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“Just a quick look” can be costly

01 January 2012

Mrs W, a 42-year-old staff nurse, had long-standing poorly-controlled diabetes. While shopping at the weekend, she twisted her right ankle stepping off a kerb to avoid a push chair, and it became swollen and mildly painful.

The following Monday, she asked one of the doctors on the ward where she worked to “have a quick look at it”. Dr J examined the ankle in the ward office and diagnosed sprained ligaments. Dr J did not document this brief consultation.

Forty-eight hours later, the swelling had not improved so Mrs W asked Dr J to have another look at her ankle and he sent for a plain ankle x-ray. Dr J reviewed the film and reassured Mrs W that there was no fracture, insisting on the sprain diagnosis.

One month after the injury, with persistent swelling and redness, Mrs W went to see her GP, Dr Y, with a self-diagnosis of cellulitis. During the consultation she mentioned the normal x-ray organised by Dr J. Dr Y prescribed amoxicillin to treat the suspected cellulitis.

The following week, Dr Y saw Mrs W again, and was unable to palpate peripheral pulses bilaterally. Dr Y queried the initial diagnosis of cellulitis and sought urgent telephone advice from Mr N, a vascular surgeon. With no evidence of acute ischaemia, Mr N was not concerned and advised that Mrs W should continue the oral antibiotics and suggested she attend a routine outpatient appointment.

Three weeks later, Mr N assessed Mrs W in an outpatient clinic, studied her x-ray, and sent her for ankle-brachial pressure indices (ABPIs) and an arterial duplex ultrasound of the lower limbs. Following a further appointment, with the investigations not revealing any significant macrovascular insufficiency, Mr N then referred Mrs W for an outpatient orthopaedic opinion. Almost three months following the initial injury, Mrs W was assessed by Mr B, an orthopaedic surgeon, who diagnosed a total midtarsal and hind- foot Charcot collapse with poor prognosis.

Mrs W made a complaint against all the doctors involved. On examination of the case, there was no documentation from Dr J’s initial consultations and it transpired that Dr J did not even know that Mrs W was diabetic. The plain x-ray requested by Dr J did reveal features of established neuropathic osteoarthropathy of the midtarsal joint of the right foot, which was missed by both Dr J and Mr N.

Having been reassured that there was no significant injury, Mrs W had continued to work and weight-bear through the affected foot until the correct diagnosis was finally made. The repeated misdiagnosis had resulted in a delay and failure to initiate potentially effective early treatment.

The experts, although not critical of Dr Y or Mr B, were critical of Dr J and Mr N. Despite two separate consultations and further investigation, the failure of Dr J to document his interactions with Mrs W was criticised. The experts were critical of Mr N’s management, believing it fell below the acceptable standard in that he failed to correctly interpret the history and findings on examination, which contributed to a delay in reaching the correct diagnosis and a poor prognosis for Mrs W.

The case could not be defended and was settled for a moderate sum.

Learning points

  • Having a member of staff ask for an informal medical opinion is a common event for most doctors. Doing things in a by-the-by way often means not taking a history, or documenting and even dealing with medical problems that are beyond our expertise. However, the medical responsibility remains the same.
  • Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal or working relationship.
  • Knowing the relevant past medical history of any patient is always useful, even for apparently minor injuries.
  • When looking at an x-ray, it is always useful to have a global look at it rather than exclude a diagnosis. The fact that in this case there was no new fracture did not make the x-ray “normal”.
  • Severe injury associated with Charcot osteoarthropathy may occur following minimal or unperceived trauma.
  • Non-weight-bearing immobilisation in the acute inflammatory stage is crucial to a successful treatment outcome.
  • Any patient with peripheral neuropathy who presents with a hot swollen foot should be regarded as having an acute neuropathic osteoarthropathy until proven otherwise. Guidance can be found here – TS Roukis, T Zgonis, The Management of Acute Charcot Fracture-dislocations with the Taylor’s Spatial External Fixation System, Clin Podiatr Med Surg (2006 Apr; 2)