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Florida – Pediatrics – Deep Laceration Of The Right Knee Treated With Debridement, Irrigation, And Suturing
On 12/7/2011, an 8-year-old male presented to a medical emergency department with a deep laceration to his right knee. The laceration was a full thickness cut with visualization of the capsule. An x-ray revealed air in the knee joint.
A pediatrician examined the patient’s knee and performed debridement, cleaning by irrigation, and suturing of the laceration. Bacitracin and dressing were applied to the patient’s knee.
On 12/10/2011, the patient returned to the emergency department with complaints of right knee swelling, redness, and pain. The patient was admitted to the pediatric floor.
Further examination revealed septic arthritis in the patient’s right knee, which required two operations and the introduction of a PICC line for long-term antibiotic therapy. The patient sustained cartilage damage as a result of the septic arthritis and suffered from significant knee pain.
The Board judged the pediatrician’s conduct to be below the minimal standard of competence given that he failed to refer the patient to an orthopedic surgeon and to fully wash out the patient’s joint by performing an open debridement under anesthesia.
The Board issued a letter of concern against the pediatrician’s license. The Board ordered the pediatrician to pay a fine of $10,000 against his license and pay reimbursement costs at a minimum of $5,496.59 and not to exceed $7,496.59. The Board also ordered that the pediatrician complete ten hours continuing medical education in pediatric orthopedic diagnosis and treatment and complete five hours of continuing medical education in “risk management.”
State: Florida
Date: June 2017
Specialty: Pediatrics, Orthopedic Surgery
Symptom: Joint Pain, Swelling
Diagnosis: Trauma Injury, Septic Arthritis
Medical Error: Improper treatment, Referral failure to hospital or specialist
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
California – Orthopedic Surgery – MRSA Bacteremia With Swelling And Erythema Of The Left Knee
On 6/11/2014, a 20-year-old male at that time presented to an emergency department with left knee pain and swelling of the left leg. On 6/15/2014, Orthopedic Surgeon A provided an orthopedic consultation, which was requested by the admitting physician to rule out infection in the knee. In his exam, Orthopedic Surgeon A noted swelling around the left leg area, satisfactory circulation of the left lower extremity, a mildly tender left leg, and definite tenderness over the tibia. Diffuse tenderness over the left knee and no obvious swelling were noted. The range of movement for the left knee was painful from full extension to beyond 90 degrees; otherwise, the knee was stable.
Orthopedic Surgeon A reviewed an x-ray of the left knee finding no obvious swelling and an essentially normal exam. No complaint of an acute infection was found on the tibia or knee by the orthopedic surgeon. Orthopedic Surgeon A’s impression was a healed fracture of the left tibia with tibial nailing with positive blood culture for infection. Orthopedic Surgeon A’s aspiration of the left knee did not show any pus and very little serosanguinous fluid was aspirated, the fluid was sent for culture and sensitivity. Orthopedic Surgeon A did not feel the patient needed aggressive orthopedic treatment, and his plan was for the patient to be treated for infection as per the infectious disease specialist’s recommendations.
On 6/17/2014, an internal medicine physician noted that the patient had severe sepsis due to methicillin-resistant Staphylococcus aureus bacteremia. The patient was receiving IV vancomycin; however, he continued to have persistent bacteremia, which was suspected to be secondary to the knee. The internal medicine physician attempted to have Orthopedic Surgeon A evaluate the patient on that day; however, Orthopedic Surgeon A felt there was no needed to see the patient on 6/17/2014. The internal medicine physician then requested a second opinion from Orthopedic Surgeon B.
On 6/17/2014, the patient was examined by Orthopedic Surgeon B. Upon his exam, Orthopedic Surgeon B noted a circumferential anterior cellulitis type of finding on the anterior left knee and that the skin appeared to be indurated in this region. Orthopedic Surgeon B’s impression was left knee infection, possible prepatellar bursitis. Orthopedic Surgeon B was not convinced that the aspiration performed by Orthopedic Surgeon A was in the knee joint as he saw the location of the aspiration was directly through the red prepatellar bursa region. Orthopedic Surgeon B found that the patient would likely need surgery for treatment of infection. However, the treatment would depend on whether the patient had prepatellar bursitis or septic knee. Orthopedic Surgeon B noted that he called Orthopedic Surgeon A on 6/17/2014 in an attempt to discuss his findings. However, Orthopedic Surgeon A did not feel the need to follow up with the patient that day.
