Wound Care: Retained Foreign Bodies and Missed Tendon Injuries
By Daniel J. Sullivan, MD, JD, FACEP, Chairman, Department of Emergency Medicine, Ingalls Memorial Hospital, Harvey, Illinois
Editor's Note: I have been acting as the executive editor of ED Legal Letter for almost two years. I have thoroughly enjoyed the opportunity. Because of the extent of the time commitment, I am now going to share that role with Robert Bitterman, MD, JD, FACEP. I am very pleased that Dr. Bitterman has agreed to work with me on the newsletter. Dr. Bitterman has written and lectured extensively in the area of risk management in emergency medicine; has written several articles for ED Legal Letter on EMTALA; and has been an integral part of a task force presently meeting with HCFA to revise the EMTALA regulations, making them more palatable to hospitals and emergency physicians. I have developed an outstanding working relationship with Dr. Bitterman, and am certain that together we can continue to provide the best emergency medicine risk management newsletter in the marketplace.
I have authored this article on wound care. As I was writing the article, I realized that there are really several subjects that need to be discussed separately. Reviewing litigation related to wound care, I find that there are cases in the following areas: retained foreign bodies; failure to diagnose tendon injury; failure to warn or failure to diagnose compartment syndrome; missed nerve injury; improper management of bite injuries; failure to properly manage high-pressure injuries; and others.
Although the dollar amounts involved in these cases are low, the frequency of cases is high. I feel that ED Legal Letter should cover the entire list of subject areas. Therefore, I will break the article into two sections. The first will deal with retained foreign bodies and tendon injuries. The other subject areas will be covered in a separate newsletter.
As always, comments and constructive criticism are welcome. Share your interesting cases, make suggestions about future subject areas, and let's continue the dialogue that we have developed over the last two years. Thank you.
Failure to Diagnose a Retained Foreign Body
Failure to diagnose the presence of a foreign body in a wound is the subject of countless malpractice actions against emergency physicians. In a recent article representative of the current literature in this area, Kaiser, et al, described 32 lawsuits involving wounds and retained foreign bodies.1 Glass was the most commonly encountered object, found in 53% of cases. Stones, metal, wood, and clothing were also noted. A piece of sock or rubber from a running shoe is often impregnated into the foot when the patient has stepped on a nail. Knives carry clothing into the subcutaneous tissue or muscle. The most common injury in this series was a laceration to the hand or foot, often with the extremity being pushed through a window. A fall on an outstretched hand is another common mechanism of injury in retained foreign body lawsuits.
In the 32 cases, x-rays were obtained on the initial visit in only nine (31%) patients. Reasons for not obtaining an x-ray included a belief that glass and wood were not radiopaque; failure to even consider a foreign body being present; pregnancy; the belief that the debris had been removed; and failure to read the nursing note where the patient said a foreign body may be present. In this series, the retained foreign body was discovered in a period from three to 1405 days post injury.
In the 32 cases, the total payment by the insurance company was approximately $1.3 million. Including the cost of defense, the cases cost about $50,000 each. Damages were awarded for loss of vision, neurologic injury, scarring, the need for an additional procedure, and pain.
The medical and legal literature supports- the contention that retained foreign bodies cause additional injury. In the above series, when an object was expected to be radiopaque (such as glass) and a film was not ordered, a plaintiff's verdict was almost certain.
Case # 1-Missed Foreign Body; Failure to X-Ray
The patient fell and cut his shoulder on broken glass. He went to the hospital where a nurse took his history and cleaned the cut. A physician sutured it and told the patient to return in a few weeks to have the sutures removed. The patient did not return and removed the sutures himself. Three months later his shoulder still hurt. He saw another physician who diagnosed bursitis and prescribed a cream to be applied to the shoulder. About eight years later he saw a third physician who also diagnosed bursitis, but later took x-rays and discovered foreign bodies in the shoulder. The foreign bodies were removed and proved to be pieces of glass related to the original injury.
A trial court dismissed the patient's action against the emergency physician. The court held that the statute of limitations had tolled, and that the period of time in which the patient could file suit had passed. The appellate court reversed the decision. The court said that there was no event that led or should have led the patient to believe his condition was the result of the original repair of the laceration. The physicians who treated him diagnosed bursitis. The statute of limitations period did not begin until the x-rays showed the glass in his shoulder. The statute of limitations had not expired when the action was filed, and it should not have been dismissed.
One interesting aspect of this case is the long delay between the alleged negligent conduct and the patient's awareness of the retained foreign body. At the moment in time that a patient is injured by a physician's negligent conduct, that patient acquires a legal right to sue the physician under the state's malpractice laws. The patient will retain that right until it is terminated by the state statute of limitations. This is a statutory limit on the length of time an injured party has to sue the physician. However, in many states, the statutory period does not begin to run until the patient actually knows or should have known of the alleged injury and related negligent conduct.
