Failure to diagnose and treat ankle fracture

Presentation

On July 23, 2013, a 61-year-old man was taken to the Emergency Department (ED) after being thrown from a dirt bike. The ED physician diagnosed “left ankle fracture, bimalleolar and back contusion, rule out fracture.” A trauma consult was ordered. 

Trauma Surgeon A admitted the patient with a diagnosis of multisystem trauma. The patient was found to have a pneumomediastinum and compression fracture at T12. CT imaging of the left ankle revealed bimalleolar fracture; fracture of the lateral talus; and comminuted fracture of the anterior process and anterior body of the os calcis through the base of the sustentaculum tali. Additional consults were ordered from orthopedics, neurosurgery, pulmonology, and pain management. 

Physician action

On July 24, Orthopedic Surgeon A performed an open reduction and internal fixation (ORIF) of the patient’s bimalleolar fracture. Postoperative x-rays of the ankle confirmed a side plate and screws through the distal fibula and orthopedic screws through the medial malleolus. The patient was discharged on July 27.

The discharge summary — dictated by Orthopedic Surgeon A’s physician assistant and signed by Orthopedic Surgeon A — included a principal diagnosis of multisystem trauma with secondary diagnoses of:

1. thoracic spine fracture of the T12 level;

2. bimalleolar fracture in the left ankle; and

3. comminuted fracture of the anterior process and anterior body of the os calcis and fracture through the base of the tenaculum tali. 

    

On August 10, the patient returned to Orthopedic Surgeon A for his first follow-up appointment. His ankle appeared to be healing well with no deformity. During appointments on September 7, September 29, and October 12, the wound was noted as healing well, with satisfactory alignment, excellent position of the hardware, no sign of infection, and intact neurovascular system. The patient was referred to physical therapy.

On January 4, 2014, the patient returned to Orthopedic Surgeon A and reported some swelling of the ankle; a very sore, tender spot on the anterolateral aspect of the ankle; and calf pain radiating behind the fibula that worsened when walking. Orthopedic Surgeon A injected the site with methylprednisone and lidocaine. X-rays showed well-healed fractures.

Due to increasing pain, the patient sought a second opinion from Orthopedic Surgeon B on February 4. A CT showed a systemic talar fracture on the medial side, but the patient was experiencing pain mainly on the lateral side. Orthopedic Surgeon B diagnosed peroneal tendonitis. He performed a triple fusion of the subtalar joint. Surgery was performed without complication, and the patient was discharged on February 11. 

Over the next two months, the patient made slow progress, but still had pain and swelling along the lateral aspect at the level of the calcaneocuboid joint. X-rays showed fusion progression and the joint was visible at the talonavicular joint. 

On July 23, the patient returned to Orthopedic Surgeon B and was noted to be walking with a limp and had pain at every step. An exam revealed full range of motion and lateral malleolus was palpable below the skin, but not causing erosion or other problems. Good plantar flexion and dorsiflexion and almost no inversion or eversion was noted. 

X-rays showed minor changes in the ankle on the medial aspect consistent with early post-traumatic changes. The talonavicular joint was still visible but completely non-tender on exam. The calcaneocuboid joint was completely fused. The subtalar joint appeared fused. Orthopedic Surgeon B referred the patient to a foot and ankle specialist, Orthopedic Surgeon C.

Orthopedic Surgeon C saw the patient on September 6. The patient reported pain on the lateral side of the foot and that his ankle felt unstable. Exam showed minimal swelling and that sensation was intact with mild numbness on the lateral side of the foot. Orthopedic Surgeon C ordered x-rays and reviewed the CT from when the patient first went to the ED. 

From reviewing all the films, it appeared that while the calcaneocuboid joint had healed, the talonavicular joint had not healed and the subtalar joint developed a nonunion. The patient agreed to Orthopedic Surgeon C’s proposal to 1.) remove the hardware from the left foot and ankle, and 2.) perform a revision triple arthrodesis to place the foot in a more plantigrade position. 

On September 14, Orthopedic Surgeon C performed a revision triple arthrodesis of the left foot, hardware removal left fibula and tibia and left foot, an opening wedge osteotomy of the left tibia, and bone marrow aspirate of the left tibia. During an office visit on September 19, X-rays showed good approximation of the arthrodesis sites and osteotomy sites. All the hardware was in good position. 

The patient continued to see Orthopedic Surgeon C over the next five months. In January 2015, the patient still had pain and difficulty walking. He was considering a total ankle replacement surgery.

Allegations

A lawsuit was filed against Orthopedic Surgeon A, alleging failure to diagnose and treat calcaneus fracture with ORIF surgery.

Legal implications

Orthopedic Surgeon C was critical of Orthopedic Surgeon A. When he reviewed the July 2013 CT scan, Orthopedic Surgeon C testified that the calcaneus fracture was evident and reported on the initial CT scan obtained in the ED when the patient’s injury first occurred. He further stated that Orthopedic Surgeon A breached the standard of care by not performing an ORIF of the fracture. 

He further criticized Orthopedic Surgeon A for failing to address the calcaneus fractures during follow-up care and failing to recognize that the patient’s continuing problems were secondary to the misaligned calcaneus fracture. He believed this failure caused the patient to undergo two additional surgeries, pain, and loss of range of motion. 

Orthopedic Surgeon A stated that he missed the evidence of the CT scan and was unaware of the fracture. His retrospective impression was that the fracture did not require reduction initially, but he acknowledged that he failed address it in the documentation of the case.

Disposition

This case was settled on behalf of Orthopedic Surgeon A.

Risk management considerations

Orthopedic Surgeon A missed that the calcaneus fracture was indicated on the CT scans taken at the time of the patient’s accident. These CT results were included on the consult note that the PA created, and Orthopedic Surgeon A signed. In this case, the error in the documentation worked against the physician and created the impression that he was not fully engaged in the patient’s care. 

Before signing off on a patient record, it is vitally important to take time fully read it. Signing documentation indicates that the signer has read and understands the contents of the record. By keeping clear, accurate, contemporaneous documentation, and thoroughly reading reports, patient care may be conducted without confusion and adverse outcomes are minimized.