***XRs and MRI results posted at bottom of post.***
***Initial XR imaging attached***
May 6th 1pm PC goes to Urgent Care for right foot pain. He tripped and fell at work and was unable to bear weight. The X-ray had a wet read by the provider on site, Dr felix who was under a sports medicine specialty. Impression was the first and second metatarsal interspace was widened but there was no fracture. PC was instructed to follow up on May 13. (The initial foot and ankle x-rays were then overread at 330pm by a diagnostic radiologist. Her read states enthesopathy no fracture. No evidence of acute bony pathology. Report below.)
This was a workers comp claim so PC returns back to Urgen Care on the 13th as instructed. They advised him to follow up with orthopedic surgery and released him. No further treatment.
His first orthopedic appointment was on May 26th with an orthopedic surgeon at his OP clinic. PC brings the X-ray CD with him and is reviewed. They diagnose it with an ankle sprain? and he is put in a low profile walker boot and told to avoid prolonged standing or walking for 3 weeks until second follow-up. His examination reads as: “The patient is 6 feet tall and weighs 231 pounds. Blood pressure 135/77. He is favoring the right ankle, which shows moderate swelling on the dorsal aspect of the foot. Swelling around the ankle medially and laterally. He has tenderness along the lateral ligamentous complex along the anterior talofibular ligament, calcaneal fibular ligament and medially along the deltoid ligament. He has mild hallux valgus deformity with hammer toe on the right. Sensation is intact.”
PC returns on June 21st. Reported to have been using the walker boot but still complains of pain and swelling to entire foot but specifically his great toe area.. Was told he can now discontinue boot and “wear a shoe with stiff sole”. No other treatments or radiology, was instructed to return in 4 weeks. This visits examination note reads: “Blood pressure 141/87. He has fair amount of swelling in the right ankle, but more so along the foot where I think the straps might have been tight. He has swelling over the first metatarsal phalangeal joint diffusely and hammertoe second and decrease in range of motion with pain. Some pain along the plantar aspect. Less pain along the lateral aspect of the right ankle.”
PC returns July 19th. Still reports symptomatic with swelling and first toe joint pain. Was instructed to avoid prolonged standing and walking and they now order MRI for further investigation. The examination note for this visit reads: “His blood pressure is 134/84. He still has a fair amount of swelling in the mid foot with more planovalgus orientation as compared to the left. Tenderness along the arch of the foot is present as well as the first metatarsophalangeal joint.”
MRI is completed on August 3rd.
Ortho office F/U on 8/11: Note reports that the MRI was reviewed and note reads “MRI was reviewed of the ankle and foot shows dorsal subluxation in medial cuneiform with displaced fragmentation of the medial navicular likely acute on chronic. Has some Lisfranc interval widening of 6 mm and this finding has suggest acute on chronic neuropathic osteoarthropathy. I saw x-ray of the foot, which shows the fracture of the medial cuneiform nd the navicular and some Lisfranc separation.”
The orthopedic assessment is that the PC has developed “post-traumatic charcot foot with collapse of the midfoot”. He says this is a relation to “his diabetic neuropathy”. He is instructed to be non-weight-bearing, use a boot and is going to be referred to a different orthopedic clinic for evaluation and treatment. His examination states that he is still having swallowing in the midfoot area and discomfort immediately and at the subtalar joint.
October 26th, PC is eventually seen by orthopedic surgeon #2. His note reads as follows:
“PHYSICAL EXAMINATION: Standing alignment shows he has obvious deformity in the right foot. He is abducted with a prominence medially. Some loss of his longitudinal arch. Some pronation. Left foot is better aligned. Seated evaluation of the left foot shows he has palpable midfoot pain and deformity. He is not grossly unstable.
DIAGNOSTIC STUDIES: Previous nonweightbearing images of his left foot from his urgent care visit shows he has clear and obvious Lisfranc injury with widening of the second Lisfranc joint with extension into the navicular cuneiform joint and proximal migration of the medial column. He has an MRI that shows diffuse midfoot arthritis. Weightbearing radiographs of each foot obtained and interpreted today show that he has asymmetry with chronic-appearing Lisfranc midfoot dislocation.
IMPRESSION: Neglected left midfoot fracture with dislocation.
MEDICAL DECISION MAKING: Reviewed findings with the patient. Discussed that this injury would typically require surgical stabilization immediately in the acute period. It is unclear why his treatment was delayed.”
He has continued care with his particular orthopedic, who eventually performed a right midfoot fusion for the Lisfranc injury. His latest update was approximately 6 weeks ago which reported that he is with 4% permanent impairment and that his arthritis and deformity in his right foot “are most definitively related to his work injury.”
Our concern is that the initial orthopedic follow-up had significant delays and was unable to give PC the correct diagnosis. Our case was based on the fact that the initial x-ray was misread, which we are handling through a radiology expert, but I have attached those films. Also, the orthopedic surgeon did have access to these films and continued to misdiagnose, in our opinion.
We are looking for an orthopedic surgeon who specializes in these particular injuries and has performed procedures in relation to a Lisfranc diagnosis. Concern for significant delay.
We appreciate your opinion in advance.
***Radiology Reads***
XR ANKLE May 6: Findings: Soft tissues are swollen. Bone density is normal. Alignment is anatomic. No acute fractures are visualized. Impression: Soft tissue swelling. No evidence of acute bony pathology.
XR FOOT May 6: Findings: Soft tissues are swollen. Bone density is mildly decreased. Enthesopathy is present at the insertion of the plantar aponeurosis on the calcaneus. The second toe is held inflexion. No fractures are visualized. Impression: Soft tissue swelling. No evidence of acute bony pathology.
