Failure to Diagnose Osteomyelitis Resulting in Permanent Damage
The Frick Case
Case Summary
This case involved a surgeon who negligently chose to operate on a patient despite clear indications that he should have postponed the non-emergent surgery. After completing this surgery, the patient was routinely seen by the surgeon and a wound care specialist for follow-up care. During those visits, the patient continued to show signs of a wound infection, which ultimately developed into a bone infection, osteomyelitis.
Despite the clear signs of infection that required immediate treatment, the surgeon and the wound care specialist repeatedly brushed off the patient’s symptoms and indications of infection until it was too late. As a result, the infection caused permanent damage leaving the patient permanently disabled.
Case Details
In late March 2019, Mrs. Frick suffered a fall and was diagnosed with a closed bimalleolar ankle fracture. As instructed by her providers, on April 3, 2019, Mrs. Frick was evaluated by an orthopedic specialist. An open reduction and internal fixation, ORIF, surgery was recommended, and Mrs. Frick underwent an ORIF the same day to repair the fracture.
Defendant Dr. Ricard performed the surgery to repair the fractured ankle. During the surgery, a nurse noted that fracture blisters were present on the medial and lateral side of the left ankle. Fracture blisters are the result of the sheer force from within the layers of skin on high impact injuries and rapid soft tissue swelling. When fracture blisters are present during a procedure, the risk of infection significantly increases, and therefore, are a known contraindication to surgery. Despite Mrs. Frick’s fracture blisters, Dr. Ricard chose to proceed with the non-emergent surgery. Following surgery, Mrs. Frick was told to be non-weight bearing and was given a course of oral antibiotics.
In addition to following with Dr. Ricard, Mrs. Frick also followed up for her wound care with Defendant Dr. Danton. On May 14, 2019, Mrs. Frick’s wound was examined by a provider from Dr. Danton’s office, and the provider found that Mrs. Frick’s wound probed to the hardware. With the wound probing to the hardware, which was attached to the bone, osteomyelitis should have been viewed as the major diagnosis to be evaluated, however, that was not the case.
Due to the appearance of Mrs. Frick’s wound, tissue cultures were obtained, which resulted in findings of a large amount of staphylococcus aureus, another clear sign of infection. Two days later, Mrs. Frick was seen by Dr. Danton. Despite Dr. Danton also noting that Mrs. Frick’s wound probed to the bone, again, a known sign and symptom of osteomyelitis, he failed to prescribe IV antibiotics. Rather, Mrs. Frick was prescribed an oral antibiotic, which is inadequate therapy for osteomyelitis. A wound probing to the bone suggests the presence of osteomyelitis and exposed hardware suggests that contamination of the area and osteomyelitis were present. As such, bone cultures were required, and Mrs. Frick should have been treated with IV antibiotics – neither of which were done.
On May 20, 2019, part of the hardware that was placed into Mrs. Frick’s ankle during the initial ORIF was removed by Dr. Ricard and tissue cultures were collected. Deep cultures again resulted in findings of a large amount of staphylococcus aureus. Dr. Ricard again ordered a course of oral antibiotics for 10 days post-op.
Infection of hardware is a deep infection.
Given that the hardware was attached to the bone, and that hardware and bacteria were not separate from one another, osteomyelitis should have been suspected until ruled out. Bone biopsies and cultures should have been taken, and IV antibiotics should have been prescribed, however, Dr. Ricard failed to do either.
Mrs. Frick’s incision failed to heal despite monthly visits with Dr. Ricard and weekly appointments with Dr. Danton. On multiple occasions, Mrs. Frick’s wound was noted as probing to the bone; however, no IV antibiotics were ever prescribed. Increasing pain, induration, and erythema in the setting of positive cultures for staphylococcus aureus should have strongly suggested the presence of osteomyelitis. However, Mrs. Frick’s condition was brushed off by her doctors who allowed her infection to go without the proper testing and treatment and ultimately caused permanent damage to her ankle.
