Orthopedic Expert Witness Report: Severe Thumb Injury

To Whom It May Concern:

Re: Medical records review and treatment of severe thumb injury of Jackson G.

I, ******, MD, am a board-certified orthopedic surgeon who has been in continuous active practice for 35 years. During my t residency, the chairman of my residency program was a hand surgeon. Also during my residency, I had a mini-fellowship in hand surgery and reconstructive hand surgery. During the first 28 years of my practice experience, I was very active in having hand surgery as my subspecialty of orthopedics and treated hundreds of finger injuries. For several years I was the company hand surgeon of choice for a large steel mill which frequently had not only single but multiple traumatic finger amputations. I have also treated pediatric hand injuries, not only crush injuries but blast injuries and sharp lacerations as well. In the adult population in addition to all forms of trauma, I also performed carpal tunnel releases; Dupuytren’s excisions and joint reconstruction surgery with implants for severe arthritis. I am very familiar with and have used various means of fracture fixation in the hand, frequently with staged procedures.

I have been asked to review the medical records and treatment of Jackson G. an 11-year-old male with a dominant thumb soft tissue and bone injuries sustained in an automobile accident. The records reviewed are listed below. After the careful and intensive review of the records provided to me, I have formed certain opinions regarding the treatment of Jackson G. These opinions are based on my training, my practice experience, my continuing medical education, and a reasonable degree of medical certainty. Should additional information come to light in this case, I reserve the right to amend or alter my opinion. Should this case come to litigation I have no financial interest in the outcome of this case.

Records reviewed

1. CHOP records.
2. Radiology records as well as copies of x-rays.
3. Operative consent and operative record.
4. Records of Jennifer T., MD at the Dept. of Orthopedics, ****, De.
5. Two unsigned reports of the medical treatment of Jackson G.
6. The chronological report was written by Dr. G. concerning his son’s thumb injury and treatment.
7. Pay only MRI center report of MRI of the right thumb of Jackson block.
8. Occupational therapy reports consisting of two pages and exercises.
9. Color photos.
10. Police report.

