Compartment syndrome after tibial fracture

In 1982 a 34-year-old heavily built man fractured his right tibia and fibula while playing football. He was taken to the accident department of a nearby hospital where the casualty officer noted that there was a puncture wound on the right calf; the foot was blue and there were no pulses palpable below the knee.

The patient was transferred to the orthopaedic unit of another hospital where he underwent an emergency operation by the orthopaedic registrar, a member of another defence organisation. It was recorded in the operation note that there was marked swelling of the right lower leg and that a fasciotomy of the three compartments of the leg had been performed using multiple small incisions. After the fasciotomy was completed the dorsalis pedis and posterior tibial arteries were still not palpable but the capillary circulation was considered to be "quite good". A traction pin was placed through the calcaneum and the patient was placed on traction.

On the following day the leg was noted to be insensitive below the fracture. The foot was warm, though still rather cyanosed, and the man could move his toes. He was seen by the orthopaedic consultant, a member of the MDU, who decided that no further treatment was then necessary.

During the next few days the patient's toes became less cyanosed and still felt warm but he developed a slight pyrexia so eight days after the injury the consultant decided that further débridement of the leg should be performed. At operation a large collection of blood clot was found between the posterior calf muscles; the posterior tibial artery was found to have been divided and had been ligated, though the tibial nerve was intact. Dead muscle in the posterior compartment was excised. A second anterior incision was made and much muscle necrosis was also found in the anterior compartment and excised. The anterior tibial artery was seen but was not pulsating below the upper third of the leg. The tibia was stabilised with an external fixation device. At the end of the operation it was noted that the circulation of the toes was "quite good".

Three days later the patient was seen by a consultant vascular surgeon, an MDU member, who commented that "despite his horrific fracture the vascularity of the foot seems satisfactory and needs no action taken at this stage". Nevertheless no improvement in the numbness or circulation occurred and the wound was found to be offensive. After discussion with the patient a below knee amputation was performed a few days afterwards.

The claim

Almost two years later the health authority received a solicitors' letter notifying them that the patient was contemplating a claim, and after the records had been disclosed a writ and statement of claim were served. It was alleged that the doctors had failed on three counts; to perform an effective fasciotomy, to monitor the circulation in the leg and to arrange an angiogram. It was claimed that an angiogram should have been performed, that extensive fasciotomy should have been undertaken and that the patient should have been referred to a microsurgeon (sic).

The trial

Both the MDU and the other defence organisation involved decided to defend their respective members and a formidable array of consultant orthopaedic and vascular experts was assembled for the trial, which took place almost seven years after the initial inquiry.

Evidence for the claimant was given by two orthopaedic surgeons and was supplemented by a written report by an associate professor of plastic and hand surgery in the USA. Their opinions differed from each other in several respects: one surgeon maintained that the posterior tibial artery had been severed during the débridement operation, but the other accepted that it had been severed in the original accident; one surgeon criticised the multiple small incisions for the fasciotomy but conceded it was a recognised procedure at the time; the two surgeons said the anterior tibial artery had not been damaged in the accident, but their view was not supported by the American professor. They also expressed the opinion that, as no improvement in the vascular state had occurred 24 hours after the accident, an angiogram should have been arranged with a view to attempting a microvascular repair of the damaged arteries.

This last opinion was strongly refuted by the eminent vascular surgeon called for the defence. He said:

"Arteriograms require movement of the patient. There were not grounds for another fasciotomy. Further interference might have been counterproductive. Collateral circulation was keeping the foot alive. Had I been called I believe I would have heard with a doppler a steady flow of blood and decided not to operate. It would have been almost quixotic to do something else. For a vascular repair the injury must be stable. Further interference has its disadvantages in already delicate limbs. It is my view that this is not routine surgery. I would not have attempted it.".

The judgement

The judge said he preferred the evidence given by the defendants' experts. Referring to the orthopaedic management he quoted the report prepared by the distinguished orthopaedic consultant for the defence.

"Mr ... clearly sustained a very severe fracture. I have no doubt that the posterior medial wound noted on the leg on admission was caused by the distal fragment of the tibia! shaft angulating acutely in a posterior direction and passing through the muscle and out through the skin. I have no doubt that on the way it divided the posterior tibial artery. I have no doubt that extensive soft tissue damage occurred at the time of the injury. The probable mechanism would have been a kick or a blow from another shin on the front of the leg. Mr ...'s momentum would have taken him forwards and his leg would have gone backwards below the break. There would have been acute angulation with associated soft tissue damage. The initial X-ray indicates that there had been a good deal of soft tissue stripping but of course the foot had been placed socially straight before he was brought to casualty. This type of tibial shaft fracture is unfortunately associated on occasion with fairly severe neurovascular damage as was the case here."

The judge said that he was not persuaded that any sensible vascular or microsurgeon would have done a repair because if he had he would not have produced a better situation than today. He thought that the defence's orthopaedic expert was right that the leg was bound to come to amputation. Judgement was given for the defendants but as the claimant was legally aided it was not possible to recover costs.

This guidance was correct at publication 01/01/2002. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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