MRI Aug 3:
FINDINGS: Bony structures redemonstrate dorsal dislocation of the medial cuneiform relative to the navicular by 1.1 cm. There is impaction of the medial cuneiform into the navicula. There is fragmentation of the medial pole of the navicula .. There is a bipartite tibial sesamoid with bone marrow edema at the fragments. There is mild hallux MTP joint degenerative change.
There is a complete tear of Lisfranc ligament with inteMI widening to 6 mm.
Mild second and third MTP plantar capsulitis.
Muscular compartment demonstrates elevated signal Intensity throughout the medial column. Also atrophy and edema in the lateral column. Extensor digitorum bre"1s demonstrates edema.
Second MTP fibular sided collateral ligament partial tear with plantar capsular retraction of 7 mm.
IMPRESSION:
1. Dorsal subluxatlon of medial cuneiform with displaced fracture/fragmentation of the medial navicular, likely acute on chronic. Recommend protected weightbearing
2. Lisfranc interval widened to 6 mm, acute
3. Medial abductor hallucis muscular strains, acute
4. Second MTP plantar plate tear with fibular collateral ligament tear, acute
5. Chronic medial sesamoiditis with bipartite tibial sesamoid 6.
6. Underlying muscular neuritis pattern and Degree of bony disorganization subluxatlon and Impaction suggest underlying acute on chronic neuropathic osteoarthropathy
7. Ankle effusion
8. Degree of bony disorganization subluxation and impaction suggest underlying acute on chronic neuropathic osteoarthropathy
Files:
No questions yet!
Do you believe there might have been medical error?
A Lisfranc injury is one that needs to be operated on as soon as possible to avoid secondary midfoot complications. The diagnosis was missed initially by multiple providers and therefore the surgery that was required was a more complex surgery needed to be performed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again this should have been treated by surgery urgently and it was not.
What makes you a good expert for this case?
I have been in practice in general orthopedics for over 25 years. I do not perform this type of surgery but I have seen this injury and the consequences of delayed care.
How often do you encounter cases similar to this one in your practice?
Rarely, do I see this in my office and rarely in the ER.
Do you believe there might have been medical error?
The patient suffered a proximal variant Lisfranc injury (widening of the Lisfranc interval with Lisfranc ligament injury and medial cuneiform-navicular dislocation. This diagnosis was missed despite being evident on x-rays.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The injury was not caused by medical error but the injury worsened over time as a result of the diagnosis not being made immediately and treated promptly.
What makes you a good expert for this case?
I am an orthopedic foot and ankle specialist who frequently diagnoses and treats these injuries with surgery.
How often do you encounter cases similar to this one in your practice?
I see several Lisfranc injuries per month.
Do you believe there might have been medical error?
This is a Charcot foot problem, not a Lisfranc issue. The Lisfranc ligament is strictly between the medial cuneiform and the base of the second metatarsal and is common source of litigation but easily treated with fusion. The Charcot is easier to litigate: a known diabetic has swelling in the foot should be immobilized in a cast or a boot until seen by a specialist, preferably non weight bearing. To do anything less will lead to further deterioration of the foot with further fracture and displacement as was seen in this case. The legal issues are easy: the failure to immobilize led to progression of the Claimant's Charcot foot deformity and permanent impairment. As the surgeon, I testify to Causation. I have been involved in a number of these cases as an academic foot and ankle surgeon.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above....clear Charcot foot progression without appropriate treatment.
What makes you a good expert for this case?
Please see CV- I am an academic foot and ankle specialist.
How often do you encounter cases similar to this one in your practice?
I see Charcot foot issues on a weekly basis.
Do you believe there might have been medical error?
The patient's injury was noted by the on call orthopedic surgeon initially as positive for widening of the 1st/2nd intermetatarsal space. This is a red flag warning sign for a Lisfranc injury. The injuries are notoriously difficult to diagnose, but was apparent to the orthopedic surgeon who looked at these initial films. The radiologist missed it, which is not the subject of this case, but is noted. Then, the orthopedic surgeon at the OP clinic likely simply relied on the radiologist's interpretation rather than conducting a thorough examination of the patient's foot and the radiograph. This is a fairly clear example of medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The medical error led to an unfortunate spiral where the patient was treated with early weightbearing, which is contrary to what should be done for a Lisfranc injury. Then, as the injury was not recognized in a timely manner, the eventual MRI, which was read by the radiologist as positive for widening, was also misinterpreted. The surgeon likely relied once again on the radiologist's read, which suggested reasons for a patient to have the appearance of a chronic Lisfranc injury (such as diabetic neuropathy), without considering that the findings on MRI may have been sequelae of the injury sustained at work several months prior. The delay in diagnosis and ultimately treatment of this injury directly can be reasonably deduced to be more likely than not the proximate cause of the patient's development of foot pain and arthritis in the midfoot.
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon with experience treating Lisfranc injuries
How often do you encounter cases similar to this one in your practice?
Delayed diagnosis of ligamentous injury, on a nearly weekly basis
Do you believe there might have been medical error?
This case really hinges on a delay in the diagnosis, and it is missed, but eventually picked up. The real question. is:. Could we have anticipated that an expectedly better outcome could have occurred if this injury had been diagnosed/treated appropriately earlier. in the time. I feel it is definitely more likely than not that that is the case, thus making this a very likely case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Had the injury been diagnosed and treated appropriately earlier, the expected outcome, more likely than not, would have been better.
What makes you a good expert for this case?
I treat traumatic foot and ankle injuries as a head team physician for a busy University Program and teach and see patients with over 28 years of clinical expereince
How often do you encounter cases similar to this one in your practice?
Missed bad foot and ankle injuries are routinely referred to my busy sports clinic
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