Facts

Jackson G. was involved as a passenger in a collision rollover type of motor vehicle accident. The circumstances of this event have been disclosed elsewhere within these medical records. Jackson G. was treated at the scene and eventually wound up at the *********. Apparently, Jackson was initially seen by an orthopedic resident concerning his thumb fracture and soft tissue injury. Then the on-call hand surgeon, Dr. C., was called. Apparently, from the records, Dr. C. had some initial conversation with the father who is a plastic surgeon and hand surgeon regarding the injury to the son’s thumb. X-rays had been taken and these revealed fractures of the thumb including what looks like a T-Condylar fracture of the distal end of the proximal phalanx of the thumb and a shattered distal phalanx of the thumb. The nail and nail bed were missing according to various reports. There are no records from the emergency room treatment concerning extensive contamination of the thumb which did include the thumb having loss of the nail and nail bed. Wishing to preserve as much tissue of the thumb as possible the father searched through the wreckage glass and other materials for a couple hours trying to find that the amputated nail and nail bed tissues. This tissue was not found. Dr. C., the treating hand surgeon, had a conversation with the patient’s father concerning the injury and the plan. In the operative report produced by Dr. C. some many days later, there is a notation of the refusal of Dr. G. to sign an op permit agreeing to completion of the partial amputation. Dr. C. then makes a statement that after further discussion the father then relented for completion of the partial amputation. Although from various reports Dr. C. did not unwrap the thumb and visualize the soft tissue damage or contamination of the wound, he then in his operative report indicates extensive contamination and using a rongeur to remove bone in order to clean up the contamination. For stabilization of fractures of the proximal phalanx, Dr. C. chose to use very small pins and left the end of these pins sticking out of the end of the thumb. There are several colored photos which reveal the condition of the thumb prior to surgery and afterward with the pins exiting the tip of the thumb. There is no mention in the operative record of any examination of the condition of the F PL tendon which attaches to the base of the distal phalanx. This examiner could find no comments concerning the extensor tendon as well, which also attaches dorsally to the base of the distal phalanx. Dr. C. reports creating a volar flap which is folded up over the remaining bone of the distal phalanx. A complete closure of the thumb was performed. After sterile dressing, the thumb and distal forearm were placed in a thumb Spica cast. In the records, there are additional color photos of the thumb with pins protruding from the end of the thumb and of an apparent significant amount of some soft tissue missing as well as the nail and nail bed. In this photo, there appears to be a large medial dog ear of skin. At the first post-op visit for Jackson with Dr. C., the mother indicates that they went to see a Dr. S. for a second opinion concerning the thumb. Apparently, a non-cast type of support was placed on the thumb which was not satisfactory with Dr. C.. Dr. C. put the patient back into a thumb Spica cast. On the post-op visit of 1/2/2012, there is a notation that the two pin sites are clean and the flap is 100% viable. There is a notation in Dr. C.’s records also that all the soft tissue was in good condition and that the x-ray showed no C.e in the alignment of the fracture fragments. Jackson was to be seen in a month and on the visit of 12/4 /2011 the patient was given a release to return to gym and sports that day. In the process of following x-rays of the thumb, it is noted that the initial x-rays in the emergency room revealed a large soft tissue defect involving the dorsal distal thumb and there was a comminuted fracture of the complete first distal phalanx as well as a displaced fractures of the distal end of the proximal phalanx. There is no comment in the initial emergency room x-rays of any bone being missing. At the time of surgery with Dr. C. specifically, points out missing bone from the distal phalanx. Later post op films show missing bone of the TU FT area of the thumb and longitudinal pins in place with one pin not traversing the fracture fragment. There is a report from Department of ************ Delaware where the patient was seen by Jennifer T., M D who felt that the F PL tendon had been amputated from the bone but was sitting at the end of the thumb and that there was nonunion of old fractures. This consultation was dated 9/12/ 13. Dr. T. in her report indicated that Jackson had been seen by additional two or three hand surgeons regarding possibilities of improvement of Jackson’s thumb condition. The complaints were those of the patient having extreme difficulty with gripping with thumb pinch, playing sports gripping racquets, and hypersensitivity of the tip of the thumb. This report of Dr. T. was generated after Jackson had had an MRI done on this thumb dated 1/5/ 2012. The MRI report states “amputation of the distal aspect of right thumb which includes the absence of distal phalanx and fracture of distal end of proximal phalanx”. There was also found to be evidence of non-union of a fracture fragment. The F PL tendon was noted to at the level of the fracture just before the DIP joint with a curving radial deviation into some scar tissue. The EPL was noted to cross the joint dorsally and connect to the remaining bone of the distal phalanx. The impression of this MRI was amputation of the distal right thumb noted at the level of the distal aspect of the proximal phalanx this MRI report was read by Valerie W. MD. Dr. T. felt that the patient was having pain from the non-union of the bone and that the weakness of grip especially holding sports racquets was coming from the transected FPL tendon.

Dr. T. went over the same options of treatment has had several other surgeons.

The pros and cons of each method were all laid out for the patient. These methods included taking a great toe from the foot and transplanting it to the thumb. There are 2 pages of exercises provided to the patient by Kelly F. an occupational therapist. I am not aware of any additional surgery on Jackson’s thumb at this time. It is clear to me that without additional surgery this young man will continue to have considerable difficulties with this right thumb and in particular strong pinch activities.

Summary

Jackson G. was involved in an unfortunate accident which injured his right thumb with the loss of the nail and nail bed with a considerable abrasion type of injury. There were also fractures present in both the distal phalanx as well as the proximal phalanx. The mechanism of the injury to the thumb was felt to be that of the thumb getting crushed between asphalt and the roof of the car which turned over two to three times. There is a discrepancy in the records regarding how much contamination of the thumb injury was actually present in the emergency room. There is also a considerable discrepancy as to the consent for or against the additional removal of bone and tissue to complete the partial amputation of the tip of the thumb. It is obvious from the records, the operative report, and the MRI findings that the flexor polices longus tendon was either torn loose from the bone of the distal phalanx in the accident or was actually cut loose in the performance of the surgery on Jackson’s hand. Jackson now has a shortened thumb digit with difficulty with considerable weakness and pinching and grasping objects such as sports equipment. It seems that participating in sports was a passion of Jackson. The function of this dominant thumb, which is the most important digit in the hand, has been decreased severely due to the negligent treatment of the injury. This disability will extremely affect the ability of Jackson to perform and enjoy sports.

