Achilles, tendon, rupture, GP, step, surgical reconstruction, referral, diagnosis, Simmonds, Thompson

Dance floor mishap

...An urgent referral after consultation with Dr P would have led to a prompt diagnosis of Achilles tendon rupture and direct primary repair...

 

BACKGROUND: A 56-year-old house painter – Mr G – presents at a minor injuries unit with a painful ankle and is seen by a triage nurse. The patient says he had been engaged in some lively dancing at a wedding four days previous and had awoken the next morning with pain and swelling. On examination swelling is noted to the lateral malleolus but no bruising, erythema or deformity is evident. Pain is noted on palpation of the posterior talofibular ligament and Achilles tendon. Mr G demonstrates a full range of movement in his ankle/foot and can weight-bear with a limp. The nurse diagnoses ankle sprain and advises rest and joint elevation with ice packs. Mr G is advised to return for review or to see his GP.

A week later Mr G attends his GP practice and is seen by Dr P. He complains of a painful ankle and in particular his Achilles tendon. The GP notes swelling and some minor bruising in the lateral aspect of the foot. He records that on examination there is tenderness in the Achilles region but no "step" in the tendon. He prescribes an NSAID with PPI cover and recommends Mr G to persevere with the ice and joint elevation. He recommends a physio who provides telephone advice on gentle exercises and pain management.

Mr G returns to the practice three weeks later and is seen by another GP – Dr J – who specialises in sports injuries. The GP records that the patient has experienced ankle pain for the last five weeks since an injury while dancing on a slippery wood floor. The patient recalls feeling a "sudden snap" with sharp pain. Examination reveals a negative Simmonds-Thompson test and a "step" in the Achilles tendon. Dr J diagnoses a ruptured Achilles tendon and refers the patient to the local orthopaedic clinic.

Next day an orthopaedic registrar examines Mr G and confirms the diagnosis. On advice the patient opts for non-surgical treatment with a "moon boot" and periodic review.

Six months later Mr G is still considerably debilitated – suffering with pain and difficulty walking. There is still a step in the tendon with grossly reduced plantar flexion, and he cannot weight-bear on his toes. Mr G undergoes surgery and is found to have a total rupture with a 2cm gap. Surgical reconstruction is undertaken using a flexor hallucis longus tendon transfer and the patient endures lengthy rehabilitation.

A letter of claim for damages is sent to Dr P alleging clinical negligence in the delayed diagnosis and referral of Mr G for a ruptured Achilles tendon. The letter cites a specific failure to adequately examine the patient and perform a Simmonds-Thompson test or tiptoe test. This led to delayed treatment necessitating secondary reconstruction using tendon transfer, with additional pain, reduced range of movement and restricted mobility in the big toe.

ANALYSIS/OUTCOME: MDDUS commissions a GP expert who reviews the case file. In his analysis the expert notes that in the letter of claim Mr G insists on having described a sudden sharp pain or "snap" in his ankle while dancing at a wedding, but in the notes from the triage nurse and the consultation with Dr P there is no specific mention of the point of injury – only a brief description of "ankle pain/swelling".

The expert also observes that the examination of Mr G did focus in part on the Achilles tendon but that "no step" was noted. However, in the expert's view Mr G is vulnerable to criticism in not having also asked Mr G to "stand on his tiptoes", with follow-up employing the Simmonds-Thompson test. This would have been particularly crucial if Mr G had indeed mentioned feeling acute pain on injury. The factual dispute is a matter for the court but if Mr G had mentioned feeling acute pain on injury then a more detailed examination was required. A negative Simmonds should have prompted certain referral.

A consultant orthopaedic surgeon is asked to comment on causation (consequences of any breach of duty of care). He opines that an urgent referral after consultation with Dr P would have led to a prompt diagnosis of Achilles tendon rupture and direct primary repair – generally indicated within four weeks of injury. This would have prevented the need for the later more extensive flexor hallucis longus tendon transfer and subsequent pain, recovery and loss of mobility in the big toe.

Given doubt over the reported nature of the patient’s injury and the factual dispute, and Dr P having not conducted any further tests other than palpation of the Achilles tendon, MDDUS seeks to settle the case with no admission of liability.

KEY POINTS

  • Ensure notes record the specific mechanism of injury and nature of pain.
  • A specific injury considered part of the differential diagnosis list calls for specific examination to investigate that potential.
  • Justify clinical decisions in the notes even if that includes taking no action.