Forklift vs Foot [Compartment Syndrome]
Case #66
A 43-year-old man was at work when a coworker accidentally ran over his right foot with a forklift.
He was taken to a corporate medical office that offers a combined urgent care and occupational health clinic.
He was examined by a PA and a physical therapist. The PA’s documentation notes swelling and limited range of motion of the right foot. He was in “too much pain to try and moving the foot”.
An x-ray of his right foot was ordered.
The results of the x-rays did not show any sign of fracture or dislocation.
He was started on Naproxen and discharged.
The patient was advised to return in 3 days for a recheck.
A physician co-signed the note but it does not appear that he ever personally saw the patient. He is IM-trained and mostly does workman’s comp.
3 days later the patient returned for a recheck.
His symptoms were unchanged and he had 9/10 pain.
He was referred to an academic ED for orthopedic consultation.
In the ED, the orthopedic surgeon found him to have elevated compartment pressures, diagnosed compartment syndrome, and took him to the OR for fasciotomies.
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The patient now suffers chronic pain and is unable to work due to his difficulty ambulating.
He was also diagnosed with tarsal tunnel syndrome.
He contacted a lawyer and a lawsuit was filed against the company that owns the urgent care.
Note: The plaintiff only sued the urgent care / occupation health company. They did not sue the PA, PT or MD.
An expert witness was hired to write an opinion:
The defense hired an expert as well.
The summary of their opinion is shown below:
The plaintiff offered to settle the lawsuit for $2.75M.
The lawsuit is ongoing.
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MedMalReviewer Analysis:
Given that the patient had a potentially severe trauma (being run over by a forklift is not a minor mechanism), it is somewhat odd that they were seen by a PT at the initial visit. Physical therapists have a unique skill set and provide necessary care for patients as they recover. However, an EM physician is best at doing initial assessments for injuries that could be life or limb threatening.
This case shines a light on the ethical dilemmas of occupational medicine and corporate medicine. At times, it seems like the occupational medicine clinic serves the patient’s employer rather than the patient.
Do not be falsely reassured by negative x-rays in patients who have suffered foot trauma. There are severe injuries that cannot be diagnosed by imaging alone, including compartment syndrome and Lisfranc injuries.
Return precautions are one of the most critical parts of patient care and documentation. Patients need to be educated about symptoms to monitor so they are equipped to return if needed.
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