On 6/18/2014, Orthopedic Surgeon A examined the patient for the second time. Orthopedic Surgeon A noted redness over the anterior surface of the knee. He did not find any evidence of prepatellar bursitis except for redness and noted that there was diffuse tenderness around the left knee. Orthopedic Surgeon A reviewed an MRI of the knee, finding synovitis with effusion. Orthopedic Surgeon A aspirated the knee again, obtaining 2 ml of bloody fluid and finding no evidence of pus. Based on the MRI and his evaluation, Orthopedic Surgeon A’s impression was that the patient had hypertrophic synovitis with effusion of the left knee per MRI. Orthopedic Surgeon A’s plan was for the patient to be treated with IV antibiotics as recommended by the infectious disease specialist until the infection was under control. Orthopedic Surgeon A did not recommend surgery of the left knee.
Orthopedic Surgeon B also reviewed the MRI of the left knee and found a large effusion with evidence of soft tissue edema. Orthopedic Surgeon B noticed a clear abscess in subcutaneous tissue and loculated fluid in the knee joint. Orthopedic Surgeon B’s impression was severe sepsis due to probable left septic knee and possible secondary cellulitis over the left knee. Accordingly, on 6/18/2014, the patient underwent a left knee arthroscopy, incision and drainage with lavage of the left knee joint; left knee arthroscopy; synovectomy; left knee arthroscopy and synovial biopsy; left knee prepatellar bursa incision and drainage; and left knee proximal tibia hardware removal of one single locking bolt of tibia intramedullary nail.
Orthopedic Surgeon B’s findings included positive gross pus in the prepatellar bursa consistent with prepatellar bursa and abscess of 150 ml of gross pus; positive gross pus and left knee joint synovitis; and medial proximal locking bolt of tibia intramedullary nail exposed in the prepatellar bursa region.
The Board reprimanded Orthopedic Surgeon A and ordered him to complete 20 hours of a continuing medical education course in reading and interpreting MRI’s.
State: California
Date: January 2017
Specialty: Orthopedic Surgery, Internal Medicine
Symptom: Joint Pain, Swelling
Diagnosis: Septic Arthritis, MRSA, Sepsis
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Internal Medicine – A Patient Treated For Hyperkalemia With Subsequent Hypokalemia
The Board was notified of a professional liability payment made on 06/15/2015.
A patient presented to the hospital for treatment of sepsis secondary to septic arthritis and associated with bacteremia. The patient also suffered from a urinary tract infection, heart murmur, and lower back pain. She was immunocompromised from daily prednisone use for severe rheumatoid arthritis.
When the patient was admitted to the hospital, her potassium level was elevated. Another physician ordered medications to lower the patient’s potassium level. The medications had the desired effect. When a hospitalist assumed care, the patient’s potassium level was within the normal range. The hospitalist cared for the patient over the next six days.
The following day, while under the care of another physician, the patient developed a cardiac arrhythmia, and her potassium level was found to be low. The patient died from a cardiac arrhythmia, which may have been caused by the patient’s potassium deficiency.
The hospitalist acknowledged that he should have but did not monitor the patient’s potassium level during his care of her.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: April 2016
Specialty: Internal Medicine
Symptom: N/A
Diagnosis: Cardiac Arrhythmia, Septic Arthritis
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Failure To Follow Up On Hip Aspirate Results
The Board was notified of a professional liability payment and finished their investigation of the matter on 02/27/2014.
In June 2006, an orthopedic surgeon performed a left total hip replacement on a 58-year-old female with degenerative joint disease of the left hip.
3 days later, the patient was discharged and later examined at a post-operative follow-up visit with no reported complications.
In the fall of 2006, the orthopedic surgeon examined the patient given complaints of worsening left hip pain.