In this case, the appellate court determined that there had not been an event that would have caused the plaintiff to know that the continuing shoulder problem was related to the care provided for the original injury. Therefore, the statute would not begin to run until the glass was discovered.
This is a unique aspect of missed foreign body litigation. The foreign body is often not recognized until some years after the alleged negligent conduct. In most cases, the defense team will raise the statute of limitations as an absolute defense to the lawsuit. In general, that motion will be dismissed if the patient reasonably did not have knowledge of the existence of the foreign body.
The risk management opportunity here is recognizing the likelihood of foreign body in patients returning to the ED with a wound complication. If the patient complains of pain out of proportion to the condition of the healing wound, or if the wound is infected, consider a foreign body.
Case # 2-Foreign Body in the Hand; Failure to Recognize High-Risk Mechanism of Injury
The patient was an 11-year-old male who presented to the emergency department (ED) with a laceration of his left hand that occurred when he fell off his bike. No loss of consciousness was noted. The nurse noted there were no allergies, and tetanus was up to date. There was no additional nursing documentation.
The physician noted that there was a "laceration in the left palm." The physician did not document any additional physical findings. He did document a procedure note: "local anesthesia/aseptic technique. Two stitches (3-O nylon). Dressing." His discharge diagnosis was "laceration left palm." The patient was discharged without wound care instructions, with follow-up to the private physician.
Two years later, the patient presented to another ED because some glass had come out of the original wound, and the child was having pain in the hand. The physician noted that there was a "large, glass foreign body palpable in the healed wound-sensory, motor, vascular appears intact." X-ray revealed a "density, probably a piece of glass seen in the base of the left thumb." The child went to surgery three days later and had a "removal of the glass foreign body and scar foreign body reaction of left hand and microsurgical excision of the neuroma of recurrent branch of the median nerve with neurolysis and microsurgical nerve repair."
The family sued, and the case was settled for an undisclosed amount.
The physician's documentation was woefully inadequate. The words in quotes above represent the physician's entire description of the incident. Poor documentation is a common finding in missed foreign body lawsuits. When caring for a patient with a laceration, certain elements must be present in the history and physical examination. (See Table 1.)
Remember, the chart is your lifeboat in case of subsequent litigation. In deposition and at trial, you will probably have absolutely no recall of the care you provided. All you can depend on is your chart. During the process of litigation, you have only two sources of information: your chart and your independent recollection. You may have some independent recollection of the missed abdominal aortic aneurysm or the missed myocardial infarction and the stormy aftermath, but you will not remember the retained foreign body case. You must pay strict attention to the elements of documentation in these cases. With the possibility of a retained foreign body in mind, detail the elements of your exploration and your intense efforts at irrigation.
If your suspicion for foreign body remains high after irrigation and failed efforts at exploration, consider imaging methods or contact a consultant. The relative merits of x-rays, ultrasound, xeroradiographs, and CT scan have been discussed at length in recent literature, including excellent reviews in the following articles: Emergency Medicine Reports, Foreign body removal: A guide for ED physicians, 1996;10:101-110; and Emergency Medical Clinics of North America, 1992;10(1):163.
In an article by Monthey, et al, the authors implanted several types of radiopaque and radiolucent foreign bodies in tissue and attempted to detect them by routine x-rays and ultrasound.4 Although ultrasound had some utility in identifying radiolucent foreign bodies, the authors conclude that ultrasound should not be relied on to rule out the possibility of a retained foreign body in the distal extremities.
When in doubt, get help. It does not matter if you make the diagnosis on day 1. If you cannot locate it, immobilize the extremity, start the patient on antibiotics, and provide the patient with an appropriate and timely referral.
Perhaps the most important risk management point is that the physician should be aware of presentations that are high risk for the presence of a foreign body. When a patient falls onto the outstretched hand and sustains a laceration, the wound should be considered at high risk for harboring a foreign body.
Case # 3-Failure to Diagnose Glass Foreign Body in Foot; Failure to X-Ray and Recognize High-Risk Mechanism of Injury
The patient was a 24-year-old male who related to the triage nurse that he kicked glass and had a laceration on the bottom of his left foot. The triage nurse noted that he "moved the great toe well. Two-inch gaping laceration plantar aspect from the great toe to ball of foot."
The physician noted that the patient had a superficial laceration on the plantar aspect of the left big toe on windowpane (no fragments). On examination the patient had full range of motion of the left great toe, and sensation was intact. He also noted that there was a shallow laceration (4 cm). The physician anesthetized the toe. He noted that there was no foreign body or tendon or muscle involvement, and closed the wound with 3-O ethilon.