Deviations from the Standard of Care

I agree with the two unsigned documents in the medical records which layout many inconsistencies in the treatment of Jackson G. I agree that in the case of a pediatric patient who is a minor that the wishes and preferences of the parents should be honored completely. There is a significant question of contamination of the thumb wound but even if the wound has been contaminated significantly, even with grease and dirt, there is not a significant worry or contraindication to simply irrigating out and minimally debriding the wound of any foreign material and not performing any pin fixation at the initial visit to the operating room. I have done this many times with contaminated Worker’s Comp. injured fingers. By doing this and bringing the patient back in 24 to 36 hours, one is more able to determine if all skin edges are viable or are going to need to be trimmed. Jackson G. was not given this benefit of a relook to determine skin and bone edge viability. It appears from the records that the surgery on the thumb of Jackson G. was done late in the day or even at night. These times in the operating room are not supported by the best personnel to assist one in cases like this. I am very familiar with stabilization of fractures in the hand and it seems that Jackson was treated with significant old-school techniques of pin fixation and just simply to cut off tissue and bone to get a complete closure of the digit. A standard treatment of the fractures would have been to reduce the fractures and maintain the fractures in a stable condition for healing while allowing motion of the joints. It is the opinion of this surgeon that Dr. C. violated the standard of care by removing more length on this young man’s thumb and by not delaying the definitive treatment of the injury for at least 24 hours with fixation of fractures. It is well within the standard of care to delay definitive debridement and also definitive fixation of fractures with the type of injury of Jackson G. Therefore it is felt to be beyond the standard of care to immediately take off the bone with rongeurs and decrease the length of this thumb. Furthermore, Dr. C. fell below the standard of care is not properly and thoroughly evaluating the flexor policis longus tendon of the thumb or to deliberately transect the flexor polices longus tendon. As stated above the thumb is the most important digit on the hand and every attempted procedure should be done to maintain as close to the full and complete function of the thumb as possible.

It Is below the standard of care to create a flap to cover bone when it is well known that leaving the amputated digit open will result in a very nice healed no sensitive tip of the finger. I have treated numerous amputated digit tips with this technique with perfectly satisfied patients. As is the case with Jackson, flaps or skin grafts over the ends of digits are very commonly hypersensitive and annoying.

Damages

Due to the blatant disregard by Dr. C. of the wishes of the father of Jackson G., Dr. C. proceeded to negligently treat the thumb injury to the dominant hand of Jackson G.. Even though the fracture of the distal phalanx was an open fracture the treatment at the time of the injury could have simply been that of cleaning up the fracture and the tissue with irrigation and minimal if any real debridement. Then in 24-36 hrs. with a staged procedure, the patient could have been brought back to the operating room with an assessment of the viability of skin edges and definitive fixation of fractures with appropriate instrumentation. Instead of shortening the thumb to produce a flap which covered the end of the thumb, the standard of care would have been to maintain as much length as could possibly be done and even leaving the thumb open for granulation tissue and healing on its own. This type of healing is especially successful in young pediatric patients. Jackson G. has sustained damages which are more likely than not irreversible with shortening of his thumb and weakness of his thumb due to the negligence of Dr. C. in particular to transecting the flexor pollicis longus tendon or failure to repair a ruptured flexor pollicis longus tendon. A secondary procedure never works as well as a primary procedure.

Had it not been for the negligence of Dr. C. it is felt that Jackson would have healed his soft tissue of the thumb as well as the fractures and would have a strong thumb and eagerly playing sports with minor cosmetic irregularity.