Renowned Radiology Expert Opines on Doctors’ Failure to Identify Wood Fragments in Patient’s Leg

This nuclear medicine case involves complications from the penetration of, and subsequent failure to detect, wood slivers in the patient’s left leg. The patient’s initial injury arose from a crash he suffered while participating in an amateur motocross event; during one of the races, the patient came off of a dirt jump and crashed into a section of wooden fencing. Immediately after the crash, the man was taken to the emergency room, where doctors treated his injuries including several abrasions, cuts, and a fracture. However, there was also a puncture wound that was not noted in the original notes from the patient’s ER visit. The patient was released from the hospital on the same day as his original presentation, however, he returned the following day complaining of 10/10 pain in his leg, and ER doctors noted swelling and discoloration. The patient was examined by the doctor and underwent x-rays of his leg, which were not significant for any additional trauma or foreign objects (although a note was made for a pocket of subcutaneous gas), and released with a prescription for pain medication. In the weeks that followed, the patient developed a persistent bacterial infection in his leg, which required multiple surgical procedures as well as an extended hospital stay to treat. It was alleged that the infection was caused by the undetected wood splinters, which should have been discovered during his initial visit to the ER.

Question(s) For Expert Witness

1. Do you routinely examine X-rays as described in the case summary?

2. What are the appropriate steps following the X-ray findings as described in the case summary?

3. Are findings of "Small focus of potential subcutaneous gas" indicative of any underlying issues?

3. Do you believe this patient may have had a better outcome if the care rendered had been different?

Expert Witness Response E-007952

I do routinely examine X-rays evaluating for possible foreign bodies. "Small focus of potential subcutaneous gas" is primarily indicative of a break in the skin in that area. Subcutaneous gas can indicate infection as well. I feel that an ultrasound evaluation of the leg would have been an appropriate step following the X-ray. X-rays will only identify materials that are radiopaque, such as metal, certain glass and rock. Wood is notoriously radiolucent, meaning that it is most commonly not visible with plain X-rays. Wood fragments are, however, visible with ultrasound. I believe this patient may have had a better outcome if an ultrasound was performed. I have searched for numerous foreign bodies in a diagnostic capacity and I have also been called upon to remove many subcutaneous foreign bodies using ultrasound guidance.