From May to September 2019, Mrs. Frick’s wound showed waxing and waning changes – with no real signs of healing – which should have made her doctors suspicious for the presence of osteomyelitis.
On September 19, 2019, Mrs. Frick had an MRI of her ankle performed, which noted “Large joint effusion and high signal noted within the talus calcaneus and fibula. Cannot exclude osteomyelitis.” Mrs. Frick was not informed about a possible infection and no additional antibiotics were ordered.
It was not until October 3, 2019 that Dr. Ricard finally noted a concern about the possibility of osteomyelitis. Nonetheless, Dr. Ricard only gave Mrs. Frick a prescription for Keflex as a trial to see if her wound would improve and scheduled a follow-up appointment in 6-weeks (Keflex is useless to osteomyelitis). Dr. Ricard’s conduct demonstrated his lack of urgency or concern and further allowed the infection to continue without being properly treated.
Finally, in November 2019, Mrs. Frick was referred to an infectious disease specialist. The infectious disease specialist was shocked at the sight of Mrs. Frick’s ankle. The infectious disease specialist diagnosed Mrs. Frick with osteomyelitis and ordered IV antibiotics immediately to be administered for two weeks. She went as far as noting in her medical record, “Unsure why patient did not receive IV antibiotics in May (standard of care).” It is very rare that a treating physician will go as far as identifying in the patient’s medical record previous providers’ breaches in the standard of care, however, these instances were so egregious that the treating physician felt compelled to document such breaches in the standard of care.
As a result of the substantial amount of time that Mrs. Frick’s providers allowed her to go without diagnosing and treating the osteomyelitis that developed in her ankle, Mrs. Frick suffered irreversible damage that significantly impacts her daily life.
The Defendants in this case, through their own testimony and through the production of expert reports, took the typical approach of denying any responsibility for Mrs. Frick’s permanent damage by claiming that their treatment was proper, and there were absolutely no indications to provide Mrs. Frick with IV antibiotics any sooner than was ultimately done – over 6 months after her wound initially probed to the hardware.
As an initial matter, Dr. Ricard took the approach of stating that “surgery is frequently performed on patients with fracture blisters,” and the presence of fracture blisters during Mrs. Frick’s surgery in no way increased her risk of infection. While fracture blisters come with a known risk of infection, Dr. Ricard testified that “the only reason” he would hesitate to perform surgery on a patient with fracture blisters is “if the fracture blister is extremely large and directly where the incision needs to be.” Dr. Ricard conveniently did not consider the emergent, or non-emergent, nature of the surgery, and therefore, the fact that Mrs. Frick’s surgery could have been postponed, and should have been postponed, until the fracture blisters resolved was of no concern to him. Operating through fracture blisters should only be done if the surgical repair is emergent, and Mrs. Frick’s minimally displaced fracture did not require immediate surgical stabilization. Dr. Ricard’s failure to postpone the surgery given the presence of open fracture blisters increased the risk that Mrs. Frick’s ankle would become infected, which it ultimately did.
Generally, Dr. Ricard and Dr. Danton claimed that there was no reason to treat Mrs. Frick’s condition as osteomyelitis in the months that they were responsible for treating her ankle wound. Dr. Ricard and Dr. Danton ignored numerous signs and symptoms that should have directed them to, at a minimum, a suspicion of osteomyelitis.
The Defendants further ignored the obvious signs that oral antibiotics were insufficient for Mrs. Frick’s treatment, and they failed to properly prescribe IV antibiotics, a known effective treatment for osteomyelitis.
Despite their claims that their “wait-and-see” approach was proper, the Defendants ignored a multitude of signs and indications that Mrs. Frick’s wound had an infection involving osteomyelitis. Their lack of evaluation, testing, and treatment permitted her infection to persist and evolve to the point that permanent damage ensued.
Result
Shortly before trial, the parties reached an agreement to settle the case for a substantial amount.