The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 2

Scientific Articles | February 01, 2005

Documentation of Acute Compartment Syndrome at an Academic Health-Care Center

Brett M. Cascio, MD¹; John H. Wilckens, MD¹; Michael C. Ain, MD¹; Charles Toulson, MD¹; Frank J. Frassica, MD¹

¹ c/o Elaine P. Henze, Medical Editor, Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A672, Baltimore, MD 21224-2780. E-mail address for E.P. Henze: ehenze1@jhmi.edu

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2005 Feb 01;87(2):346-350. doi: 10.2106/JBJS.D.02007

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Abstract

Background: Documentation of the clinical course of a compartment syndrome is critical to effective treatment; however, such documentation often is found to be inadequate.

Methods: Notes and consent forms for thirty consecutive patients with adequate follow-up who had undergone fasciotomy for the treatment of compartment syndrome were reviewed for legibility, notation of the time and date, and documentation of the presence of core physical examination and history findings, including pain, paresthesias, tenseness, pain on passive stretch, sensory deficit, motor deficit, pulses, compartment pressures, and diastolic blood pressure.

Results: Documentation was inadequate for twenty-one patients (70%): the notes and consent forms were not timed or not dated (or both) for nine patients (30%), and the notes were at least partially illegible for sixteen patients (53%). The documentation was incomplete with regard to the presence of paresthesias in eleven patients, pain on passive stretch in ten, sensory deficit in nine, motor deficit in eight, pulses in seven, pain in five, and tenseness in three. The documentation was incomplete with regard to the blood and compartment pressures for sixteen and six patients, respectively.

Conclusions: The documentation of the core history and physical examination findings was inadequate in this series of patients with compartment syndrome. On the basis of the results of this study, and through an organizational systems approach, we have instituted for our residents, nursing staff, and faculty an educational program on the documentation of compartment syndrome in patients who are at risk for this condition.

Figures in this Article

Effective as of July 2003, the Accreditation Council for Graduate Medical Education endorsed six general core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice¹. The Council stated that residency programs must require their residents to develop these competencies in order to become effective practitioners. A thorough knowledge of the patho-physiology of acute compartment syndrome and a systematic approach to the treatment of this condition are important, and residency-program directors could apply elements of each of the core competencies to the education of residents to accomplish the goals of early recognition and treatment. Interpersonal and communication skills are necessary in order to communicate with both patients and other health-care professionals. Written communication is important in the evaluation of patients with compartment syndrome because such patients often require serial examinations so that physicians and nurses can compare a current assessment with a previous one. Thorough documentation, especially in cases of suspected compartment syndrome, can contribute to the identification of subtle changes in the physical examination findings, which may aid in diagnosis.

Documentation recently has been called the common denominator in defense malpractice². In a recent study of orthopaedic malpractice cases, more than one-half of paid closed claims concerned problems with documentation^3,4. In cases of compartment syndrome, adequate documentation can establish the time of development of the compartment syndrome, describe the time-interval to decompression, and reflect the clinician's thought process during the evaluation. In addition, meticulous documentation might aid the clinician in establishing the diagnosis and effecting early treatment.

In our opinion, a possible reason for the widespread lack of proper documentation is a lack of emphasis on careful documentation in medical school, residency, and orthopaedic practice. The purpose of the current study was to examine the adequacy of chart documentation in a series of patients with an acute compartment syndrome who had been managed with fasciotomy at one academic health-care center.

Materials and Methods

Materials and Methods | Results | Discussion | References

Records at two trauma centers associated with one academic health-care center were reviewed, with an institutional review board exemption, to identify patients who had been seen between 1992 and 2002 with diagnoses matching the ICD-9CM codes for compartment syndrome and the Current Procedural Terminology (CPT) codes for fasciotomy. Of the thirty-eight patients who were identified as having undergone emergent fasciotomy for the treatment of acute compartment syndrome, eight patients had inadequate follow-up or unavailable records and were excluded; the remaining thirty patients formed the study group.

The twenty-four adult patients had an average age of 31.6 years (range, twenty to seventy-one years). The average age for the six pediatric patients was 10.8 years (range, four months to seventeen years). The study group included twenty-three male and seven female patients. The most common location of the compartment syndrome was the leg (sixteen patients), and the most common associated injury was a tibial fracture (Table I).