The physician diagnosed a 4 cm laceration to the big toe. On discharge he ordered wound precautions, sutures out in seven days, amoxicillin 250 mg tid for four days. The wound was dressed with bacitracin ointment, 4 ´ 4, and kling. The nurse noted that the wound was scrubbed with betadine soap and sterile saline.
Neither the nurse nor the physician noted that the patient had intentionally put his foot through a plate glass window.
The patient continued to have pain in the toe for several weeks. He returned to his family physician who ordered an x-ray of the toe. X-ray revealed a large piece of glass measuring 2.0 ´ 1.0 cm.
The patient sued for failure to diagnose a foreign body, alleging that the emergency physician had a duty to order an x-ray. The patient further alleged that as a result of the retained foreign body, he had permanent injury and continuing pain.
The jury rendered a verdict against the emergency physician, but awarded a nominal amount of monetary damages.5
Table 1
Elements Present in History and
Physical Exam
History: Mechanism of injury, how did it occur?
Is glass involved?
Is the wound contaminated?
High-pressure injury?
Time of injury - early vs. late presentation
Retained foreign body sensation?
Motor or sensory changes?
Medical history - peripheral vascular disease/diabetes?
Tetanus status?
Intoxication, drug use?
Exam: Length and depth of wound
Active resistance of possibly involved tendons
Palpation of bone adjacent to wound
Two point discrimination of digits distally
If laceration is near a vascular bundle, exam for compartment syndrome
There is a major discrepancy in the nursing and physician notes. The nurse described a gaping laceration, and the physician found the laceration to be "superficial" and "shallow." It looks like the nurse and physician were looking at two different patients. If a wound is superficial and shallow, and the base of the wound is clearly visible with no possibility of a foreign body, then x-rays are unnecessary. But if the wound was superficial and shallow, how did a 2-cm piece of glass get into it? Obviously, the nursing note was correct. It was the physician examination, and not the wound, that was superficial. Any attempt to carefully probe the wound would have demonstrated that the wound was not superficial.
On review of the x-ray taken on the follow-up visit, the glass foreign body looked so large as to be almost impossible to miss with a probing instrument. The physician thought the wound was superficial, and did not know about the foreign body because he did a poor job of evaluating the wound and did not do a thorough search for a foreign body. Also, the mechanism of injury should have been clarified and recognized as high risk for the presence of a foreign body.
Case # 4-Alleged Failure to Remove Foreign Object From Hand
The patient was a 52-year-old male who suffered a laceration of the middle finger of his right hand at work. He went to the ED at Prince George's County Doctor's Hospital, which was operated by the defendant association, Capitol Emergency Associates. The emergency physician cleaned the wound. An x-ray showed a 3 mm metallic foreign body that had been left in the middle finger. The emergency physician determined that it was not necessary to remove the foreign body if the patient received follow-up care and antibiotics. The plaintiff took antibiotics and sought follow-up care within the time recommended, but the finger worsened. Four weeks after the accident, the patient underwent emergency surgery, during which an infection was discovered. The patient subsequently underwent numerous surgeries, and ultimately had his middle finger amputated.
The plaintiff alleged that the ED physician was negligent in failing to remove the foreign body immediately. The defendant denied negligence.
According to reports, a $681,752 verdict was returned in April of 1992.6
It is difficult to determine if there was a breach in a standard of care. It is no surprise that the emergency physician was unable to remove a 3-mm foreign body, and referral seems appropriate. The patient took the antibiotics, and follow-up occurred as scheduled. Perhaps the risk management opportunity here is making sure the patient gets a rapid referral to the correct specialist. The emergency physician is not required to remove every foreign body, particularly when there is a potential danger to surrounding structures. The emergency physician should also carefully communicate that a foreign body remains, the importance of follow-up, and the possibility of infection.
Case # 5-Failure to Diagnose Glass Foreign Body in Ankle; Failure to X-Ray and Recognize a High-Risk Mechanism of Injury
The patient presented to the ED and told the triage nurse that he cut his ankle kicking a glass window. The triage nurse noted that the patient had a 6-cm laceration on the posterior aspect of the right ankle. She described the wound as deep and gaping. Dorsiflexion was normal. However, the patient was unable to plantar flex the foot against resistance. Pulses were intact. She also noted that there was a cut tendon visible through the wound.
The physician anesthetized the wound and irrigated with 400 cc of sterile saline.
The emergency physician noted that there was a complete laceration of the Achilles tendon, but that the neurologic and vascular exams were normal. The physician closed the skin with 4-O nylon sutures after "copious irrigation with normal saline." The emergency physician ordered a posterior mold and admitted the patient to the hospital with a diagnosis of lacerated Achilles tendon. The plan was antibiotic therapy and Achilles tendon repair in the morning.
There was no x-ray ordered in the ED. In fact, there was glass imbedded in the area of the original wound.
