Negligent Treatment of Tibia Fracture Alleged in Delayed Diagnosis of Compartment Syndrome

Allegation:

The physician assistant negligently applied a long-leg splint which caused the onset of compartment syndrome and subsequent providers failed to diagnose the compartment syndrome.

Case Details

The employment status of this locum tenens physician assistant (PA) was a key factor in the outcome of this malpractice lawsuit.

A two-and-a-half YOF child fell while vacationing several hours from home. When severe pain and a refusal to walk did not subside, the parents took her to a local urgent care center where the insured PA evaluated the patient. Vital signs were stable with pain 8/10 on the FLACC pain scale. The radiology exam noted an acute non-displaced oblique fracture of the distal half of the tibia. The skin was intact but bruised and swollen in the region of the fracture.

The PA placed a long anterior and posterior splint with knee flexion to discourage weight bearing. Splint placement from foot to thigh included stockinet and a fiberglass padded splint formed to the leg. The splint was covered by elastic compression bandages. The toes were exposed to monitor capillary refill and blood flow. Lateral splint reinforcement described as a distal stirrup was applied, and the PA confirmed via finger placement that the splint was not too tight. The parents assert the toes were discolored immediately following the splint placement and comments were made regarding capillary refill that the PA adamantly disputed. In addition, the parents state the patient was in extreme pain which is not consistent with a documented FLACC pain reduction to 4/10 at discharge. A referral to an orthopedic specialist was made and an appointment scheduled for the following day. Discharge instructions included splint maintenance and pain control.

The orthopedic specialist confirmed the diagnosis and, noting a toe down position, removed and placed a short leg cast, split all the way to the skin to allow for swelling. The foot was brought up to near full neutral position. The patient’s skin was intact with good circulation and normal capillary refill. The parents were instructed to follow-up with an orthopedic specialist in three weeks for cast removal and a radiology exam. The parents were further advised to go to the ED if there were changes in the toe color or temperature.

The family remained on vacation three more days and returned home following an approximately 6-hour ride with the child in a car seat. The next day the patient was seen by her pediatrician with complaints of increased swelling and pain, fever, and vomiting. The pediatrician referred the patient to an orthopedic specialist who saw the patient the same day. The orthopedic specialist noted swelling with good capillary refill and opined that the swelling was a result of the long car ride with the leg in a dependent position. The cast remained in place with direction to return in a week for an x-ray and fitting of a boot. Three days later the patient returned to the orthopedic specialist with increased upper leg swelling. The cast was removed with evidence of what appeared to be burns at the ankle and calf. The x-ray revealed good alignment and a short top walking boot was fit. Two days later the patient was admitted to the hospital with a fever and pressure ulcer after experiencing edema, blisters, and tenderness. The patient subsequently underwent emergency surgery for debridement fasciotomies. The operative report diagnosed compartment syndrome with complete ischemia and non-viability of the entire gastrocnemius, soleus, extensors, and tibialis anterior. Notes indicate aseptic necrosis of anterior and posterior compartments. Treatment included antibiotics and a wound vac.

Subsequent care included ongoing physical therapy and surgical repair of an ankle plantar flexion contracture. Over the course of the next three years, the patient improved and participated in soccer, swimming, and ballet. An issue of limb length discrepancy was not significant, and the child is not receiving treatment on a regular basis.

Expert Testimony

The plaintiff’s expert opined that the PA’s application of the splint with a circumferential dressing caused the compartment syndrome. Her opinion was based on the parents’ report that the child was agitated and inconsolable after the application of the splint. However, this was not consistent with medical record documentation regarding pain and patient demeanor. Plaintiff’s expert also faulted subsequent providers alleging they failed to diagnose compartment syndrome in the 24-48 hours following splint application. A subsequent orthopedic specialist provider suggested the splint application contributed to the compartment syndrome.

Defense experts supported the care provided by the PA, finding no issue with the splint application and no evidence to support the family statements that the splint was too tight. Subsequent providers found no evidence of neurovascular compromise which mitigates assignment of blame to the initial treating PA. The defense expert suggests that the long car ride in a dependent position may have played a role in the development of compartment syndrome.

Resolution

The court granted summary judgment for the defendant. The resolution of the case was legally driven by dismissals and appeals. The decision was largely based on the plaintiff action of voluntarily dismissing with prejudice the presumed employer of the PA. The PA had to be an employee of some entity and as the plaintiff had dismissed the employer from the suit, a motion for summary judgment against the PA followed. The court of appeals affirmed the trial court decision and a petition for review was denied by the state Supreme Court.

Risk Reduction Strategies

The defense of this case rested heavily on the documentation. The plaintiff alleged symptoms and behavior that was contrary to documentation in the record. Consider these strategies to mitigate risk:

• Discuss the assessment and treatment plan with the patient or guardians.
• Allow the opportunity for questions and document any discussion and consent, or lack thereof.
• Personalize the documentation to add an element of specificity that supports the discussion that took place.
• Document the treatment steps taken including any resulting safety assessments.
• Facilitate referrals and communicate findings to the physician assuming care.

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