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TABLE I Predisposing Factors

Predisposing Factor	Number of Cases (N = 30)
During postoperative period or after manipulation of extremity with patient under anesthesia	10 (33%)
Intramedullary nailing or external fixation of tibia	3 (10%)
Supracondylar pinning of humerus	1 (3%)
Osteotomy and spica casting of tibia or femur	2 (7%)
Tibial fracture after manipulation	2 (7%)
Intramedullary nailing of femur	1 (3%)
Open reduction and internal fixation of distal part of radius	1 (3%)
Tibial fracture	3 (10%)
Contusion to leg or forearm	5 (17%)
Forearm fracture	3 (10%)
Gunshot wound without fracture	2 (7%)
Vascular occlusion	2 (7%)
Prolonged positioning due to drug overdose	2 (7%)
Prolonged positioning in surgery	2 (7%)
Forearm abscess	1 (3%)
Total	30 (100%)

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TABLE I Predisposing Factors

Predisposing Factor	Number of Cases (N = 30)
During postoperative period or after manipulation of extremity with patient under anesthesia	10 (33%)
Intramedullary nailing or external fixation of tibia	3 (10%)
Supracondylar pinning of humerus	1 (3%)
Osteotomy and spica casting of tibia or femur	2 (7%)
Tibial fracture after manipulation	2 (7%)
Intramedullary nailing of femur	1 (3%)
Open reduction and internal fixation of distal part of radius	1 (3%)
Tibial fracture	3 (10%)
Contusion to leg or forearm	5 (17%)
Forearm fracture	3 (10%)
Gunshot wound without fracture	2 (7%)
Vascular occlusion	2 (7%)
Prolonged positioning due to drug overdose	2 (7%)
Prolonged positioning in surgery	2 (7%)
Forearm abscess	1 (3%)
Total	30 (100%)

Consent forms that had been completed before fasciotomy were evaluated for legibility as well as for notation of the date and time. Physician progress notes were evaluated for legibility and for documentation of ten core physical examination and history findings: pain, paresthesias, pallor, tenseness, pain on passive stretch, sensory deficit, motor deficit, pulses, compartment pressures (measured in one or more compartments for twenty-five patients before fasciotomy), and diastolic blood pressure^5-7.

Results

Materials and Methods | Results | Discussion | References

The thirty patients who had undergone fasciotomy for the treatment of acute compartment syndrome had been followed for an average of fifteen months (range, nine months to five years). Table II provides the frequency of inadequate documentation according to history and physical examination findings. The records for twenty-one (70%) of the thirty patients did not provide full documentation (Table II). When pallor was included, the records for twenty-eight patients (93%) did not provide full documentation. The notes for sixteen patients (53%) were at least partially illegible, and the notes and consent forms for nine patients (30%) were not timed, not dated, or both. In addition, the result of the motor examination was not graded in the notes for four patients, the pulse in the involved limb was compared with that in the contralateral limb in the notes for only three patients, and compartment pressure measurements were recorded in the notes for twenty-seven patients, two of whom had repeat measurements.

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TABLE II Number of Patients with Inadequate Documentation

Core History or Physical Examination Finding	Number of Patients with Inadequate Documentation (N = 30)
Tenseness	3 (10%)
Pain	5 (17%)
Compartment pressures	6 (20%)
Pulses	7 (23%)
Motor examination	8 (27%)
Sensory examination	9 (30%)
Pain on passive stretch	10 (33%)
Paresthesias	11 (37%)
Diastolic blood pressure	16 (53%)
Pallor	28 (93%)
Overall (not including pallor)	21 (70%)

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TABLE II Number of Patients with Inadequate Documentation

Core History or Physical Examination Finding	Number of Patients with Inadequate Documentation (N = 30)
Tenseness	3 (10%)
Pain	5 (17%)
Compartment pressures	6 (20%)
Pulses	7 (23%)
Motor examination	8 (27%)
Sensory examination	9 (30%)
Pain on passive stretch	10 (33%)
Paresthesias	11 (37%)
Diastolic blood pressure	16 (53%)
Pallor	28 (93%)
Overall (not including pallor)	21 (70%)

Ten of the thirty patients had permanent sequelae. Of those ten patients, nine had incomplete documentation in the areas of motor function (five patients); pain on passive stretch or recording of pulses (four patients each); paresthesias, tenseness, or compartment pressures (three patients each); and sensory function or diastolic blood pressure (two patients each). Two of the ten patients had sustained a severe crush injury of the forearm and presented with a nerve injury, presumably secondary to direct trauma rather than to elevated compartment pressures.

Nine of the thirty patients had motor or sensory deficits that resolved after fasciotomy. Two patients had development of reflex sympathetic dystrophy in association with contusions to the leg, and one patient had an amputation after prolonged upper extremity compression secondary to drug overdose.