The next morning, the orthopedic surgeon examined the ankle, found the tendon was only partially torn, and did not operate. Neither the emergency physician nor the orthopedic physician ordered an x-ray, and the glass foreign body remained in the wound.
The patient was managed conservatively for two months, after which he suffered a complete laceration of the Achilles tendon. At issue was whether the tendon ruptured because there was already a partial tear and further mechanical injury resulted in complete rupture, or, alternatively, whether the glass imbedded in the area of the original wound resulted in further injury to the Achilles tendon.
The surgeon who repaired the tendon noted that there was a foreign body, a small piece of glass, which was found just underneath the subcutaneous tissue, nowhere near the Achilles tendon.
The plaintiff brought suit against the emergency physician, alleging a failure to x-ray and a failure to identify the foreign body. The emergency physician argued that the reason she did not order an x-ray of the ankle was that she had an open and fully irrigated laceration, which she was able to view fully and probe with an instrument. She argued that the standard of care did not require an x-ray.7
Not a bad argument, but, unfortunately, it is incorrect. The mechanism of injury strongly suggested a retained foreign body, and the emergency physician should have ordered an x-ray in order to comply with the standard of care. The physician argued that she had an open and fully irrigated laceration, and she was able to view fully and probe with an instrument. That is a losing argument. Do not depend upon visual inspection and probing to identify the foreign body. As a test, visual inspection and probing are not sensitive enough to adequately detect the presence of a foreign body.
Table 2
Common Findings in
Missed Foreign Body Lawsuits
· Physician failure to read the nursing or EMS notes
· Disregarding an obvious history (e.g., foot through picture window; face struck tree; fall onto outstretched hands)
· ot listening to the patient complaint of possible foreign body
· Failure to use x-rays liberally
· Letting the patient's intoxication or drug use cloud the physician's thinking
· Expecting the physical examination to disclose the presence of a foreign body
· Thinking that the wound is too small to contain a foreign body
Case # 6 Retained Wooden Foreign Body
An 11-year-old girl presented to the ED with a complaint of an injury to the right side of her face after she struck a tree while running in a local park. The nurse noted that she had an abrasion to the forehead and around the eye, and a puncture wound to the right cheek. No loss of consciousness. She was alert and oriented and pupils were equal and reacted to light. The nurse cleansed the wounds and noted no injury to the inside of the mouth. She applied topical anesthesia (PAC) to the wound, noting that she was keeping it away from the mucous membranes. The wounds were cleansed with betadine.
The physician noted "Hx as above - ran into thick-bark tree." On exam, he noted superficial abrasions extending along the right side of the face. There was a small defect in the right eyebrow, and a slightly larger puncture laceration just below the right corner of the mouth. Eye exam was completely normal. Neck exam-full range of motion (FROM), nontender.
He noted that the wound was cleansed with betadine and anesthetized with PAC and 1% lidocaine. Four simple sutures were placed to approximate and evert the wound edges at the site of the puncture wound. The diagnosis was "facial laceration." The physician ordered a bacitracin bandage changed tid, and follow up in four days to the private physician and return if worse.
The nursing discharge form instructed the patient to keep the dressing clean and dry; may apply hydrogen peroxide to wound 3-4 times per day, followed by bacitracin ointment and a Band-Aid. There is no indication that the parents were instructed to watch for signs of infection. There was no x-ray.
The plaintiff's expert report indicates that the child's wound was explored, irrigated, and sutured. Subsequent to that treatment, a retained foreign body, which was missed on the initial examination of the wound, was noted. This required further surgery to remove and revise the subsequent post-infection scar. No x-rays were obtained during the initial examination. It was this expert's opinion that since this laceration occurred from contact with a foreign body containing wood, the potential of a missed retained foreign body, which would not show on x-ray, was not entertained. This was a deviation, and the possibility needed to be entertained and communicated to the parents.
In the plaintiff's complaint, the parents alleged that the emergency physician failed to obtain x-rays during the initial examination; failed to diagnose a foreign body inside the laceration; failed to properly evaluate whether or not a missed retained foreign body was within the minor plaintiff; failed to inform the parents that there might be a foreign body such as wood inside the child's wound.
This case was settled on behalf of the emergency physician for undisclosed amount, but the figure was under $30,000.
As you can see, these cases do not involve large amounts of money. Regardless, they are all too frequent, involve physician time away from the job, and large amounts of mental and nervous energy that would be better spent elsewhere. Also, no matter what the size of the settlement, it is reportable to the National Practitioner Data Bank, and it will follow you from job to job for the rest of your career.
This is an excellent example where an ounce of prevention is worth a pound of cure. Look at the expert's statement. The emergency physician had a duty to inform the parents that there might be a foreign body such as wood inside the wound. Even if he did not take the x-ray or diagnose the foreign body, based upon the mechanism of injury, there was a duty to inform the parents about the potential of a retained foreign body. This warning may have minimized the likelihood of subsequent litigation.
