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Trophic ulcer leads to foot amputation

01 May 2006

Mr L, a builder in his forties, visited his GP, Dr M, and gave a history of a painful knee. He was noted as smoking 10 to 15 cigarettes a day.

Mr L re-attended the practice about seven months later, this time with a painful right foot. As Mr L’s toes were red and tender, Dr M referred him to the A&E department at the local hospital. On examination, Dr Z noted tenderness. X-rays were found to be normal but a detailed vascular examination was not carried out.

A year later Mr L again attended A&E with the same condition. A&E doctor, Dr D, noted that his dorsalis pedis pulse was poor and advised him to stop smoking. A trophic ulcer was noted between his toes.

Over subsequent months Mr L’s trophic ulcer showed no sign of healing, despite repeated dressings and administration of antibiotics. A repeat examination in A&E three months after the first found Mr L to have a good femoral pulse but absent popliteal and pedal pulses and a pale painful foot with no sensation. An acutely ischaemic limb was diagnosed.

Angiograms showed an occlusion of the popliteal artery with no collateral formation, suggesting an acute event. Thrombolysis was therefore attempted but failed to salvage the foot. The angiograms also showed distal small arterial disease which could not be bypassed or angioplastied. Mr L eventually underwent a below knee amputation.

He subsequently brought an action against Dr Z and Dr M.

Expert opinion

An emergency medicine expert for the defence felt that Dr Z should have referred Mr L to a vascular surgeon if he found the pulses absent in conjunction with critical ischaemia.

A GP expert for the claimant believed that Dr Z should have sent Mr L for an immediate vascular referral. He felt that failure to take an adequate history, examine the limb to a basic standard and to consider the significance of the developing wound amounted to an unacceptable standard of care.

Two vascular experts felt that Mr L’s right leg was irretrievably lost by the time he was admitted to hospital. His chance of limb survival was poor because of a long history of smoking and failed thrombolysis. He would not have avoided a major amputation as he had distal small arterial disease which could not be bypassed by surgery or treated by angioplasty.

Investigations following Mr L’s second visit to an A&E department would probably have revealed a thrombotic tendency and diseased leg vessels. If Mr L had been seen by a specialist earlier, he would have received the same treatment but with less urgency.

MPS successfully defended the claim on causation, and the claim was eventually discontinued.

Learning points

  • For a claim of negligence to be successful, it must be proved not only that the treatment of a patient has been negligent but that he or she has been harmed as a result.    
  • Always be aware of peripheral vascular disease in patients who present with a history of heavy smoking.    
  • If trophic ulcers show no signs of healing, this is a sign of poor circulation and the patient should be referred to a vascular specialist.   
  • Risk factor modification, including attendance at a smoking cessation clinic, can help patients with a long history of smoking.

Further information

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