This case involves a female patient with a history of diabetes who sustained a bruising injury to her right hand. Despite her injury, the patient continued to work regularly in her position at a grocery store; however, after several days had passed she was taken by EHS to the emergency room (ER), where she was seen and treated. She was given a splint and referred to orthopedic surgeon whom she saw the following day. The orthopedic surgeon applied a cast to the patient’s hand, and scheduled a follow up visit in 2 weeks. The following day, the patient returned to hospital complaining of pain in her hand. The patient’s cast was removed in the emergency department, however the orthopedic surgeon was not informed of this. No additional testing was performed during the visit. Several days later the patient presented to the orthopedic surgeon’s office, and based on clinical signs of infection he immediately sent the patient to hospital for admission for surgery. The patient was found to have a significant infection, and required surgical debridement which led to numerous complications. It is alleged that the infection should have been diagnosed sooner.
Question(s) For Expert Witness
- 1. If a patient's cast is removed, should his orthopedic surgeon be informed of this?
- 2. If a diabetic patient presents with recurrent pain in her hand due to previous trauma, would that warrant further workup?
Expert Witness Response E-045177
It is the standard of care to be very cautious in treating hand wounds, especially in a diabetic, and the patient’s orthopedic surgeon should probably have been called when the patient returned to the ED the next day. However, if there was no fracture and the patient was returning with pain, it was fine to remove the cast and, in fact, it is often the cast that is causing the problem – casts can cause compartment syndrome which can be dangerous. If the hand did not appear to be infected, no blood tests would be indicated. However, a few important questions remain. Were there breaks in the skin to cause infection? Did the hand at the second ER visit have any signs or symptoms consistent with infection? Was the cast too tight and possibly causing early compartment syndrome that was fixed by cast removal? If there were no signs of infection on the initial hand evaluation at all, there would not be any reason to do any further evaluation, especially if the cast was tight and thought to be causing the pain. It was not wrong to remove the cast though, as the cast prevented the ED doctor from actually examining the hand. A cast placed in first week might cause compartment syndrome as swelling occurs. Furthermore, no one needs a cast for this sort of injury, so that is probably why the ER doctor removed the cast and did not put it back on.
Expert Witness Response E-025783
If a patient’s cast is removed, her orthopedic surgeon typically should be informed of this. If a diabetic patient presents with recurrent pain in her hand due to previous trauma, further workup is warranted depending on the presenting clinical signs. It is true that patients with diabetes are at higher risk for infection. X-rays would be an important test to conduct, but that depends on if the patient had had an x-ray on the initial visit. A repeat x-ray would not necessarily be required, unless there was new trauma or concern for a necrotizing infection as discussed above.