Medical Malpractice Insights – Think necrotizing fasciitis in all wound infections

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

This month’s case again illustrates basic clinical medicine. Necrotizing fasciitis is among the top causes of medical malpractice claims. Take a history. Do an exam. Avoid anchoring bias. Avoid confirmation bias. Avoid the cost and stress of a lawsuit.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

I banged my knuckle and now my hand and wrist REALLY hurt

Think necrotizing fasciitis in all wound infections

Facts: A 45-year-old male is working at home dismantling some old scaffolding. His hand slips and strikes a metal support, causing a laceration of the dorsal second MCPJ. He applies a bandage and goes to bed. The next morning he awakens with severe pain in the hand and arrives in the ED 13 hours after the injury. His triage chief complaint is logged as “pain L wrist, worse with motion.” The EP sees the complaint on the tracking board and orders a wrist x-ray 20 minutes before seeing the patient. A subtle triquetrum avulsion fracture is suspected and dorsal soft tissue wrist swelling is noted. Exam shows a deep, 2 cm laceration of the dorsal 2nd MCPJ and tenderness in the finger, hand and wrist. The wound is cleansed under local anesthesia, left open and dressed. The pain resolves, a wrist splint is applied and he is discharged with a dx of “triquetrum fracture.” He returns 26 hours later due to increasing 8/10 pain and progressive swelling and sees the same EP. This time his triage note is “sustained a laceration yesterday.” The wrist splint is removed and exam reveals soft tissue tenderness, swelling into the forearm and normal ROM. The laceration is not mentioned. He is given hydrocodone/APAP and discharged 34 minutes after arrival. He returns 27 hours later with full-blown necrotizing fasciitis and is transferred by air to a trauma center. A long hospitalization with multiple surgeries results and he is left with a nearly useless scarred left upper extremity. He consults an attorney and a lawsuit is filed against the EP.

Plaintiff: You didn’t take a history. You relied on the triage nurse and ordered a wrist x-ray before you even heard my story. Nothing hurt for the first 13 hours. If I had a broken wrist, it would have hurt. It was my knuckle, not my wrist. You left the finger wound open, so you must have been concerned about possible infection, but you did not to a wound culture or put me on antibiotics. You had “anchoring bias” when you saw that the triage nurse erroneously said I had a “wrist injury” and just ordered an x-ray. Then you thought you saw a triquetrum fracture, which my expert says is old and was never present on any later x-rays, yet you assumed that was my problem and stopped thinking. That’s “confirmation bias.” I came to the ED because of my knuckle wound, not any wrist pain, and you minimized that. My pain was so bad the second time I saw you that I was “out of it.” All I remember is that you didn’t take me seriously. If you’d done your job, I’d be able to use my arm.

Defense: The record says you hurt your wrist. You had a fracture of the triquetrum. You had no fever until the third visit. We treated you appropriately. And even if we diagnosed the problem earlier, there’s no guarantee that you would be any better today.

Result: Pre-trial settlement for undisclosed amount.


  • “Pain out of proportion to injury” (POOP) is the earliest hallmark of necrotizing fasciitis. Think of that whenever a patient with a skin injury seems to be exaggerating their pain.
  • Reading the nurses’ notes, taking a history and doing an exam remain the responsibility of the attending caregiver.
  • When discrepancies exist between nursing notes and physician findings, acknowledge and resolve them in the record
  • Listen to the patient and avoid anchoring bias (“wrist injury”).
  • Listen to the patient and avoid confirmation bias (“triquetrum fracture”).
  • Skipping basic steps in the diagnostic process and relying only on subtle lab or x-ray findings is a common pathway to a lawsuit.
  • Before discharge, ask yourself “Does this make sense? Am I missing anything here?” The patient is often the one who can best answer those questions. Knowing what you don’t know is called metacognition and is a worthwhile practice.

Reference: Necrotizing Fasciitis. Schulz SA. Medscape eMedicine, Updated Oct 17, 2018.

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