$3.5 Million Settlement For Client Who Suffered Compartment Syndrome And Transtibial Amputation
Client, a 20 year-old young man with a history of muscular dystrophy, underwent vulpius heel cord lengthening surgery and a right midfoot osteotomy with staple fixation at a leading Boston hospital. Tourniquet time during the surgery substantially exceeded the time limits set by hospital policy. Following the surgery, the attending surgeon casted Client’s leg and admitted Client to the hospital for monitoring.
On the day after the surgery, Client experienced calf spasms and extreme pain under his cast, which Client rated a 12 on a scale of 1 to 10. The attending surgeon attributed Client’s pain to the surgery and a wearing off of the nerve block. He increased Client’s pain medication and the nerve block without first performing or investigating a differential diagnosis of Client’s pain.
Later the same evening, Client again complained of extreme pain (14/10) under his cast, even though he was receiving increased pain medication and additional nerve block. The nurses appropriately paged the orthopedic resident and the pain team, but the orthopedic resident failed to visit Client in response to the page. Moreover, there was no evaluation of Client’s leg under the cast or any loosening or removal of the cast. Rather, the hospital’s pain team, in the absence of the orthopedic team, made the treatment decision to leave Client’s leg and cast alone, and increase further Client’s pain medications and nerve block.
The following morning, after the pain team removed the nerve block, Client complained of loss of sensation in his right toes, and his foot was noted to be cooler than his left foot. The attending surgeon cut off Client’s cast. For thirty minutes after the cast was cut off, Client experienced inconsolable pain with significant muscle spasms. Nevertheless, the attending surgeon did not order imaging of Client’s leg or undertake any other investigation of the etiology of Client’s extreme pain.
In discovery, we learned that after Client’s first episode of extreme pain a staff member alerted the attending surgeon to possible etiologies of the pain other than normal pain from the surgery, including compartment syndrome. Compartment syndrome is a condition in which increased pressure within a limited space compromises the circulation and function of tissues within that space. Common causes of compartment syndrome include bleeding from vascular injuries or from cancellous bone following fractures or osteotomies and tight casts that reduce the compartment size or volume. Unchecked compartment syndrome leads to catastrophic results, including loss of limb. The most important step in diagnosing a compartment syndrome is being aware of it as a potential complication and performing appropriate clinical evaluation of the patient’s complaints. Severe pain out of proportion to the injury, pain on passive stretch of the affected muscle compartment, tenseness of the affected compartment, altered sensation and circulation, are all clinical findings of compartment syndrome.
We claimed that when Client first complained of extreme pain, and the staff alerted the attending surgeon to the possibility of compartment syndrome, the surgeon should have considered compartment syndrome as a potential complication and performed an appropriate clinical evaluation of Client’s complaints, particularly in light of the extensive amount of time Client’s leg had been tourniqueted during the surgery. We claimed the surgeon should have removed Client’s cast and examined Client’s leg for signs of compartment syndrome, including whether Client experienced pain in the compartments on passive stretch and whether there was any tenseness in the compartments under the cast. Unfortunately, even after the third episode of extreme pain, there is no indication in the record that the attending surgeon was suspicious for compartment syndrome, or that he evaluated Client for compartment syndrome or took any steps to rule out the condition or treat Client urgently. It was not until Client was transferred several hours after the third episode of pain to another Boston hospital for urgent vascular care that Client was diagnosed with and treated for compartment syndrome. Client underwent several operations to try to save his foot and leg, but unfortunately the diagnosis and surgeries came too late and Client’s leg eventually was amputated just below the knee.
The attending surgeon maintained in the litigation that Client’s pain was not unusual given the nature and extent of Client’s surgery, that he loosened Client’s bi-valved cast in response to the first episode of pain, that Client showed no signs of compartment syndrome, that the nerve block confounded a proper analysis of Client’s complaints, and that Client suffered subtherapeutic anticoagulation and an underlying vascular disorder that caused the problems with Client’s right foot.
We settled Client’s claims and his mother’s loss of consortium claim for $3.5 million.