My Toughest Case: Fixing A Rare Emergency Muscle Disorder

New York Magazine—June 6, 2010

As part of New York Magazine “Best Doctors” issue, a feature article highlights the work of a select group of physicians recalling their toughest cases in their career.  Dr. Austin Fragomen of the Limb Lengthening and Reconstruction Service provides a first-hand account of a challenging case he handled early in his career at Hospital for Special Surgery.

I was in the office seeing patients when my secretary told me I had a phone call from the operating room. The chief of our department was about to start a surgery but had just been informed that another patient of his was having a complication on the floor. He asked me to take over.

The patient was a young woman who had been operated on two days earlier to correct a congenital deformity that made it difficult for her to walk. The chief had straightened one of her legs and was going to do the other leg later. Everything had gone well, but now she was having a problem. We suspected something called compartment syndrome—basically, a massive swelling of muscles in the leg. There are four compartments in the leg, each containing a major muscle group. Each compartment is defined by its fascia, the thin white sheaf of tissue that separates muscles from skin and bone. When a muscle swells, it can squish the nearby nerves and artery, and at some point, it can’t swell anymore because the fascia locks it in. In compartment syndrome, the swelling gets so severe that it strangles the muscles. In rare cases, amputation is necessary.

Once compartment syndrome starts, you have about eight hours to open the fascia so the muscle can expand. But in most cases, no one knows when the clock starts, because the signs are subtle. There may be some numbness in the foot. Or a bit more pain than usual. But the patient is already in pain, and the leg is already swollen—they just had surgery. So the symptoms are hard to notice.

Compartment syndrome is rare, so we needed to determine that this wasn’t a false alarm. We poked a needle into the muscle to measure the pressure. Normally it’s less than ten on the scale we use. Hers was 80. Her muscle was definitely getting squished, but we didn’t know how long that had been going on. Given the high pressure reading, maybe we were in the sixth hour. Maybe the eighth. There aren’t many true emergencies in orthopedics, but this was one of them.

I was nervous: This wasn’t my patient, and I felt like I was jumping on a hand grenade. It was under an hour from the time I met her to the time we got in the operating room. Because the patient had already had a little breakfast, the anesthesiologist had to use a special tactic for trauma patients called rapid-sequence intubation. It means you knock them out very quickly to avoid a gag reflex, but it’s a little more dangerous than general anesthesia. So that added to the tension.

The patient was out within two minutes of entering the operating room. We prepped her leg, cut the skin, and got into the fascial layer. As soon as I opened the fascia, the muscle bulged out of this narrow opening at twice its normal size. It was pink, and contracted when I poked it. It bled when I made a small cut in it. It was viable, healthy muscle. We had caught it in time, with no permanent damage. Just then, the chief came in; he was relieved.

Six weeks later, the patient went through with the surgery on her other leg. We determined that she had a congenital narrowing of her muscle compartment that made her predisposed to the condition, so for the second leg, the compartment release was done prophylactically. Now her legs are totally straight and looking great.

Read the full article at nymag.com.