A Clinical Risk Case Study- Failure to Treat a Hand Injury Appropriately

Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Dr Stephen Metcalf MB BS BSc (Hons) FRCP FCEM, Consultant in Accident and Emergency Medicine

The Scene

The Patient attended Accident and Emergency in the early hours of the morning, two days after sustaining an injury to the left hand, suffering cuts to both the index and middle finger.

The FY2 A&E doctor noted a large oozing cut at the side of the main knuckle joint and index finger, with reduced movement. X-rays identified a non-displaced, intra-articular fracture of the head of the middle finger metacarpal.

The A&E doctor discussed the fracture with the on call orthopaedic team (FY2) who advised if the fracture was 'closed' to undertake conservative treatment. The A&E doctor diagnosed the Patient with a closed fracture and proceeded to close the wound with glue, instead of sutures. The doctor did not assess nerve or tendon function, did not undertake any exploration or washout of the wound nor administer antibiotics.

At the Patient's follow up consultation 3 days later, he was diagnosed with an open fracture and was advised that he would require surgical extensor tendon repair, a washout of the wound and intravenous antibiotics.

TMLEP's Independent Clinical Findings

The TMLEP Independent Review identified that the care provided by the FY2 A&E doctor to the Patient was substandard and the diagnosis and subsequent treatment was incorrect, resulting in unnecessary harm to the patient.

When wounds to the hand are over joints, concerns should be raised, as any rupture to the joint capsule can allow pathogen entry, which can result in the joint being damaged rapidly. Therefore, it is standard practice for such an injury to be carefully examined, explored, cleaned and irrigated and antibiotics administered if appropriate. In addition, 'open fractures' should always be seen by the specialist team at the time of presentation.

TMLEP's Independent Review identified that in this case, the doctor's examination was inadequate. They did not carry out the appropriate exploration and washout to identify that there was an open fracture beneath the laceration and at the joint, and therefore failed to diagnose an open fracture rather than a closed one. Had the open fracture been identified the Patient would have most likely been admitted under the care of an orthopaedic expert, antibiotics would have been administered and they would have been sent to theatre.

The review raised further concerns due to the fact that the Patient had sustained the injury two days prior to attending A&E without receiving treatment. The likelihood of the infection developing in this time is extremely high, especially as the treating clinician did not administer antibiotics and closed the wound using glue, which was highly inappropriate given the fact that the wound was old and would almost certainly lead to infection. This demonstrates further substandard care.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

Hand trauma management is generally poor within the 'urgent care' setting. Capsule, tendon, nerve and joint injuries are often missed. To ensure that substandard care is prevented in the future, clinicians and healthcare providers need to ensure the following:

  1. There is sufficient middle grade supervision in A&E 24/7 for associated Urgent Care Centre's to seek advice from.
  2. On call FY2s should not be giving telephone advice and should be physically present to examine the patient.
  3. Wounds to the hand over a joint should always be cleaned and irrigated and antibiotics administered, especially if the wound is old and/or an open fracture is diagnosed.
  4. Open or old wounds should not be closed with glue, even if preferred by the patient given the risk of infection. Stitches are the most appropriate way to close a wound of this type but only by an experienced clinician.
  5. Awareness should be given to the fact that the longer you leave an open wound, the higher the chance of infection. Dirty and contaminated wounds do better when treated early.
  6. Lacerations to the flexor surface of the hand should always be examined by an experienced doctor. A tendon and nerve injury should always be assumed until proven otherwise. Partial tendon injuries are easily missed.

To Conclude

This case is a prime example of substandard care and how this can be prevented in the future. When the Patient attended A&E initially he should have either been admitted under the care of the orthopaedic team who would have elevated the hand, administered intravenous antibiotics and sent the Patient to theatre for exploration and washout. Alternatively,  the Patient could have been discharged from A&E with the wound cleaned and dressed, his hand elevated in a high sling,  and with antibiotics. Arrangements would then be made to the local hand service the following day, with the anticipation of going to theatre.

 

Important Notice: This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0)203 355 9796.

The TMLEP Clinical Risk and Patient Safety Publishing Group and Dr Stephen Metcalf MB BS BSc (Hons) FRCP FCEM, Consultant in Accident and Emergency Medicine. (2018). A Clinical Risk Case Study- Failure to Treat a Hand Injury Appropriately. TMLEP Clinical Risk Case Studies. 1 (6), 1.