On September 6, 2018, the patient, a 59 y.o. man, had a syncopal episode and passed out on the side of the road injuring his right ring finger. He had a history of several heart surgeries and had similar events previously. The patient i was on numerous medications including blood thinners. He was taken by ambulance to to an emergency department and was evaluated and treated by the ER physician.
After any acute cardiac issues were ruled out an X-ray was taken. The radiology report states “Partial dislocation with angulation at the proximal and pharyngeal joint of the fourth digit. Questionable tiny chip fracture at the distal most portion of the proximal phalanx”. The ED physician testified that he personally reviewed the X-rays in the ER. His clinical impression states: “Synocope. Dislocation of the proximal interphalangeal joint of the right ring finger”. After injecting a digital block with 1% lidocaine, the ED physician performed a reduction in the ER and splinted the finger. His instructions state: “Drink plenty of fluids. (Follow up with Hand Surgeon as discussed)”. No time frame was noted as to when to follow up. The patient was not provided with the name of any physician to follow up with. Further, the patient was not provided with the note from the ED physician. The ER discharge instructions signed by the patient and given to him at discharge state “Drink plenty of fluids. Follow-up with your health care provider”.
The patient testified that before the reduction he questioned whether the ED physician had ever performed this procedure before. According to the patient, the ED physician told him he had performed it many times. The ED physician had been a volleyball player and had even performed reductions on the field for these injuries. At his deposition, the doctor admitted that he was both a volleyball player and was the team doctor for a college volleyball team.
According to the patient, the ED doctor made light of the injury. He never said it was serious or severe. Further, the patient testified that he was never told to follow up with a hand surgeon and never told that there was a potential for surgery. The patient testified that he never refused any treatment while in the ER.
On August 17, 2018, the patient presented to an orthopedic surgeon. Another X-ray was taken which revealed “a slightly comminuted, mildly displaced intra-articular fracture of the base of the fourth middle phalanx; punctate ossific fragment at the ulnar aspect of the fourth proximal interphalangeal joint likely representing sequela of the recent injury”.
The orthopedic surgeon advised that this was a severe injury with most likely some form of permanent impairment. He discussed non-operative and operative treatment. The patient testified that the orthopedic surgeon discussed that to achieve optimal results with surgical treatment of this type of fracture, the surgery should have been performed within one week of the injury. Since 11 days had passed and because of the need for a cardiac clearance and discontinuance of the blood thinners, he could not guarantee optimal results. Based upon this the patient opted for conservative treatment. The orthopedic surgeon ordered a CT scan.
On August 17, 2018 (same day as the office visit), the CT scan was performed. It revealed a “small avulsion fracture at the palmar radial aspect of the fourth middle phalangeal base at the PIP joint; and a tiny calcification within the ulnar collateral ligament indicative of previous injury. Alignment of the PIP joint was preserved”.
On August 21, 2018, the patient returned to the orthopedic surgeon and the results of the CT scan were discussed. Once again conservative versus operative treatment was discussed and the patient once again decided against surgery due to the late stage of the mal healing of the fracture. The patient continued to follow up with the orthopedic surgeon and received physical therapy. Due to a change in his insurance plan he switched his orthopedist and continued therapy. He currently has limitation of his range of motion, stiffness, pain and is unable to perform certain activities.
The defendant radiologist testified that had misread the films while the patient was in the ER. The correct diagnosis was “Fracture at the distal portion of the proximal phalanx, and an avulsion (chip) fracture at the PIP joint”.
At the deposition of the ED physician, he testified that upon reviewing photographs of the X-rays he saw “an unstable avulsion fracture of the PIP joint (distal portion of the proximal phalanx). He further called it a “dislocation with a fracture of the PIP joint”. The ED physician admitted that this diagnosis was not contained in his hospital note.
At his deposition, the ED physician testified that his treatment of reduction and splinting was correct. He further testified that a “hand surgeon” by the name was available to consult while the patient was in the ER but the patient refused. It should be noted that the available consultant is not a hand surgeon but instead a plastic surgeon specializing in cosmetics (there is no mention of hand surgery on their website or qualifications).. I have since learned that there was an orthopedic surgeon/hand specialist on call at the time but he was not called to consult with the patient.
The patient has stated that he was never told that a hand surgeon was available to see him and would have never refused such a consultation. The patient testified that the ED physician never told him that there was a fracture or potential fracture. The patient is a chiropractor and has never refused medical treatment in the past.
Before the commencement of the lawsuit, this case was reviewed by a hand surgeon who opined that the ED doctor had committed medical malpractice. (This expert is unable to testify due to a conflict). This expert opined that it is crucial to be seen by a hand specialist within 3-5 days since a fracture to the PIP joint heals so quickly if it is mal aligned it will be harder to treat if you wait. If surgery is done right away and you restore the anatomy to the joint surface, you will improve the chance of a more normalized healing and result. An orthopedic hand specialist would have also recommended hand therapy soon after the surgery to minimize the swelling and stiffness. This is all consistent with the patient’s testimony of his conversation with his own physician.
Should the patient have been seen by an orthopedic hand specialist in the emergency room? Was it proper for the ER physician to perform the reduction and splinting with this type of fracture? Should post-reduction X-rays been taken which may have been properly interpreted to see the fracture? Should the patient have been told when to follow up with a hand specialist? Do you agree with the prior expert that the patient should have been seen by a hand surgeon within 3-5 days since these types of fractures heal so quickly you lose the opportunity for a good result from surgery?
