Undiagnosed Compartment Syndrome Causes Residual Nerve Pain

Allegation 

The orthopedic surgeon and orthopedic nurse practitioners failed to timely diagnose and treat compartment syndrome leading to residual nerve pain in her leg.

The Case

A 60 YOF (5’7”, 180 lbs.) underwent a right total knee replacement surgery performed by the orthopedic surgeon. The patient had undergone a left knee replacement by another surgeon four years prior. She was on several medications, including warfarin with her goal INR of 2.5-3.5.

On the first post-op day, the patient was seen by the orthopedic surgeon and an orthopedic nurse practitioner (NP1). Her labs were Hgb 10.4, HCT 32, and INR 1.3. The physical examination revealed soft compartments and no calf tenderness. The patient was due to be discharged if she cleared physical therapy (PT) and her pain was better. The patient was seen later in the day by a second orthopedic nurse practitioner (NP2) who noted that the patient reported 10/10 pain and refused to attend afternoon PT due to pain.

On post-op day two, the patient reported right calf pain to a third orthopedic nurse practitioner (NP3). The patient refused to participate in PT due to pain. Other exam results were WNL.

On post-op day three, the patient was seen again by NP3 and complained of pain 7/10. NP3 ordered an ultrasound of her right upper leg which showed no evidence of DVT. She texted the orthopedic surgeon who proceeded to disparage the patient in a series of text messages.

In the morning on post-op day four, the patient was seen by a fourth orthopedic nurse practitioner (NP4). NP4 noted the patient was up in her chair and reporting pain. Labs were Hgb 8.0, HCT 24 and INR 1.9. Examination revealed intact sensation in all extremities, brisk capillary refill in toes, palpable pulses, and no calf pain. She noted the patient was to be going home and declined a skilled nursing facility transfer. That same day, the patient was also seen by PT and OT and noted pain 8/10 and the patient requested a pillow under the knee. The patient refused PT due to pain in her foot.

Mid-afternoon on post-op day four, the patient’s nurse noted the patient complained of right leg edema and pain and numbness in her toes. Examination revealed RLE with moderate edema, capillary refill less than 3 seconds, bounding pedal pulse, and sensation of numbness that decreased after the TED stocking was removed. The nurse noted that she reviewed the case with NP4. An hour later, the nurse noted the patient wanted her pain better under control before discharge. She noted she contacted NP4 and the joint care liaison nurse.

The joint care liaison nurse examined the patient and noted moderate edema from the calf through the ankle and pedal pulse present. The patient reported numbness and tingling in her right great and pinky toes, and she only minimally wiggled them due to pain. The joint care liaison nurse noted she contacted NP4 who then spoke to the orthopedic surgeon who said the patient should elevate her leg above her heart and use ice and to continue with discharge plans. The orthopedic surgeon later denied that he was told about the patient’s pain, only that she was refusing discharge. This conversation was not documented.

A fifth nurse practitioner (NP5) on the hospitalist service noted the patient was in pain and refused discharge. Exam found RLE with moderate edema, 2+ pedal pulses, very tight. A stat H&H revealed Hgb 7.7 and HCT 23. She noted if the patient continued to have pain they should consider a CT to rule out a hematoma. She also noted the patient’s nurse would update the orthopedic surgeon. The nurse contacted the orthopedic practice and informed NP1 that the patient was refusing discharge. NP1 then contacted NP4 and advised that the patient was refusing to leave due to pain and swelling. NP4 texted the orthopedic surgeon and advised him that the patient would not leave. None of the contents of the text conversations were documented in the medical record.

Later in the evening, the patient was sitting up in bed, talking and calm, beginning to eat and reporting the IV morphine might be enough to break the pain. A half hour later, however, the nurse noted the patient was moaning and her pain was 10/10. Approximately two hours later, the patient received oxycodone 15 mg followed by morphine 4 mg IV two hours after the oxycodone.

Several hours later, early in the morning of post-op day five, the patient received oxycodone 15 mg. An hour later, the patient received morphine 4 mg IV reducing the patient’s pain to 8/10. Within an hour, the nurse noted the patient was moaning loudly, complaining of 10/10 pain around the ankle and calf. The patient’s INR was 2.4. The patient received oxycodone 15 mg. The nurse notified the orthopedic surgeon of the patient’s pain and swollen calf and ankle. Shortly thereafter, NP4 and the orthopedic surgeon exchanged text messages complaining about the patient and discounting her complaints of pain.

Although the visit was not documented, the orthopedic surgeon did examine the patient later in the morning of post-op day five and diagnosed compartment syndrome. He took the patient to surgery and performed an emergent four compartment fasciotomy of the right leg. He noted all four compartments were full with tense posterior compartments. Upon opening the deep fascia, he noted a hematoma within the gastrocnemius in the superficial compartment but not in the deep posterior compartment which was evacuated. He also noted viable muscle in the anterior compartment and the lateral compartment.

Two weeks later the patient underwent a split thickness graft of the right leg. The patient was discharged to a skilled nursing facility for rehabilitation. She eventually saw a neurologist and complained of an electric shock feeling in her leg and stabbing pain in her right foot.

Expert Testimony

The plaintiff’s expert testified that the compartment syndrome should have been diagnosed on post-op day four. If the patient had undergone surgery on that day, she would not have the residual nerve damage. The defense expert testified that the window for symptoms of compartment syndrome to exist without causing damage is about six hours. The fact that there was no finding of non-viable tissue at the time of the surgery indicated that the surgery was performed timely and appropriately.

Resolution

Due to miscommunication among multiple providers, a lack of continuity of care, and the poor optics of the disparaging text messages, the case was settled.

Risk Reduction Strategies

Establish sound and consistent methods for communication between physicians and advanced practice professionals.

Thoroughly document all pertinent clinical information, including conversations between healthcare providers. Develop a system to ensure that all text messages that are used for clinical decision-making are automatically preserved in the medical record.

Text messages and other electronic communication should be objective, pertinent, and concise. Do not send messages that reflect unprofessionalism.

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