Finding tree bark, a toothpick, or any other wooden object inside a wound can be extremely difficult, and sometimes impossible. Any emergency physician in practice for a number of years will have been frustrated in the search for a wooden foreign body. Wood in the form of tree bark, splinters, and thorns constitute the highest risk of undetected foreign bodies. CT scanning appears to be the optimal method of visualizing these foreign bodies.8 Ultrasound may also be useful.9
Do not tell the patient that there is nothing left in the wound. That statement has little utility and may be potentially harmful. Also, if you find one foreign body, look for another. By finding one foreign body, you already know it is a high-risk wound.
Retained Foreign Body: Summary and
Recommendations
Take a careful patient history and review all prior notes for clinical clues. Recognize the high-risk presentations. Do a careful physical examination and exploration for a foreign body. Carefully document those elements related to your search for and attempts to remove a foreign body; that is, copious irrigation and your efforts at exploration. Feel free to use adjectives in your documentation that make it clear to the reader that you diligently searched for the foreign body. Remember that you have to provide care that is reasonable under the circumstances, no more and no less. If x-rays are negative, and you feel you have reasonably ruled out the likelihood of a foreign body, discharge the patient with instructions for follow-up wound care.
If, based upon the history or some aspect of your exam, you still suspect the presence of a foreign body, get help. Call the radiologist for assistance in imaging, call plastic surgery, or a hand or orthopedic surgeon for a discussion and possible referral. If you think there is a significant possibility of a retained foreign body, involve the patient in the discussion. Make it clear that patient care does not end when the patient leaves the ED. Indicate that a foreign body may remain, infection is possible, and follow-up is critical.
Read the nurse's note, the chief complaint, and the EMS notes for clues that the case may involve a foreign body. Many times the patient makes it very clear to anyone listening that there is a foreign body in the wound. Sometimes there is a barrier to effective communication between patient and physician. The physician may not hear about the possibility of a retained foreign body.
X-rays should be used liberally in all but the most minor or straightforward cases. Consider enlisting the assistance of nursing and triage, and allow ordering of extremity films to evaluate for the presence of a foreign body. If x-rays are negative but suspicion remains, or if pain is out of proportion to the clinical picture, consider ultrasound or CT.
The ED staff should perform a quality monitor to determine the adequacy of documentation of wound care, including appropriate irrigation and exploration for foreign body when indicated.
Failure to Diagnose Tendon Injury
Failure to diagnose tendon injury is another common cause of malpractice suits against emergency physicians. When a tendon is injured, the patient cannot perform a critical movement. What are the barriers to making this diagnosis? Why is this a common problem? If the patient cannot flex or extend a finger or a wrist, how could the diagnosis be missed?
As you will see from the case review, several problems exist. The most obvious is the imperative to perform a careful, focused tendon evaluation whenever a patient presents with an extremity wound. It is common in missed tendon-injury cases that the physician simply did not look for a tendon injury. There is no documented tendon evaluation, and during the process of litigation, certainly no independent recollection of the tendon examination.
Another common factor is that the physician makes a statement regarding tendon function, but the actual examination is inadequate and does not prove the recorded statement. For example, the physician will document "normal tendon examination," but will not actually have performed an exam, or has performed an inadequate examination. In fact, a tendon is injured, and the injury is missed.
There is another group of cases in which the physician has actually performed a maneuver, such as asking the patient to "make a fist," in order to test for tendon function. However, the documented maneuver is not specific to a particular tendon. For example, the examiner may see a finger move when the patient makes a fist, but that test is inadequate to evaluate flexor tendon function of the fingers. This problem is probably related to knowledge base.
When these patients are discharged from the ED, they generally return to their private physician. This physician is typically an internist or family practitioner, often with little training in evaluation of tendon function. Although many of these patients are discharged with a mandatory wound care follow-up, the follow-up physician does not re-check tendon function. Therefore, if the injury is missed in the ED, it is often not diagnosed for an extended period of time. The ED is often the last stop, the last opportunity to identify the deficit before a lengthy delay, lost function, and the likelihood of litigation.
Case # 7-Failure to Diagnose Tendon Injury, Hand; Questionable Tendon Evaluation
The patient presented to the ED by ambulance with a complaint of a laceration to the right index and middle finger. The EMTs noted that the patient sustained this injury due to a knife and that the patient was also bitten on the left shoulder. There were no other injuries. The EMTs also noted that the lacerations would require sutures. They bandaged the fingers and transported the patient to the ED. On the ED "Ambulance Report Form," the ED staff noted that "movement is good to affected fingers."