Files:
No questions yet!
Do you believe there might have been medical error?
3-5 days follow-up in not definitive in terms of treatment of these injuries. Although these should be treated sooner rather than later, this is not a hard and fast tool. If he had not seen the hand surgeon until 3 or 4 weeks, then it would have been too late. I think this case more lies in whether or not the patient was instructed to see a hand surgeon ASAP - ie - within a week at most. If he was not told to the patient, then this deviates from the standard of care. In addition, the patient certainly should have had the option to consult a hand surgeon, if that service was available to the patient at that particular ER.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
No - but certainly post-reduction X-rays should always be taken after a reduction.
What makes you a good expert for this case?
I have 20 years of experience in hand and upper extremity surgery. I have consulted on a number do such case and have been deposed.
How often do you encounter cases similar to this one in your practice?
Fractures and or dislocations of the fingers - at least 5 a weeks.
Do you believe there might have been medical error?
To fully understand this case, one must understand the PIP joint - and unfortunately, few doctors do. It is vital for hand function, but prone to injury and stiffness. Most PIP dislocations are stable injuries once they are reduced, and can be treated with simple buddy tape, or a splint for a few days and then transition to buddy tape and beginning motion to prevent stiffness. The radiologist's interpretation, while clearly somewhat garbled by dictation software, indicates that this was likely a dorsal PIP dislocation (the most common type) with a very small avulsion fracture fragment. Avulsion fragments are essentially similar to ligament tears, and do not typically affect clinical outcome or treatment, and do not need to be repaired. Thus, the overwhelming majority of PIP dorsal dislocations with small avulsion fragments are able to be successfully treated without surgery. This patient's injury was likely no exception. The emergency department physician, from all available evidence, performed an appropriate procedure that they had the training to perform. A PIP dislocation, a common injury, especially in sports, is likely something they have indeed treated many times before, and their treatment sounds appropriate. The acute treatment of a dorsal PIP dislocation involves performing a reduction maneuver with the finger anesthetized and either applying either buddy taping/strapping, or a splint for a few days and then transitioning to buddy taping to prevent stiffness. Post-reduction X-rays should be obtained, but neglecting to do so is not malpractice. Fractures are often more visible on the injury (dislocated) film than the post-reduction films, and the post-reduction film in the ED would not have affected treatment, as they would likely have been repeated by the hand surgeon anyway to dictate whether the joint was stable or not. While the documentation from the ED physician may be lacking, and the communication perhaps could have been improved (though there is no way to know for sure what was or was not said), it does not appear that they reached the standard for malpractice. Consultation with a hand surgeon in the ED for a reducible PIP dorsal dislocation, even with a fracture, is unnecessary. The on-call hand surgeon (and plastic surgeons do often take hand surgery call even though they may not practice much hand surgery, they all have at least some basic training in it) would not likely have come in for it, nor should they have. They would typically instruct the ED physician to reduce it, splint or tape it, and have the patient see them in the office within a few days. The follow-up x-rays from the orthopedic surgeon do not indicate any reason to obtain a CT, nor to deviate from the standard non-surgical treatment. The CT scan does not either. The PIP joint is concentrically reduced, according to the radiologist. I do not know why the orthopedic surgeon was discussing surgery or getting a CT scan. If the reasoning was "the fracture," I would disagree on the available evidence, since there is no documentation of any fracture other than the small avulsion fracture, which can almost always, as mentioned above, be ignored. The correct treatment by the orthopedic surgeon would have been to transition to buddy tape, or if he felt the digit was unstable in extension, to a dorsal-blocking splint. Motion should have been initiated immediately, not delayed, and HAND therapy should have been initiated, not PHYSICAL therapy. There was absolutely no reason to even consider surgery for this. Radiologist's interpretations, however, are commonly incomplete, in my experience, and radiologists often do not comment on potentially-significant associated fractures or injuries. It is possible the orthopedic surgeon identified subtle dorsal subluxation of the PIP joint or an associated fracture which they radiologist did not mention. However, they should have documented that finding clearly.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do not think there is enough here, at least from the description provided, or causation. First of all, the dates are incorrect. I believe the first date should be AUGUST 6 rather than September, otherwise the chronology is incorrect. The orthopedic surgeon got the patient into therapy at 11 days after the injury, which is a reasonable time frame still. Some amount of stiffness after a dorsal PIP fracture-dislocation, especially when a patient is middle-aged or above, is sometimes unavoidable. The ED physician is not expected to know enough to counsel the patient about that. That is what the hand surgeon is supposed to do at the follow-up visit.
What makes you a good expert for this case?
I am a fellowship-trained hand and orthopedic surgeon who trained with nationally-recognized experts in not just hand surgery but the PIP joint specifically, and helped write textbook chapters on this very subject. I treat dorsal PIP dislocations very frequently.
How often do you encounter cases similar to this one in your practice?
In part, very frequently. PIP dorsal fracture-dislocations reduced in the emergency department, I probably see a few per month. Ones that presented in a delayed fashion, I see less frequently, but still sometimes. PIP dorsal fracture-dislocations that become stiff, probably once a month or so. Ones that were mismanaged or over-diagnosed by a general orthopedic surgeon, probably only once or twice a year.
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