Does a worker's compensation (workers comp) doctor's initial failure to diagnose a flexor tendon laceration, followed by a delayed referral to a hand specialist, constitute malpractice in a patient with persistent limited flexion 2 months post-surgical repair?

From the Guidelines

There may be a case for medical malpractice against the workers' compensation doctor for delayed diagnosis of the flexor tendon laceration, as the two-week delay in recognizing the tendon injury could be considered a deviation from the standard of care. The standard of care for suspected tendon injuries typically involves a thorough physical examination including specific tests to assess tendon function, as noted in general medical practice standards 1. The two-week delay in recognizing the tendon injury could be considered a deviation from the standard of care if a reasonably competent physician should have identified it during the initial evaluation. Flexor tendon injuries generally have better outcomes when repaired within 7-10 days of injury, and delayed diagnosis can lead to poorer functional outcomes like the difficulty with full flexion the patient is experiencing. However, establishing malpractice would require proving that this delay directly caused the patient's current limitations, which would need expert testimony, as expert witnesses play a crucial role in explaining scientific matters and providing opinions to jurors and judges 1. The hand specialist appears to have acted appropriately by performing surgery promptly after the referral. To definitively determine if malpractice occurred, a medical expert would need to review the complete medical records, including the initial examination documentation, to assess whether the workers' compensation doctor's failure to diagnose the tendon laceration initially represented negligence that directly caused harm to the patient, considering the principles of malpractice litigation and the importance of timely referral to specialists 1. Ultimately, the assessment of malpractice should focus on improving the overall process of care delivery, providing professional safety tools, training, and support to clinicians, and fostering a shift from a culture of blame to one of collaboration and collective learning, as recommended in recent consensus guidelines 1.

Some key points to consider in this case include:

• The importance of timely diagnosis and treatment of flexor tendon lacerations
• The potential consequences of delayed diagnosis, including poorer functional outcomes
• The role of expert witnesses in establishing malpractice
• The need for a thorough review of medical records to determine if malpractice occurred
• The importance of fostering a culture of collaboration and collective learning in healthcare.

In terms of the quality of care, it is essential to evaluate the outcomes according to the consequences of the intervention and whether all required conditions were met, including compliance with the law and informing patients about the risks, as noted in recent recommendations on assessing the quality of surgical interventions 1. The discussion of clinical outcomes should be supported by evidence-based decision aids as part of shared decision-making and advance care planning, considering the benefits and harms jointly identified by care practitioners, individual patients, and experts.

From the Research

Malpractice Case

• The patient's case involves a flexor tendon laceration of the finger, which was not initially noted by the workers' comp doctor, but later recognized as a cause of difficulty with flexion of the finger 2.
• The workers' comp doctor referred the patient to a hand specialist and ordered an MRI, which led to surgery being performed 4 days later 3.
• The patient has difficulty with full flexion 2 months post-repair, which may be related to the timing and technique of the surgery, as well as the rehabilitation protocol used 4.

Potential Malpractice

• The workers' comp doctor's initial failure to note the tendon laceration may be considered a breach of standard care, as timely recognition and treatment of flexor tendon injuries are crucial for optimal outcomes 5.
• The delay in referring the patient to a hand specialist and ordering an MRI may also be considered a deviation from standard care, as prompt evaluation and treatment are essential for preventing further complications 6.
• The hand specialist's decision to perform surgery 4 days after the referral may be considered appropriate, as early intervention is often necessary to prevent further damage and promote optimal healing 2.

Responsible Parties

• The workers' comp doctor may be held responsible for the initial failure to diagnose and treat the tendon laceration, as well as the delay in referring the patient to a specialist 6.
• The hand specialist may be held responsible for the outcome of the surgery and the rehabilitation protocol used, as the patient's difficulty with full flexion 2 months post-repair may be related to the technique and timing of the surgery, as well as the postoperative care 4, 3, 5.