Distal phalanx amputation

An infection rapidly progressed to osteomyelitis as a result of the patient's poorly-controlled diabetes

A 51-year old patient came to a walk-in centre with a history of having knocked his finger while playing cricket. He was seen by a nurse practitioner who noted a pus-filled blister on his right index distal interphalangeal joint. She noted that the patient was a diabetic. She cleaned and dressed the finger and treated him with flucloxacillin. She advised him to see his GP if the finger did not improve.

Four days later the patient saw his GP, an MDU member, who noted that he still had discharge from the lesion. The doctor advised him to continue with the antibiotic and asked his practice nurse to change the dressing on the finger, which she did. The patient returned for a further re-dressing the next day.

The day after this visit, the patient returned to the walk-in centre and was seen by the same nurse practitioner he had seen originally. It was noted that the finger was much worse, very swollen and with widespread redness and blistering.

He was referred to hospital where he was found to have osteomyelitis of the finger. Several attempts at debridement were made. However, it was found necessary to amputate the distal phalanx. The patient had a long period of recovery to regain movement in the finger.

The GP received a letter from a solicitor alleging that the care given was inadequate. It alleged that the patient should have been referred to hospital and that the practice nurse was not sufficiently trained to assess and care for such a lesion. It was further alleged that if treatment had been instituted earlier, the patient would not have needed an amputation and would have better hand function.

The MDU obtained a report from an independent GP expert who noted that the records were not very full, the GP had not referred to the fact that the patient's diabetic control was poor and the management plan was unclear. The expert commented that there was no indication that the GP had considered that the patient may have osteomyelitis.

The GP expert was also critical of the nurse practitioner who saw the patient originally. He felt that she should have been cautious about using oral antibiotics in a potentially deep-seated infection and should have arranged formal follow-up.

The MDU obtained a report from an independent nursing expert. This expert felt that the nurse had made an excellent record of a thorough and thoughtful assessment. She had recorded a full range of painless movement and made a reasonable management plan.

The MDU then asked an independent orthopaedic surgeon to give an opinion as to when the osteomyelitis started and at what stage treatment could have resulted in a better outcome. The expert advised that it is likely that the infection progressed very rapidly as a result of the patient's poorly controlled diabetes. If the GP had referred him to hospital when he first presented, he would have avoided amputation and been left with better function in his dominant hand.

The patient's claim was settled for £10,000 in damages.

Dr Alison Cooper
Senior medical claims handler

This page was correct at publication on 10/01/2014. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.