Presentation
On a Saturday night, a 53-year-old man came to the ED with an ankle injury from a fall. “The problem was sustained at home, resulted from twisting.” The patient had a history of hypertension, diabetes, alcohol abuse, and neuropathy.
Physician action
The patient reported his pain level as four. The left ankle was documented as tender and had deformity, swelling, and limited movement. A general skin assessment recorded no abnormalities. “No abrasion or laceration” was specifically noted.
An emergency medicine (EM) physician examined the patient and ordered x-rays. The radiologist described the injury as “comminuted fracture of the left distal fibula with lateral displacement and a fracture through the medial malleolus of the distal tibia.” The EM physician noted the ankle was “grossly normal except: noted in the left lateral malleolus and left medial malleolus: abrasion, swelling, tenderness, medial mall abrasion no open wound or lac or open fx.”
The EM physician splinted the ankle and noted “examined by me: post splint application: good alignment with good DP pulse palpable; all toes pink afterward.” He discharged the patient with a walker and instructions to see an orthopedic surgeon in two to three days. According to the medical record, the patient was “Educated On: Follow up with Primary Care MD” and “Reporting any Change in Condition.”
On Tuesday, the patient went to his primary care physician (PCP). The PCP documented, “He has a sugar tong and posterior splint in place. When I removed the splint and bandage there was blood dried on the bandage over the medial aspect. I removed and the skin is tight and warm, there is a small puncture over the bone that is easily palpable in the area. In viewing the CD the ankle is trimalleolar and unstable joint.”
One week after this office visit, the PCP added a late entry to the medical record: “when the splint was removed there was Xereform dressing over the open area on his ankle to indicate the opening was present before the splint was applied.”
The patient was transferred by ambulance to a hospital. His white blood count was 28.0 and his glucose was 248. He was admitted with the diagnosis of “1. Recent trimalleolar ankle, open fracture with underlying infection, 2. Diabetes mellitus.” The patient was treated with open wound reduction and an external fixator. Treatment with IV antibiotics (for MRSA contaminant) and debridements was unsuccessful, and the patient’s leg was amputated below the knee. The patient spent four weeks in the hospital.
Allegations
A lawsuit was filed against the EM physician, alleging failure to admit the patient and obtain an orthopedic consult for an open ankle fracture. This led to an infection, sepsis, and below-the-knee amputation.
Legal implications
The plaintiff’s expert stated that the patient’s injury was severe, with a splinter of bone on the medial malleolus that could likely cause additional injury and infection. The patient’s diabetic status made him more susceptible to infection and delayed healing. Therefore, the patient required admission to the hospital and an immediate orthopedic evaluation.
The defendant testified that he performed a thorough exam and considered the possibility of an open fracture. He believed the patient only had an abrasion to the epidermis with no injury or breach to the dermis. Defense experts agreed this was reasonable, but one EM physician stated, “Everyone involved underestimated and minimalized the injury, including the patient.”
There was less support among defense experts for the EM physician’s decision to splint the ankle and discharge the patient with a walker, given the nature of the injury and the patient’s diabetes. Yet, an orthopedic surgeon stated that the patient had diminished tissue and healing potential because of this diabetes and may have had the same outcome with admission and timely orthopedic consultation.
There was discussion among the experts about whether the patient walked on his splint after he left the ED and before he came to his primary care physician. They questioned whether the severity of the fracture increased after discharge based on different documented histories and the description of the fracture changing from bimalleolar to trimalleolar. However, a radiologist who reviewed the imaging from the first ED visit confirmed that the patient had a trimalleolar fracture when he came to the ED.
Disposition
This case was settled on behalf of the EM physician.
Risk management considerations
EM physicians who reviewed this case noted that this patient visit occurred on a busy Saturday night in the ED. This — along with the radiologist’s misread of the break as bimalleolar when it was trimalleolar — could explain why caregivers may have underestimated the seriousness of patient’s injury.
In this case, it may have been preferable for the EM physician to request an orthopedic consult. Absent a consultation, the EM physician’s care could have been more defensible if he had taken another x-ray to confirm proper splinting or discharged the patient with a wheelchair or crutches instead of a walker.
Because certain conditions can delay healing, it is important for those providing care in emergent settings to be mindful of their patients’ underlying health conditions. This patient’s diabetes put him at higher risk for delayed wound healing and infection, which further complicated his injury.