Discussion

Materials and Methods | Results | Discussion | References

Acute compartment syndrome is a true orthopaedic emergency. Delay in diagnosis or fasciotomy may result in permanent sequelae, including paralysis, numbness, painful dysesthesias, contractures, and (in some patients) loss of the limb. The tolerance of skeletal muscle to complete ischemia is only approximately three to four hours. Experimental studies have shown variable recovery after six hours of ischemia and no recovery after eight hours of total ischemia⁸. As is the case with all clinical conditions, clinicians should evaluate patients in a systematic fashion and should carefully record their findings. A systematic evaluation should include a careful history and physical examination as well as the measurement of compartment pressures, if necessary, to confirm or exclude the diagnosis of compartment syndrome. Because many compartment syndromes evolve over time and are not apparent at the time of presentation, serial physical examinations are critical to the process of recognition and diagnosis. Careful documentation can help the clinician to compare a current examination with a previous one and also can help one health-care provider to compare his or her findings with those of a previous provider.

Compartment pressures are often measured to confirm the clinical suspicion of compartment syndrome. There are both continuous and noncontinuous methods of monitoring compartment pressure, and there are several types of invasive instruments with which to measure pressure. There is no consensus about the ideal measuring device or about the threshold pressure for fasciotomy in each anatomic region. The most widely studied anatomic region has been the lower extremity. Some investigators have recommended that a fasciotomy should be performed if the lower extremity compartment pressures measure >30 mm Hg in a normally perfused patient, whereas others have recommended a threshold of >45 mm Hg^5,9. Other investigators have recommended comparing compartment pressures with the diastolic pressure or mean arterial blood pressure for a more accurate measurement of tissue perfusion^10,11. The currently recommended differential pressure thresholds for fasciotomy are a diastolic pressure of 10 to 30 mm Hg or a mean arterial blood pressure of 30 mm Hg^10,11. One study that examined the use of compartment-pressure monitoring in 116 patients with tibial fractures demonstrated no missed cases of compartment syndrome when a differential pressure of 30 mm Hg was used as the threshold for fasciotomy¹¹. After measurement of the tissue pressure, the clinician may compare it with either the diastolic pressure or the mean arterial pressure. We compared the tissue pressure with the diastolic pressure because we believe that this method is safer (that is, it provides a lower threshold for fasciotomy) and because the threshold for muscle ischemia is measured in relation to the diastolic pressure in most basic-science studies⁸. Both basic-science and clinical studies have shown that muscle ischemia in injured limbs generally occurs when the tissue pressure increases to within 20 to 30 mm Hg of the diastolic pressure¹⁰, and we recommend fasciotomy when the compartment pressure is within 30 mm Hg of the diastolic pressure. It also may be safe to use a tissue-pressure difference of 20 mm Hg⁸.

Recording the compartment and diastolic pressures in the progress notes serves at least two purposes. First, it enables the clinician to establish his or her thought process in choosing either continued observation or fasciotomy. Second, the documentation provides a permanent entry for review in case of future litigation.

According to the compartment syndrome algorithm at this institution, the decision to perform a fasciotomy is based on the clinical picture when the patient is cooperative. In cases in which the diagnosis of compartment syndrome is made clinically or is suspected on the basis of core history and physical examination findings, compartment pressures are measured to confirm the diagnosis while the patient awaits transport to the operating room for immediate fasciotomy. For example, if an at-risk patient has pain out of proportion to the injury, pain on passive stretch, and abnormal neurologic findings, the patient is scheduled for fasciotomy and the tissue pressures are measured while the perioperative preparations are made. In cooperative patients with equivocal physical examination findings, the measurement of compartment pressure is used to guide the clinician in decision-making. If the tissue-pressure measurements are within 30 mm Hg of the diastolic blood pressure, fasciotomy is recommended to the patient. Patients who are unresponsive or who cannot detect pain (secondary to head injury, stroke, or spinal cord injury) undergo measurements of the tissue pressure in injured limbs if the compartments are swollen and tense. Small children present a challenge with regard to their ability to undergo multiple needle sticks, and conscious sedation or even general anesthesia may be necessary in order to measure tissue pressures in these patients. Our protocol is to release all compartments of an anatomic region (for example, the forearm, leg, thigh, foot, etc.) if one of the compartments is involved, as described by Rorabeck¹². Specifically, the two-incision technique is used to release the four compartments of the leg. Occasionally, compartment pressures are measured after fasciotomy in order to verify release.

