Medical Malpractice Insights: Dirt left in wound leads to infection

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. Stories of med mal lawsuits can save lives. If you have a story to share click here.

Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Dirt left in wound leads to infection.

Dirt present on X-ray. Radiologist missed it. EP doesn’t over-read.


509 words… 2 minutes

Facts: An adult female falls from a ladder, lands on her elbow and sustains an avulsion. She is seen briefly by the ED physician who orders wound cleansing” and an elbow x-ray for “elbow pain.” The tech cleans the wound and documents it as 2cm long and dirty.” She cannot remove the debris despite using tweezers, cotton swabs and sponges” and reports this to the ED physician. Meanwhile, the radiologist reports the x-ray as showing no radiopaque foreign bodies” and no acute abnormality.” The ED physician documents suturing a 3 cm laceration in a single layer, omitting any reference to any wound exploration, cleansing or debridement. He does not mention viewing the x-rays himself. The patient sees her PCP when the wound appears infected, and a repeat x-ray is ordered. This shows two specks of dirt, also visible on the x-rays from the ED. Recovery is prolonged and a lawsuit is filed.

Plaintiff: I sustained blunt trauma to my elbow from falling onto a dirty surface in my yard. It was severe enough to tear the skin and inject dirt into the wound. Elbow avulsions often contain dirt in the depths of the wound; mine did, as the tech told you. You did no further cleaning; didn’t debride the wound edges; didn’t tell the radiologist that I had an open wound; and didn’t consider antibiotics, a drain, or simply leaving the wound open to heal on its own. And you didnt look at the x-rays yourself, which you are trained to do. You just closed it with the dirt still in it. And the radiologist missed the dirt specks in the soft tissues of my elbow. His later claim that they were bone islands” in the olecranon process is ludicrous.


Radiologist: Of course I saw the FBs on the x-ray. I thought they were incidental bone islands” so I didnt document them. “Orthogonal positioning” proves they were in the olecranon process.”

EM Doc: I depend entirely on the radiology report. I dont ever view x-rays myself. I always clean dirty wounds. I just didnt document it.

Result: The patient healed with scarring. Negligence was present. Care cost over $55,000 (damages). Causation was present because the damages resulted from the negligence. But long-term disability was minimal to none, so the case settled pre-trial for an amount below the expectations of both the plaintiff and her attorney.



  • Listen to your staff.
  • Look for dirt in wounds. Elbows and knees are especially prone to retaining dirt in the depths.
  • Give radiologists enough information to help them help you. “Elbow pain” doesn’t even suggest trauma.
  • Look at the imaging you order. Four eyes are better than 2, especially when yours know the clinical context.
  • View x-rays systematically. Avoid viewing only the obvious.



1. 2019 Model of the Clinical Practice of Emergency Medicine, p. 11. ABEM
2. Wound Closure Technique. Medscape eMedicine. Danks RR, Jun 22, 2021.

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