Did the workers' compensation (workers comp) doctor commit malpractice by failing to initially diagnose a flexor tendon laceration, leading to a delayed referral to a hand specialist?

From the Guidelines

There is likely not a strong case for malpractice against either physician, as the workers' compensation doctor's timely referral and the hand specialist's prompt surgical intervention resulted in a good clinical outcome with full flexion recovery within 2 months post-repair. The workers' compensation doctor initially missed the flexor tendon laceration, but they appropriately referred the patient to a hand specialist and ordered an MRI when symptoms became apparent at the two-week follow-up, as supported by the use of MRI for evaluating tendon injuries and surgical planning 1. The hand specialist then performed surgery within a reasonable timeframe (4 days after referral), which is consistent with the standard of care for flexor tendon injuries. For malpractice to be established, four elements must be proven: duty of care, breach of that duty, causation, and damages, as outlined in the role of the expert witness in malpractice proceedings 1. Although there was a delay in diagnosis, the prompt corrective action and good outcome suggest minimal or no permanent harm resulted from the delay. The workers' compensation doctor's timely referral once the problem was identified likely mitigates liability. Additionally, flexor tendon injuries can sometimes be difficult to diagnose initially, especially if there is minimal functional deficit at first presentation, and MRI is ideal for evaluating tendon injuries, as reported by Rubin et al with a sensitivity of 92% and specificity of 100% in cadavers 1. The good surgical outcome further suggests that the standard of care was ultimately met through appropriate referral and treatment, making a successful malpractice claim unlikely against either physician.

Key points to consider in this case include:

• The use of MRI for evaluating tendon injuries and surgical planning, as supported by 1
• The role of the expert witness in malpractice proceedings, as outlined in 1
• The importance of timely referral and prompt surgical intervention in achieving a good clinical outcome
• The difficulty in diagnosing flexor tendon injuries initially, especially with minimal functional deficit at first presentation
• The standard of care for flexor tendon injuries, including the use of MRI for evaluation and surgical planning, as reported in 1

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 and referred to a hand specialist 2.
• The delay in diagnosis and treatment was approximately 2 weeks, after which the patient underwent surgery and achieved normal full flexion 2 months post-repair.
• According to a study on delayed primary repair of flexor tendons in Zone 2, the time elapsed between injury and surgery is not a significant risk factor for a good outcome, as long as proper surgical methods and early mobilization are applied 2.

Potential Liability

• The workers' comp doctor may be liable for malpractice due to the initial failure to diagnose the tendon laceration, which led to a delay in treatment.
• However, the study on flexor tendon repair rehabilitation protocols suggests that modern improvements in surgical technique, materials, and rehabilitation may allow for good outcomes even with delayed treatment 3.
• The hand specialist's timely referral and surgical intervention may have mitigated the potential harm caused by the delay, but the initial delay in diagnosis and treatment may still be considered a breach of standard care.

Comparison to Similar Cases

• A study on open Achilles tendon lacerations found that prompt surgical treatment and proper wound care can lead to excellent outcomes, even in cases with significant delays in treatment 4.
• Another study on triceps tendon injuries highlights the importance of proper diagnosis and treatment, as well as the potential for good outcomes with timely and appropriate intervention 5.
• A study on postoperative complications after acute Achilles tendon rupture repair found that surgical delay can increase the risk of certain complications, such as wound dehiscence and sural nerve injury 6.