The nurses noted that the patient related grabbing the knife from someone, thus cutting his hand. The nurse also noted that the patient had a 2 cm laceration across the palmar side of the right index finger just above the MCP joint. Tetanus was up to date.
The nurse noted that the wound was cleansed with betadine and water, and bleeding was controlled. Duricef was administered in the ED and a bacitracin dressing applied.
The physician noted that this was a 29-year-old male who sustained a laceration to his right index finger by a knife. The patient denied numbness in the fingers.
On physical examination, the physician drew a picture of the index finger and noted that there was a large deep laceration, 3 cm, no visualization of foreign body or bone. He then noted "+ PIP/DIP," neurovascular intact, and + capillary nail flush. The physician performed a digital block and sutured the finger with 8, 5-O nylon sutures.
The patient was discharged on Duricef for five days, with no heavy lifting and a wound recheck in two days. Final diagnosis was "index finger laceration."
The patient did not follow up for a wound check in two days. Three weeks following the ED visit, the patient presented to the same ED, stating that he had taken his antibiotics, he had removed his own sutures three days ago, and the he was unable to flex his index finger.
On physical examination, there was "extensive scarring not only to the surface, but also underneath the skin with a mild dehiscence of the wound edges. There was no pain or tenderness. The patient was unable to flex the distal interphalangeal joint "on three different occasions." There was good capillary refill and sensory intact. The physician's impression was "possible flexor tendon disruption of the right index finger."
The tendon injury was repaired at a later date. The patient ultimately had diminished range of motion of the index finger, and sued the emergency physician that originally missed the diagnosis of tendon laceration. The parties settled early during the process of litigation for an undisclosed amount.10
Statements made in the medical record should have a definite and obvious meaning. The statement "+ DIP/PIP" is ambiguous. What did the physician mean? Does that mean that he checked for tendon function at proximal and distal interphalangeal joints? Does it mean that he checked for both flexor digitorum profundus and superficialis function? The problem is that if the statement if not clear, you will have to let a jury decide what you meant. Each statement must convey a clear thought. It would have been better to state "tendon function intact."
The second important issue in this case is that the mechanism of injury suggested the possibility of a tendon injury. The exam should have been carefully designed to rule out tendon injury.
This case also demonstrates another aspect that is typical of missed tendon injury litigation. The patient has obviously injured his own tendon. The physician did not cause that injury, the patient did. It is likely that there would be some patient impairment as a result, some decrease in function. Did the delay cause any injury to the patient? Maybe and maybe not. Regardless, the delay in diagnosis is the patient's ticket to the litigation arena. Whatever the cause of the diminished function, the physician's insurance policy is going to pay for it.
This outcome is entirely preventable. A textbook exam and excellent documentation is your defense against this type of lawsuit.
Case # 8-Failure to Diagnose Tendon Injury, Hand; Inadequate Tendon Examination
The patient was a 38-year-old male who presented to the ED after cutting his "right middle knuckle on a machine blade at work." The nurse noted that there was a laceration present. The physician noted that the patient had a 3.5 cm laceration in the web space right under the middle finger, "movement of all fingers of hand normal. Neurovascular exam intact. No tendon injury." X-ray of the hand was negative.
The physician's diagnosis was "deep laceration of right hand." In the treatment section of the chart, the physician noted that he ordered a betadine scrub and anesthetized with 0.5% lidocaine. He placed three deep vicryl sutures 4-O and six skin sutures 4-O. That is the full extent of the procedure note. He discharged the patient on Duricef and Tylenol. The patient was supposed to follow up in two days for re-evaluation by the private physician.
Ultimately the patient was diagnosed with an injury to the extensor tendon of the right middle finger. This was repaired. The patient alleged permanent injury. The insurance company settled with the patient prior to the initiation of litigation for $2,500.11
Case # 9-Failure to Diagnose Tendon Injury, Hand
The patient was a 50-year-old male who presented to the ED with a complaint of a laceration to the inner aspect of the third finger, left hand, possible crush injury. The patient had pain over his metacarpal joint and limited range of motion secondary to pain. The emergency physician noted that the patient lacerated his left middle finger on a metal edge, and that he was right-handed. On exam, the patient had a 1.2 cm transverse laceration on the palmar aspect of the left middle finger, proximal to the proximal interphalangeal joint. The wound extended into the subcutaneous tissue and was dirty. There was no visible foreign body. Skin margins were jagged. Neurovascular response was intact.
The wound was anesthetized with 1% lidocaine and then irrigated with 100 cc of saline. It was "carefully explored." Mechanical cleansing was performed with normal saline. On direct inspection, there was no tendon involvement and no foreign matter detected. Three 4-O nylon sutures were placed. A sterile dressing was applied and the wound bandaged. The x-ray was negative. Tetanus was administered.
