Failure to diagnose and treat complications

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 surgery 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.

Postoperative 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, the patient was followed closely by Orthopedic Surgeon A 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 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 10 times 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. The results were consistent with osteomyelitis. Orthopedic Surgeon B requested an infectious disease consult and intravenous antibiotics were started.

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
A lawsuit was 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; 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 treating the wound infection.

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.
 

Risk management considerations
When a patient returns with recurring symptoms or concerns, a referral to a specialist may be warranted. When concerns regarding 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.