this case is
to help physicians practice safe medicine. An attempt has been made
to make the material less easy to identify. If you recognize your
own claim, please be assured it is presented solely to emphasize the
issues of the case.
Presentation
A 16-year-old girl was brought to the emergency department
(ED) after sustaining an injury to her leg while playing soccer.
X-rays revealed a right bimalleolar ankle fracture dislocation.
Physician action
An emergency medicine physician evaluated the patient,
attempted a closed reduction of the fracture, and applied a splint.
Post-reduction x-rays still showed displacement of the fracture.
The following day, Orthopedic Surgeon A reviewed the x-rays
and recommended surgical intervention to openly reduce and stabilize
the fracture with internal fixation hardware. The potential risks
and complications of the surgery were discussed with the patient and
her mother. They agreed to proceed with surgery.
Intravenous antibiotic prophylaxis was administered just
before the surgery. An open reduction internal fixation of the left
ankle fracture was performed including placement of a syndesmosis
screw to restore and maintain a repair of the distal tibiofibular
syndesmosis. Post-operative x-rays showed a satisfactory reduction
of the fractures. The patient had an uncomplicated postoperative
recovery and was discharged two days after surgery. She was sent
home with a prescription for oral antibiotics.
In the early postoperative period Orthopedic Surgeon A
followed the patient closely for concerns of wound healing and
treatment of blistering on the medial aspect of the ankle.
During an office visit three months after the surgery, it
was noted that the patient had been experiencing low-grade fevers
since discharge from the hospital, even though she had been taking
antibiotics. She was referred to a plastic surgeon for further
evaluation and management of the wound. The plastic surgeon noted
dark skin along the medial aspect of the ankle, some fracture
blistering along the posterior aspect of the ankle, and minimal
erythema of the foot. The patient was instructed to continue taking
the antibiotics and return for a follow up visit in three days.
Over the next two months, the patient was seen by the
plastic surgeon on 10 occasions for treatment of fracture blistering
and concerns about wound healing on the medial aspect of the ankle.
The plastic surgeon performed incision and drainage of the wound
with debridement and the placement of a flap. The syndesmosis screw
was removed during this procedure. The patient remained in the
hospital on intravenous antibiotics. Four days later, she was
discharged with a prescription and instructions to take oral
antibiotics.
The patient returned to see the plastic surgeon five days
later due to the eruption of a blister on the skin graft. Three days
later, the plastic surgeon received a call from the mother informing
her that the prescription was lost and the patient had not had any
antibiotic coverage since discharge. A new prescription was called
in for six weeks duration.
A referral to Orthopedic Surgeon B was made when the wound
continued to show signs that it was not healing. This surgeon
suspected the presence of an infection and felt the x-ray changes
were ominous for recovering function of the ankle joint. He
anticipated the need for an ankle fusion.
A few weeks later, the patient was admitted to the hospital
due to high fever and fluid around the ankle. Orthopedic Surgeon B
performed incision and drainage of the ankle wound and sent
specimens for culture. Results were consistent with osteomyelitis.
Orthopedic Surgeon B requested an infectious disease consult and
intravenous antibiotics were initiated.
A week later, Orthopedic Surgeon B took the patient back to
the operating room for debridement of the osteomyelitis and removal
of all ankle fixation hardware. Following the surgery, a CT scan
showed significant bone loss. Orthopedic Surgeon B recommended that
the patient get a second opinion regarding a fusion of the ankle.
The patient saw Orthopedic Surgeon C two weeks later. This
surgeon was supportive of Orthopedic Surgeon B's assessment. The
patient then went to see Orthopedic Surgeon D for another opinion,
and this surgeon was also supportive of Orthopedic Surgeon B's
assessment. Orthopedic Surgeon D confirmed that there were
destructive changes in the ankle, and he indicated the patient's
ankle would never return to normal function. The patient chose to
continue care with Orthopedic Surgeon D, but did not undergo the
ankle fusion.
Problems with the wound continued and the muscle flap
developed necrosis. The wound was debrided and the flap was excised
by the plastic surgeon. All options for treatment were discussed
with the patient and family by the plastic surgeon.
A below the knee amputation was performed a few weeks later
by Orthopedic Surgeon D. Recovery from the amputation was
uneventful. Following rehabilitation, the patient adapted well to
the use of a prosthetic. The patient returned to the soccer field
six months after the amputation and has won several medals competing
in track and field events.
Allegations
Lawsuits were filed against Orthopedic Surgeon A and the
subsequent treating physicians. The allegations against Orthopedic
Surgeon A included:
-
failure to
ensure and confirm the proper reduction of the dislocation by
the ED physician;
-
failure to
recognize and treat the postoperative wound aggressively and
properly;
-
failure to
refer the patient to a plastic surgeon or infectious disease
specialist promptly; and
-
failure to
properly monitor the patient during the postoperative period.
Legal
implications
The plaintiff's experts asserted that the defendant failed
to meet the standard of care. One expert, an orthopedic surgeon,
stated that the amputation was required because the skin became
ischemic due to the fracture dislocation. The fracture was only
partially reduced in the ED, and surgery was performed approximately
24 hours after the original injury. This expert also felt that the
defendant was slow in his treatment of the wound complications.
Another expert, a plastic surgeon, stated that the initial
report of drainage in the postoperative period should have been a
red flag. An infectious disease physician was critical of both
Orthopedic Surgeon A and the plastic surgeon for failing to
recognize the seriousness of the infection for almost two months,
making no attempt to find the proper antibiotic, failing to perform
a wound culture in a timely manner, and failing to remove the
hardware in a timely fashion. They were also critical of the
defendant's failure to recognize the possibility of an infection and
of the delay in referral to a plastic surgeon and/or an infectious
disease specialist.
Defense experts argued that Orthopedic Surgeon A did not
deviate from the standard of care. They felt that he appropriately
evaluated and treated the ongoing symptoms and appropriately
referred the patient to specialists when it was necessary.
Disposition
This case was settled on behalf of Orthopedic Surgeon A
during mediation.
Risk management
considerations
When a patient returns to his or her physician with
recurring symptoms or concerns, a referral to a specialist may be
warranted. In retrospect with knowledge of the outcome, it is easy
to question a physician's care. When concern from wound healing
surfaced, an immediate infectious disease consult may have altered
the patient's outcome.
In this case, the physicians did a good job documenting
complete encounter notes. Follow up and wound care assessment were
also well noted. Dictation was done in a timely manner. The
documentation of noncompliance regarding failure to take the
prescribed antibiotics was also important information to include in
the patient's medical record. Current, complete medical records are
useful in the diagnosis and treatment of patients as well as
increasing the physician's credibility.
The information
and opinions in this article should not be used or referred to as
primary legal sources nor construed as establishing medical
standards of care for the purposes of litigation, including expert
testimony. The standard of care is dependent upon the particular
facts and circumstances of each individual case and no
generalization can be made that would apply to all cases. The
information presented should be used as a resource, selected and
adapted with the advice of your attorney. It is distributed with the
understanding that neither Texas Medical Liability Trust nor Texas
Medical Insurance Company is engaged in rendering legal services. ©
Copyright 2009 TMLT.
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