The patient was discharged on Tylenol No. 3 and Keflex, with sutures to be removed in 12 days. Wound care instructions were provided, with a wound check in one day. The patient had orders to follow up with the company physician.
The patient followed up at the industrial clinic five days later. The clinic physician noted the presence of sutures, and with little additional documented description, discharged the patient with a return in five days for suture removal. On the return visit, now 10 days post injury, the patient complained of some soreness over the injured finger. All sutures were removed. On the 15th day, the patient returned complaining that it was difficult to flex the distal interphalangeal joint of the injured finger. The clinic physician ordered hot soaks. There was no documented neurovascular, or tendon evaluation at any of the visits.
Approximately two weeks later, the patient returned with continuing pain and stiffness, and was referred to physical therapy and to a hand specialist. The hand specialist ultimately diagnosed a lacerated flexor digitorum profundus and performed a surgical repair. During the surgery, the physician found that the edges of the tendon could not be brought back together, and he had to place a tendon spacer in order to reattach the two ends.
The patient sued the emergency physician, alleging failure to diagnose a tendon injury and resulting chronic pain and disability.12
Answer this question. In the last two cases, was the tendon injury present and demonstrable at the time of the ED visit, or did it happen later? Was this a partial injury turned permanent by some act of the patient? In both cases, the physician documented that tendon function was intact. In both cases, it probably was not. The barrier here is probably the quality of the tendon examination. This is a critical risk management point for the emergency physician.
The tendon examination must be meticulous. The exam must challenge a specific tendon, and the patient should demonstrate tendon function against active resistance. Testing should be specific for a specific tendon. It is nearly impossible to remember all the tendons and the method for testing for every tendon in the hand, wrist, foot, and ankle. You might remember them for a few weeks after boards, but after a few years out without using the knowledge on a day-to-day basis, it is easy to forget. Knowing this is the case, the ED should have a quick tendon reference or a protocol (cheat sheet) for tendon function testing. Make your documentation tendon specific or location specific. For example, if the injury is near the base of the thumb, document that thumb tendon function is normal, or that the thumb has a full active range of motion.
Whether you document generally that "tendon function is intact" or you are tendon specific (e.g., ulnar carpi radialis function is intact), the key is to be meticulous and prove your statement. It is easy to walk away from the exam without a complete tendon evaluation and write or dictate that tendon function is normal. That is what happened in these two cases. Tendon function was not normal. A good exam would have identified the deficit and avoided litigation.
Case # 10-Inadequate Tendon Evaluation
The patient was a 15-year-old male who cut the palmar aspect of his right hand. He was taken to the ED at Hillside Hospital, which was staffed by Coastal Emergency Services of Memphis. Dr. R. was the physician on duty. The plaintiffs alleged that Dr. R. negligently failed to perform tests to assess profundus and sublimis tendon function; failed to determine that the profundus tendon on three fingers was severed; and failed to perform tests for sensation, which caused him to fail to diagnose severance of the digital nerve. Dr. R.'s treatment consisted of asking the patient to make a fist, cleaning the wound with betadine, and then suturing the laceration. No referral was made to an orthopedic surgeon, nor was the patient informed of the risk of tendon injury. The patient was given instructions for the care of the sutures, and was told to see his family physician to have the sutures removed. However, the four sutures fell out on their own.
The patient noted that as the swelling reduced, he could not flex his fingers toward his palm. Three weeks after the injury, his family physician diagnosed tendon injury. His physician referred him to an orthopedic surgeon. A secondary repair of the tendon injuries was performed by grafting the tendons and the digital nerve injury in a two-stage procedure. The plaintiff fully recovered and has no permanent impairment. The plaintiff did lose income for two summers as a carpenter. Claims were made against Dr. R. for negligence and against Coastal for breach of the duty to determine Dr. R.'s fitness for the position.
A jury returned a $100,000 verdict against Dr. R. and a $250,000 verdict against Coastal.13
Once again, the examining physician must check a specific tendon with a test designed to check that particular tendon. For example, the flexor digitorum profundus is tested by asking the patient to flex the distal interphalangeal joint while the proximal joints are held in an extended position. The flexor digitorum superficialis is tested by holding all the other fingers in the hand fully extended and asking the patient to flex the finger to be tested.14 Asking the patient to simply make a fist does not adequately test the profundus and superficialis tendons, and this resulted in a lawsuit.
Case # 11-Failure to Perform a Tendon Examination
The patient was a 26-year-old male, who presented to triage with a complaint that he injured his right hand on glass at 2:30 a.m. and sustained a jagged laceration to his palm. In fact, the patient slipped and fell while holding a beer bottle in his right hand. In the patient history, the physician noted "as above." On physical examination, the physician noted "right hand-stellate laceration base of the palm. Third finger, one inch laceration, distal pulses." Impression was "Lacerations: right hand: palm and third finger."