Our study clearly demonstrated inadequate documentation of the date, time, and core history and physical examination findings for these patients in whom a compartment syndrome had been treated with fasciotomy at an academic health-care center. Documentation of pain on passive stretch, which has been noted to be one of the most sensitive and specific signs of incipient compartment syndrome⁷, was particularly lacking. The recording of diastolic blood pressure at the time of measurement of compartment pressure also was not consistent. Notes and consent forms often were found to be undated or untimed, or both, and often were illegible. Progress notes or informed-consent forms often lacked both the date and time of the entry. Many physicians do not include a detailed patient assessment and plan that accurately reflects the clinician's thought process during decision-making. Poor documentation increases the difficulty of defending malpractice cases, and quality documentation is of the utmost importance^2,4. In addition, this poor level of documentation suggests that patients were not evaluated in a systematic manner.

Of the ten patients with permanent sequelae, nine had inadequate documentation. This finding further highlights the importance of documentation. The present study also underlines the heightened level of suspicion that is demanded when a patient has an altered sensorium. One-third (ten) of the thirty cases of compartment syndrome occurred during the postoperative period or after the manipulation of a fracture with the patient under anesthesia. The combination of an altered sensorium (caused by general or regional anesthesia) and a fracture of sufficient severity to warrant open or closed manipulation creates a scenario in which compartment syndrome may be difficult to detect. It also should be remembered that an altered sensorium secondary to closed head injury or other circumstances also warrants increased vigilance and a lower threshold for invasive monitoring of compartment pressures.

In an academic medical center, patient documentation is reviewed repeatedly by many parties, including physicians (for data on morbidity and mortality rates), educators (for teaching points), investigators (for research material), and, lastly, individuals involved in malpractice claims. In the cases of many patients in the present series, the timeline of care could not be clearly or completely reconstructed, which is often a difficult process even in the presence of complete clinical information.

In the present study, the tool that was used to evaluate documentation was the chart review, which has been shown to be an efficient and effective method for identifying adverse events and for evaluating documentation^13-19. A drawback of the chart review is that it is time-intensive and expensive²⁰. When a chart review has been combined with analysis and action to prevent recurrence of an adverse event, nursing documentation has improved¹⁶ and adverse patient events have decreased²⁰. We believe that this approach also could be used to improve physician documentation, leading to improved patient care.

Our study was limited in that it was essentially a one-center study involving residents and staff from the same institution. In addition, the chart review was conducted only by the first author (B.M.C.), only one emergent surgical problem (compartment syndrome) was included, and only the orthopaedic service was involved. This study was also limited by the fact that eight of the thirty-eight patients had to be excluded because of inadequate follow-up or unavailable records. In this retrospective review, it was difficult to reconstruct the process of decision-making because of the poor quality of the notes. However, the inadequate documentation underlines the need for an organizational approach to improve evaluation and documentation in the care of patients. Simplifying complex medical organizational systems, including reminder checklists and internal crosscheck mechanisms, standardizing evaluation forms and procedures, providing adequate resources, and forming an oversight quality-assurance committee have been shown to lead to a decrease in adverse patient events in an emergency-room setting and could be of benefit in other settings as well²¹.

The evaluation, decision-making, and documentation processes related to the management of patients with compartment syndrome could serve as an excellent model for the development of core competencies in orthopaedic residency education programs. A systematic approach, which would include patient education, a core knowledge base, verbal and written communication skills, and systems-based practices, could facilitate early recognition and full documentation. We have initiated an organizational systems approach to the evaluation of compartment syndrome in order to improve the documentation of this condition and also potentially to decrease the prevalence of adverse events associated with this condition. This approach consists of improved education and simplification of the evaluation process with use of evaluation checklists.

In conclusion, documentation is important for the purposes of patient care, education, and malpractice defense. Documentation was found to be inadequate in the present review of patients with compartment syndrome who had been managed at one teaching institution. On the basis of the results of the present study, and through an organizational systems approach, we have instituted for our residents, nursing staff, and faculty an educational program on the documentation of compartment syndrome in patients who are at risk for this condition. ?

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Topics

compartment syndrome ; pain ; fasciotomy ; health care

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Brett M. Cascio, John H. Wilckens, Michael C. Ain, Charles Toulson, Frank J. Frassica; Documentation of Acute Compartment Syndrome at an Academic Health-Care Center. The Journal of Bone & Joint Surgery. 2005 Feb;87(2):346-350.

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