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The Pitfalls of Flexor Tendon Lacerations

Papadatos, Anthony MD, MBA

Emergency Medicine News: May 2005 - Volume 27 - Issue 5 - p 8
Expert Witness

Dr. Papadatos is an emergency physician in the Chicago area. He can be contacted at apmdmba@yahoo.com.

A 17-year-old right-handed student presented to the emergency department for treatment of a laceration he sustained to the third finger of his left hand on the palmar side. (Med Malpract Verdicts Settl Exp 2003;19[7].) The emergency physician examined and x-rayed the patient's hand, and did not discover any fractures, dislocations, foreign bodies, or structural injury to the finger. The laceration was repaired, and the stitches were removed 10 days later. In the subsequent days, the patient had some stiffness, pain, and difficulty properly flexing his finger. He was subsequently diagnosed with a flexor tendon laceration.

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Figure

The patient filed a lawsuit against the staff at the defendant hospital claiming that they failed to diagnose and treat the lacerated tendon properly. It also was claimed that the emergency physician did not perform flexion or strength tests to determine the integrity of the tendon. The emergency physician contended that such tests are ordinarily performed as part of the physical examination that patients with hand lacerations undergo. There was no documentation, however, that such tests were performed. The defending physician presented an orthopedic expert who contended that the patient may have been able to demonstrate normal range of motion while in the emergency department.

The court found for the defendant, claiming that the care provided did not deviate from the standard of care. It also was noted that the defense expert witness provided convincing testimony to support the treatment that was provided. (Court of Claims, Rochester, NY. Claim No. 97660.)

Comments: This patient probably was able to move his finger when the emergency physician saw him. He might have had a partial tendon injury that was inadvertently missed during the initial examination that eventually converted to a full tendon laceration. Despite our best efforts, we will never be perfectly accurate in diagnosing everything, and we work in a profession where bad things happen to people. We will inadvertently take the blame for some of them. Having a good expert witness can make all the difference in a case, as we can see here.

Trying to convince a jury that an examination was performed based on usual and customary practice is more difficult when there is no documentation to support it. Documenting that the “bottom of the wound was visualized in a bloodless field and no foreign bodies or tendon injuries were seen after the finger was placed through full range of motion” will protect our patients and us from future tribulations. Documentation of neurologic examination also is important. Liberal use of x-rays and ultrasound where available to rule out retained foreign bodies also is recommended. Finally, with complex wounds, including MCP joint and high pressure injection injuries, we should not hesitate to step back and ask our specialist colleagues for assistance.

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Decision for the Defendant

Patient: 17-year-old boy with finger lacerations.

Work-up: X-ray did not reveal any fractures, dislocations, foreign bodies, or structural injury. Ten days later, stiffness, pain and limited flexion seen.

Outcome: Patient later diagnosed with flexor tendon laceration.

Judgment: Decision for the defendant based on finding of no deviation from standard of care.

Source: Med Malpract Verdicts Settl Exp 2003;19[7]).

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$17.5 Million Settlement for Plaintiff

Patient: 34-year-old afebrile woman with sudden onset headache, nausea, vomiting, and neck stiffness.

Work-up: Mental status and physical exam unremarkable. Diagnosed with acute neck sprain. Ten days later, patient returns with altered consciousness, and work-up reveals ruptured arterial aneurysm.

Outcome: Patient left with limited movement of left arm and impaired memory and cognitive abilities.

Judgment: Settlement just before closing arguments for $17.5 million for the plaintiff.

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‘It's a Bad Headache, Doctor’

A 34-year-old woman presented to the emergency department complaining of sudden onset of headache, nausea, vomiting, and neck stiffness. She was not febrile, and her mental status and physical examinations otherwise were unremarkable. The emergency physician diagnosed the patient with acute neck sprain and discharged her with acetaminophen for her pain.

Ten days later, the patient was brought back to the emergency department with an altered level of consciousness. Further diagnostic work-up indicated that the patient had sustained a hemorrhagic stroke from a ruptured arterial aneurysm. The patient, a former fashion model and manager of a cosmetics section at a department store, was able to regain only limited movement of her left arm; her memory and cognitive abilities were impaired. Her speech and ability to navigate in her electric wheelchair on her own also were limited.

The plaintiff filed a lawsuit claiming that the emergency physician's failure to elicit a proper medical history regarding the plaintiff's chief complaint of “worst headache” had led to the misdiagnosis of a sentinel leak and the subsequent subarachnoid hemorrhage (SAH). A big point during trial was that the triad of the patient's presenting symptoms (sudden onset of headache, vomiting, and neck stiffness) are considered highly suspicious for an aneurysmal leak. It also was claimed by the plaintiff that a CT scan and a lumbar puncture would have confirmed with 100 percent accuracy the diagnosis of the leaking aneurysm. This, according to expert testimony, would have allowed for timely surgical intervention which should have ensured a greater than 90 percent likelihood of a full recovery. The emergency physician maintained during trial that his diagnosis of acute neck sprain was an appropriate diagnosis given the patient's presentation.

After two weeks of trial and before closing arguments, the case was settled for $17.5 million on behalf of the plaintiff. Cook County (IL), unknown case number.

Comments: This is a case as presented by the plaintiff's attorney, and we are only privileged to one side of the story. There probably was more to the physician's side. Otherwise, this case most likely would have been settled outright. Also the physician and his attorney perhaps believed they could challenge the plaintiff's case on the causation and proximate cause issue because the patient was fine for several days after she was sent home. Yet, sometimes this line of reasoning can unravel with a capable presentation of the foreseeability argument of proximate cause, which can be used to prove substandard medical care. In other words, a physician practicing according to the standard of care could have foreseen and prevented a catastrophic event in the future if he had managed the problem appropriately initially.

Missed SAHs represent about five percent of malpractice claims and approximately six percent of total dollars paid. When there is a suspicion of SAH, all patients require a CT, and if the CT is negative, a lumbar puncture is mandatory. Physicians tend to miss about 25 percent of SAHs, and a fair number of these are missed secondary to a spectrum bias trap: sick patients tend to have positive CTs because of large bleeds. On the other hand, clinically well appearing patients tend to have small bleeds and negative CTs and accordingly are more in need of an LP. Yet, we are more likely to forego doing an LP on these patients because clinically they look good. Ironically, these are also the patients most likely to benefit from an intervention.

© 2005 Lippincott Williams & Wilkins, Inc.