Pain Out of Proportion: Missed Thrombosis Results in Limb Loss

Description

A patient with severe lower extremity pain and neurologic symptoms was evaluated in the emergency department after a minor injury and discharged with a presumed musculoskeletal diagnosis. Delayed recognition of an underlying vascular condition resulted in irreversible tissue injury and eventual limb loss.

Key Lesson(s)

• Strong consideration should be given to specialty consultation or referral when a patient’s symptoms are severe, worsening, atypical, or not adequately explained by the suspected diagnosis.
• Comprehensive physical examination and ongoing reassessment are critical to identifying changes in clinical status and ensuring diagnostic accuracy.
• A broad differential diagnosis should be maintained throughout the evaluation process, with deliberate efforts to avoid diagnostic anchoring and to consider alternative causes when the clinical picture remains unclear.

Clinical sequence

A 42-year-old female presented to an emergency department with complaints of severe lower extremity pain following a minor leg injury after strenuous exercise. During triage, she reported intense pain along with numbness and tingling in the affected leg.

The patient was evaluated by an advanced practice provider under the supervision of an emergency medicine physician. Physical examination revealed localized swelling and tenderness. Distal pulses were documented as present, and initial imaging did not identify any fracture or other acute bony abnormality. A Doppler study was reportedly performed but not documented.

Despite receiving multiple doses of pain medication, the patient’s symptoms remained significant. She was diagnosed with a musculoskeletal injury and discharged with supportive treatment instructions and plans for outpatient follow-up the next day.

The following day, the patient returned for reevaluation after experiencing worsening symptoms. Examination revealed concerning changes in the affected extremity, including sensory deficits and evidence of compromised circulation. She was referred back to the emergency department and subsequently transferred to a higher level of care for further diagnostic evaluation.

Additional imaging identified a previously unrecognized vascular abnormality with thrombosis resulting in acute limb ischemia. The patient underwent urgent surgical intervention. Despite aggressive attempts to restore blood flow, significant ischemic injury had occurred.

Over the subsequent days, the patient required additional surgical procedures to address ongoing tissue damage and complications associated with prolonged ischemia. Ultimately, limb salvage was unsuccessful, and a below-the-knee amputation was required. Following recovery from surgery, the patient underwent rehabilitation and was discharged home.

Allegation

The patient alleged that emergency department providers failed to recognize and timely diagnose acute arterial thrombosis and limb ischemia despite symptoms that were inconsistent with a simple muscle strain.

Named defendants included the emergency medicine attending physician and physician assistant.

Disposition

The case was settled for >$1 million.

Clinical Analysis

Complete Assessment and Clinical Judgment Should Guide Evaluation

The patient presented with severe pain, neurologic symptoms, and persistent distress despite treatment—findings that were not fully explained by the presumed musculoskeletal diagnosis. Clinicians should integrate the patient’s history, examination findings, and clinical course to ensure that concerning symptoms prompt reassessment of the differential diagnosis and further evaluation when warranted.

Diagnostic Anchoring Can Delay Recognition of Serious Conditions

Diagnostic anchoring can occur when clinicians become overly focused on an initial diagnosis despite evidence suggesting an alternative explanation. In this case, persistent severe pain and neurologic symptoms may have been attributed to a musculoskeletal injury, delaying recognition of a time-sensitive vascular emergency.

Timely Specialty Consultation Is Essential When Vascular Injury Is Suspected

When symptoms raise concern for vascular compromise or are not adequately explained by the working diagnosis, prompt specialty consultation should be considered. Early referrals can facilitate additional diagnostic evaluation, expedite treatment, and improve opportunities to prevent irreversible injury.

Discussion Questions

• What processes does your organization have in place to facilitate timely specialty consultation when further evaluation is necessary?
• How can emergency department teams reduce the risk of diagnostic anchoring when an initial diagnosis does not fully align with a patient’s clinical presentation?

This is a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.