The fun thing about being on call is when you realize you don’t care that this patient has kept you from getting sleep, it’s the coolest case ever!
We had a patient come in just as my resident and I had tidyed everything up, seen and written notes on 3 broken arms, done our post-op checks, and had already said “goodnight, hope we get some sleep..” Just as we were exiting the elevator, the emergency room number pops up 😦 But when I saw the X-ray, that frowny face turned into a smiley face!! (Did I mention I love trauma?)
It was a fracture known as “comminuted” because there were a bunch of fracture lines creating multiple pieces of bone . Because the limb was turned at an obviously weird angle, we gave a mix of fentanyl and propofol for pain control, brought in the fluoro machine ( live x ray vision!) and had our plaster splint on standby. Then we pulled on it to straighten it out, which is known as reducing the bone. Given the past reductions I’d seen, I expected to have to really tug hard to get the pieces back together. Instead, it moved almost too well! I guess when you have bones in that many pieces you don’t have to force it.
The only thing is, I recently saw a patient who had a lot of muscle taken out of his leg after a fracture that led to “compartment syndrome.” When this happens, the swelling gets so bad that you cut off blood supply to a bundle of muscles within that compartment. The fascia and skin create an almost tourniquet-like effect and the muscle can die within 24 hours. Because this new case was so severe and had so much swelling, I was really, really worried that this fracture might progress also. On admission I placed orders for neurovascular checks every 2 hours to make sure there were still pulses and sensation beyond the fracture site but still went to sleep biting my nails…
So, I learned a little bit and was able to expand my knowledge on the classic compartment syndrome’s “pain, pallor, pulselessness, parasthesia, and pain out of proportion” Though the compartments were really tense from all the swelling, it wasn’t compartment syndrome. I hear it’s pretty obvious when you find compartment syndrome on physical exam (the leg/arm will feel like a block of wood. Really!) But it’s scary nonetheless when you see such a severe fracture with so much swelling! I’m glad I had someone there to tell me NOT to do a fasciotomy, if I was in the middle of Afghanistan on my own and this happened to one of my marines….I still would have waited but I’m just glad everything turned out ok today 🙂
… 1 week later…. After I left post-call, I heard that they did end up taking this patient to do a fasciotomy, but no muscle tissue seems to have been compromised. Compartment syndrome is a clinical diagnosis, though you can use a Stryker compartment pressure machine to get actual numbers. This is used more in exercise-induced compartment syndrome because patients will occasionally consent to having long needles inserted into their muscles for this kind of evaluation.
The Inspired Dr.Mom 