CASE STUDY #2: Orthopedic Case Gone Wrong Compartment syndrome leads to permanent disability. Could anchoring bias be involved? ( 12 ) A patient had surgery to repair a fractured tibia/fibula and was discharged home the next day. The patient returned to the ED on post-op day three with severe pain, fever, and numbness throughout the foot and leg. A PA examined the patient and immediately suspected compartment syndrome. The consulting orthopedic surgeon, who did not physically examine the patient, concluded via text message communication that the patient had cellulitis. The same orthopedic surgeon arrived four hours later to examine the patient and still concluded that the patient had cellulitis. Later that night, the patient developed increasing pain and numbness and was taken to surgery. A fasciotomy was performed revealing dusky muscle from compartment syndrome and peroneal nerve palsy. This young patient suffered necrosis of the entire anterior compartment of his lower leg requiring multiple surgeries and permanent disability. | HIDDEN IN PLAIN SIGHT | Exposing the Drivers of Diagnostic Error A DOSE OF INSIGHT ® Coverys |