Surgical Management Challenges

Background

During a game of football, a nineteen-year-old male sustained a fracture to his tibia/fibula. The patient was referred to a private consultant who undertook a surgical repair of the fracture by Open Reduction Internal Fixation (ORIF).

Incident

On the first postoperative day, a Saturday, nursing staff noticed that the patient’s toes were dusky, his pedal pulse was difficult to palpate and he complained of numbness. The nursing staff contacted the consultant, who asked them to continue to observe.

The consultant visited the patient on Monday morning, day three postoperatively and diagnosed the patient with compartment syndrome and arranged for emergency surgery. Unfortunately, the delay led to the patient developing osteomyelitis, necessitating further surgeries and the possibility of a future below-knee amputation.

The patient initiated legal proceedings against the consultant, alleging a delay in further surgery and a failure to respond appropriately to his changing clinical condition.

Learning points

1. Clinical Judgment and Decision-Making: The clinical judgment of the surgeon was identified as a factor in the outcome of this case. A review of PMP cases notified over a six-year period revealed that in 71% of cases, the clinician’s decision-making was a contributing risk factor, impacting patient outcomes. This highlights the need for consultants to regularly update their skills and knowledge of surgical techniques and to follow best practice guidance.

2. Compartment Syndrome Management: Acute compartment syndrome is a limb/life-threatening surgical emergency requiring immediate decompression. Tibial fractures are a common cause of this condition. Clinicians should have a low threshold for reassessment when a patient’s symptoms persist or deteriorate. In this case, inadequate patient assessment and insufficient postoperative monitoring by the consultant led to delayed intervention.

3. Documentation: Accurate and thorough documentation of clinical findings is essential. In this case, there was insufficient documentation, which is crucial for high-quality patient care and the defense of malpractice cases. Adhering to the British Orthopaedic Association (BOA) best practice guidelines on documentation can help support and defend clinical decision-making.

4. Reflective Practice: Adverse events, while distressing, should be viewed as an opportunity for reflection, learning, and adapting changes to a clinician’s practice, ultimately aiming to improve patient care.

Summary

Adverse patient outcomes rarely arise from a single cause. Factors such as suboptimal technical skills, poor clinical decision-making, procedural complications and ineffective communication within the surgical team can all contribute to an adverse outcome.

Additionally, Inadequate informed consent that fails to advise the patient of the possible complications that may arise may also contribute to a patient’s dissatisfaction with the care provided, which ultimately may give rise to a claim or a complaint.

Consultants should ensure they have adequate professional insurance to cover all the interventions they undertake. In addition, they should notify their insurance provider of any changes to their scope of practice, in line with the terms and conditions of their policy.