The physician ordered an x-ray of the hand that was negative for fracture or foreign body. The physician wrote the following procedure note: "No. 10 stitches, 4-O nylon; wound care; stitches out in 7-10 days; F/u FMD." The patient received a betadine dressing and a tetanus shot. The patient was discharged with an instruction sheet from the physician that noted, "See your doctor in 7-10 days to have sutures removed. Keep clean and dry. Tylenol for pain. There was a check mark next to a "Wound Care" box, but there were no additional specific wound care instructions given.
After one week, the patient became concerned because he was unable to voluntarily move the index, middle, and ring fingers of his right hand. He also developed numbness in the thumb and around the palm laceration. At seven days post injury, he went to a clinic and was seen by the general physician on duty. The physician cleaned the wound and referred the patient for suture removal. At 10 days the sutures were removed, and the patient was referred to a surgeon for a hand evaluation. The surgeon examined the patient's hand and discharged the patient without follow up. Two weeks later, now 21-days post injury, the patient saw a hand doctor who said to the patient, "You should have seen me sooner," and told the patient that he had sustained tendon and nerve injury to the hand. The patient was "unable to flex the right middle finger at all." That physician also carefully noted two-point discrimination in the fingers at 5 mm in the fourth and fifth fingers, and 20 mm in the thumb, index, and middle fingers. The patient had surgery 23-days post ED visit.
At one year, the patient had residual numb sensation in the entire middle finger and index finger of the right hand. The strength in his hand was 75% normal. The patient was able to return to full-time work.
The emergency physician group and the insurance company settled the matter for an undisclosed amount.15
Once again, who caused the injury here? The patient did, with a broken beer bottle. The physician did not document a tendon examination, and probably did not perform a tendon examination. While testifying in court five years after the alleged injury, it is hard to convincingly claim that you remember specifically testing tendon function.
It is also very common for a patient to delay follow up for an extended period of time. Perhaps the patient went back to work too early and turned a partial tendon injury into a complete injury. Carefully document mandatory follow-up instructions. The patient's failure to follow up can create a strong defensive position for the emergency physician. Don't lose this opportunity to demonstrate good patient care and to assert that the patient contributed to his own injury by not following up as instructed.
Missed Tendon Injury-Summary and Recommendations
The emergency physician should perform a tendon examination on all extremity wounds. That examination should be specific to the tendons that may be involved based upon the wound depth and location. The second emergency physician should carefully document the results of the examination.
It is impossible to remember all the tendons and their specific functions. That barrier should be overcome through a systems approach. The examining physician should have a guide to assist in tendon identification and evaluation of function.
The ED staff should do a regular wound care quality monitor in order to make sure that tendon evaluation is documented in the appropriate cases. If there is any question regarding tendon function, or if there is a partial tendon injury, consult orthopedics. Return visits for wound complications may represent a wonderful opportunity to identify a missed diagnosis. The emergency physician should not rely upon the initial examination. Perform an independent evaluation of tendon function when patients return to the ED.
Conclusion
There is a lot of opportunity here. A meticulous examination, good documentation with aggressive management, and early mandatory follow-up could have a dramatic impact on this hotbed of emergency medicine malpractice litigation. The emergency physician can take significant strides toward limiting exposure in both areas: retained foreign bodies and missed tendon injuries.
References
1. Kaiser CW, et al. Injury infection and critical care. J Trauma 1997;43(1):107.
2. Sparks V. Blanchard Valley Hospital, 596 N.E. 2d 541 Oh. Ct. of Appeals, March 13, 1991 Ohio.
3. Re: Collazo.
4. Monthey DE, et al. Ann Emerg Med 1996;28:7-9.
5. Anonymous.
6. Robert Petty v. Capitol Emergency Associates, Georges County (Md) Circuit Court, No. 89-11204 Maryland.
7. Anonymous.
8. Lammers RL, et al. Detection & Management of Foreign Bodies in Soft Tissue. Em Clin North Am 1992;767-781.
9. Al-Zahrani S, et al. Ultrasound detection of radiolucent foreign bodies in soft tissue compared to CT scan. Ann Saudi Med 1995;15:110-112.
10. Anonymous.
11. Anonymous.
12. Anonymous.
13. Daniel E. Hickman and Father James Hickman v. Robert E. Ray, M.D. and Coastal Emergency Services of Memphis, Inc. Jiles County (Tn) Circuit Court, No. 8750 Tennessee.
14. Simon RS, et al. Emergency Orthopedics: The Extremities 2nd ed. Chicago: Appleton and Lange; 1987.
15. Re: Blasek.
Correction
Due to an oversight, the title of the April 1998 issue contained a misspelling. If you would like a corrected copy of this issue, please contact American Health Consultant's Customer Service Department at 1-800-622-2421.
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