Safety of care
Well-limb compartment syndrome
An article for physicians by physicians
Originally published September 2005 / Revised September 2008
Although most physicians are aware of the possibility of compartment syndrome following trauma to a limb, it may occur in other situations.
Of interest to physicians doing surgeries
The diagnosis of acute compartment syndrome is often a challenge for health care professionals and can elude even the most astute clinicians. This is despite the fact that the majority of physicians involved in treating lower extremity injuries are aware of the possibility of this serious clinical entity in obvious trauma situations.
A recent review of the CMPA's closed legal files reveals a less-recognized area of concern known as well-limb compartment syndrome. Well-limb compartment syndrome secondary to surgical positioning associated with the lithotomy or semi-lithotomy position, although known and recognized in the literature, is also an area of litigation for CMPA members. This syndrome can develop as a result of positioning the patient for gynaecological, general, plastic, orthopaedic and other surgical procedures that require support for the lower extremities (e.g., leg holders and various types of stirrups).
A 50-year-old menopausal, obese woman with complaints of incontinence, dysuria and episodes of enuresis was referred to a gynaecologist. A physical examination of the woman demonstrated a Grade III cystocele and a Grade III uterine and posterior vaginal wall prolapse with a left ovarian mass which was confirmed by a pelvic ultrasound. The gynaecologist recommended surgical excision to rule out malignancy.
The procedure was performed with the patient positioned in the lithotomy position (hyperflexion of the hips) with stirrups, and TED stockings on both lower extremities. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, followed by a Burch suspension, was performed. Right-sided pelvic bleeding was encountered. Venous clips were applied and the bleeding was controlled. The procedure lasted more than six hours and the patient required intraoperative blood transfusions.
After the procedure, the patient was transferred to the intensive care unit (ICU) for monitoring. She complained of abdominal and pelvic pain. The epidural infusion rate was increased. She complained of bilateral leg pain through the night. Early the following morning she was assessed again; she was complaining of pain in the calf area and of generalized abdominal pain.
Later, on the first postoperative day, the pain in her legs became severe. The ICU physician assessed her; her calves were tense with decreased sensation on the dorsum of the left foot. An orthopaedic surgeon then assessed the patient urgently and confirmed a diagnosis of bilateral compartment syndrome. The patient was taken to the operating room and had fasciotomies of both legs. The wounds were closed four days later. She was left with a foot drop on the left side and limitations in mobility.
The bottom line
- Well-limb compartment syndrome has been associated with prolonged surgical procedures with non-anatomical positioning of the lower extremities.
- The syndrome is a potential cause of injury to patients.
- To manage the risk, consider:
- Is this patient at higher risk of this complication for any reason?
- Is positioning appropriate?
- Is padding adequate?
- Are there any particular post-operative management issues?