspected, compartment pressure measurements should be obtained promptly. —DML