From the Guidelines
There is a potential case for medical malpractice against the workers' compensation doctor due to the delayed diagnosis of the flexor tendon laceration, which may have contributed to the patient's ongoing difficulties with finger flexion. The initial failure to identify the tendon injury during the first examination represents a possible deviation from the standard of care, as prompt diagnosis and treatment of tendon lacerations is crucial for optimal outcomes, with MRI being ideal for evaluating tendon injuries and helping with surgical planning 1. The two-week delay before recognizing the flexion difficulty and referring to a specialist could be considered negligent, as flexor tendon injuries typically require repair within 7-10 days of injury for best results. This delay likely contributed to the patient's ongoing difficulties with finger flexion even after surgical repair. However, the workers' comp doctor did take appropriate corrective action by ordering an MRI and promptly referring to a hand specialist once the problem was identified, as MRI is commonly used to evaluate the level of tendon retraction, the quality of the tendon stump, and the associated injuries including pulley injuries 1. The hand specialist appears to have acted appropriately by performing surgery within a reasonable timeframe after the referral. Some key points to consider in this case include:
- The importance of prompt diagnosis and treatment of flexor tendon lacerations
- The role of MRI in evaluating tendon injuries and guiding surgical planning
- The potential consequences of delayed diagnosis and treatment, including decreased finger function and increased risk of complications
- The need for a medical expert to determine whether earlier diagnosis and treatment would have likely resulted in better finger function. To establish malpractice, it would need to be proven that the initial missed diagnosis fell below the standard of care and directly caused the patient's poor outcome, with consideration of the sensitivity and specificity of MRI for diagnosis of tendon injuries, as reported by Rubin et al with a sensitivity of 92% and specificity of 100% in cadavers 1.
From the Research
Assessment of Malpractice
- The workers comp doctor initially failed to note the tendon laceration, which could be considered a breach of standard care 2.
- The delay in diagnosis and subsequent referral to a hand specialist may have impacted the patient's outcome, as early intervention is crucial in flexor tendon injuries 3, 4.
- The hand specialist's decision to perform surgery 4 days after the referral, and the patient's difficulty with full flexion 2 months post-repair, may be related to the initial delay in diagnosis and treatment 5, 6.
Potential Liability
- The workers comp doctor may be liable for the initial misdiagnosis and delay in referral, which could have contributed to the patient's poor outcome 2.
- The hand specialist's management of the case, including the decision to perform surgery and the post-operative rehabilitation, may also be subject to scrutiny 3, 4.
- However, it is essential to note that the complexity of flexor tendon injuries and the variability in patient outcomes make it challenging to determine liability without a thorough review of the case 5, 6.
Rehabilitation and Outcome
- The patient's difficulty with full flexion 2 months post-repair may be related to the rehabilitation protocol, which is a critical component of flexor tendon injury management 5, 4.
- The limited evidence on rehabilitation interventions for flexor tendon injuries highlights the need for further research in this area 5.
- The patient's outcome may have been influenced by various factors, including the timing and technique of the repair, the post-operative rehabilitation, and individual patient characteristics 3, 2, 6.