In November 2006, the orthopedic surgeon ordered a fluoroscopic guided aspiration of the patient’s left hip and a left hip arthrogram. The results were positive for staphylococcus haemolyticus; however, the orthopedic surgeon did not review the test result or take any action based on the result.
The orthopedic surgeon continued to treat the patient over the course of the next six months as her left hip pain worsened.
In January 2006, the orthopedic surgeon scheduled the patient for surgery, but the patient cancelled the surgery. She remained unaware of the positive aspiration in November 2006.
In May 2007, after the patient returned with continued complaints of pain, the orthopedic surgeon admitted the patient to the emergency department for pain management of the severe left hip pain. The orthopedic surgeon ordered a second aspiration of the patient’s left hip that revealed a staphylococcus haemolyticus.
The orthopedic surgeon then explanted the patient’s infected hip prosthesis and placed an antibiotic spacer in the left hip joint space. The patient was later discharged from the hospital with six weeks of intravenous antibiotics.
The Board judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to review the results of the first aspiration and to take action given the finding of staphylococcus haemolyticus.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: July 2015
Specialty: Orthopedic Surgery
Symptom: Joint Pain
Diagnosis: Septic Arthritis
Medical Error: Failure to follow up
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF
Washington – Family Practitioner – Rash On Palms And Legs With Arthralgias And Right Knee Swelling
On 2/6/2008, a 48-year-old female presented for her first appointment with a family practitioner complaining of cough, fever, and a sore throat. The family practitioner treated the patient for worsening of her asthma and hypertension and prescribed prednisone, an inhaler, and antihypertensive medication.
Five days later, on 2/11/2008, the patient presented at the emergency department with a rash on her palms and legs, and arthralgias of the left foot and right knee. Her right knee was warm to touch and slightly swollen with redness. Lab reports showed elevated white blood cell count with predominance of lymphocytes. The diagnosis by the ED physician stated, “consider viral syndrome, possible Coxsackie.” The ED physician consulted with the family practitioner by phone and placed the patient on a prednisone taper. The patient was scheduled for a follow-up appointment with the family practitioner in three days.
On 2/14/2008, the patient presented to the family practitioner with continuing joint pain and diffuse ecchymotic lesions across her body, including her soles and palms. The family practitioner notes that Coxsackie viral infection is possible given the rash distribution. He states that consideration of an alternate diagnosis is appropriate based on the increase in her white blood cell count and an increase in her sedimentation rate. No joint exam is noted.
On 2/19/2008, the patient presented to the family practitioner for a recheck of her rash and acute arthritis. The rash had nearly resolved, and the joint pain was largely limited to her right knee, which the family practitioner described as red and swollen with effusion. The patient’s white blood cell count and sedimentation rate were still elevated and essentially unchanged. The family practitioner’s impression is now “acute arthritis and resolving rash.”
On 3/2/2008, the family practitioner referred the patient to a rheumatologist. The rheumatologist saw the patient on 3/4/2008. He aspirated the patient’s knee, and ordered an MRI. Test results showed staph infection and findings compatible with osteomyelitis. Following his review of the test results, on 3/5/2008, the rheumatologist referred the patient for surgery. The patient was admitted to the hospital the same day and underwent surgery, debridement, and synovectomy.
The patient’s presentation on 2/19/2008, with a swollen, red, warm tender right knee and significant elevated white blood count and sedimentation rate warranted aspiration of the knee. The family practitioner’s failure to recognize the patient’s symptoms of bacterial arthritis resulted in delayed aspiration of the patient’s right knee, surgery, and the discovery of staph infection. The delay caused significant cartilage damage to the patient’s knee, most likely requiring total arthroplasty in the future.
The Commission stipulated that the family practitioner reimburse costs to the Commission, have his license be placed on probation, and write and submit a paper of at least 1000 words, with references, on the diagnosis and treatment of infectious arthritides.
State: Washington
Date: March 2011
Specialty: Family Medicine, Emergency Medicine, Internal Medicine
Symptom: Joint Pain, Cough, Rash
Diagnosis: Septic Arthritis
Medical Error: Diagnostic error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF