Lydia Jones v. State of Connecticut (2010)

MEMORANDUM OF DECISION

After trial the court finds the following facts.   On September 26, 2006, the plaintiff, Lydia Jones, fell at her home in Farmington, Connecticut, and injured her right ankle.   She was transported by ambulance to the University of Connecticut Health Center (UCONN) emergency room.   The physicians at UCONN x-rayed the plaintiff's ankle, diagnosed the fracture as a bimalleolar ankle fracture, splinted the ankle, prescribed the plaintiff some medication, and discharged her with instructions to keep the ankle elevated above the level of her heart and to see Dr. Kevin Shea, an orthopedic surgeon employed by UCONN, the following morning.

The plaintiff, accompanied by her husband, went to Dr. Shea's office on the following day at 1 p.m. Dr. Shea advised the plaintiff that she had sustained a trimalleolar fracture of her ankle and told her that he could schedule her for surgery for the following day, September 28, 2006, a Thursday, and the day on which he generally performed surgeries.   He also advised the plaintiff that the ankle needed surgery, an open reduction and internal fixation, and advised the plaintiff that she would have problems with her ankle, including arthritis, if she did not have surgery.

Upon hearing Dr. Shea's advice that she undergo surgery on her ankle the following day, the plaintiff became hysterical and indicated to Dr. Shea that she did not wish to undergo surgery.   Dr. Shea spoke to the plaintiff's husband and asked him to try to convince her that she required surgery.   The attempt to enlist the aid of the plaintiff's husband in convincing her to undergo surgery was to no avail.

After failing in his efforts to convince the plaintiff to undergo an operation on her ankle the following day, Dr. Shea advised the plaintiff that she should take some time to “get her nerves in order” before surgery.   He scheduled another appointment with her for the following Monday, hoping that she then would be more amenable to undergoing a surgical procedure on her ankle.   However, the plaintiff did not return to Dr. Shea. Instead, she sought a second opinion from Dr. Jambor, another orthopedic surgeon, on September 28, 2006.

Dr. Jambor changed the plaintiff's splint and advised her that she needed surgery.   The plaintiff had developed a fracture blister, which Dr. Jambor treated.   He advised the plaintiff that he would have to wait until the blister healed and asked her to return the following week to discuss surgery.   On October 2, 2006, the plaintiff went to Dr. Burstein, Dr. Jambor's associate, and Dr. Burstein changed her splint because she complained that it was too tight.   Although she was scheduled for surgery with Dr. Jambor on October 4, 2006, she went to yet another orthopedic surgeon, Dr. Robert Carangelo.

Dr. Carangelo performed an open reduction and internal fixation of the plaintiff's trimalleolar right ankle fracture on October 6, 2006.   His operative note indicates, “Happy with the preliminary reduction of both the fibula and the posterior malleolar fragment ․” Dr. Carangelo did not encounter any complications due to the temporal gap between the date of injury and the date of surgery.   He believed that he had achieved an excellent anatomical reduction of the fractures.

Dr. Carangelo testified that the plaintiff did quite well post-operatively until she fell and twisted her ankle on December 6, 2006.   It was only after that fall that she began to complain of pain in the anterior aspect of her foot and arch.

A post-operative MRI showed that there was an articular cartilage step-off of 2.5 millimeters along the posterior half of the tibial plafond.   That condition caused the plaintiff to experience pain.

Dr. Michael Roback, an orthopedic surgeon, testified as an expert witness on behalf of the plaintiff.   Dr. Roback graduated from the University of California at Irvine Medical School in 1968, was Board Certified in Orthopedic Surgery in 1974, and has never taken a recertification examination.   He practiced in California until 2005 when he moved to Connecticut.   He is licensed to practice medicine in Connecticut, but does not have hospital privileges anywhere in this state.

Dr. Roback testified that the applicable standard of care required that the defendant perform an open reduction and internal fixation of the plaintiff's trimalleolar right ankle fracture within 24 hours of the fracture occurring.

Dr. Richard Kamin testified on behalf of the defendant.   Dr. Kamin has been Board Certified in Emergency Medicine since 2002.   He treated the plaintiff when she arrived at the emergency room at the UConn Health Center.   Dr. Kamin testified that the plaintiff did not have an open ankle fracture.   An open fracture is one where the bone has broken through the skin.   In addition, Dr. Kamin stated that there was good blood flow to the area of the fracture and swelling on both sides of the ankle.

Dr. Lewis Iorio testified as an expert witness for the defendant.   Dr. Iorio attended Cornell University and the Albert Einstein College of Medicine, graduating in 1982.   In addition to completing an orthopedic residency, Dr. Iorio also did a fellowship in foot and ankle surgery.   He became Board Certified in Orthopedic Surgery in 1989.   He has subsequently been recertified in Orthopedic Surgery two times.

Dr. Iorio opined that the defendant treated the plaintiff appropriately and within the standard of care.   The occurrence of the surgery 11 days after the plaintiff injured her ankle did not cause any adverse effects to the plaintiff.   Dr. Iorio testified that orthopedic literature is replete with studies that a delay in treatment can be advantageous rather than disadvantageous in a fracture of the type suffered by the plaintiff.   He specifically identified a study by Gregory Konrath, M.D., et al,¹ which found no significant difference in outcome in patients who had their open reduction and internal fixation procedures done early, defined as within 5 days of the injury, or late, defined as after 5 days with a mean of 13.6 days from injury.

One of the plaintiff's claims of negligence was the defendant's failure to immediately admit her to the hospital.   Dr. Iorio testified that the prevailing standard of care absolutely did not require the defendant to admit the plaintiff to the hospital because there was nothing that could be accomplished in the hospital that could not be accomplished at home by a compliant patient.

Dr. Iorio also opined that it was absolutely appropriate for the plaintiff to be sent to see Dr. Shea the day following her injury.   According to Dr. Iorio, there was no reason the defendant should have admitted the plaintiff immediately to the hospital because there was no evidence of neurovascular compromise in the injured area.   Moreover, seeing Dr. Shea on the day following the injury permitted Dr. Shea to view the amount of swelling so he could make a prudent decision relative to surgical timing.

Dr. Iorio further testified that there was absolutely no necessity to perform emergency surgery on the plaintiff.   In fact, performing surgery within 24 hours of injury was contraindicated because at that temporal point, swelling could result in compromised healing.   Dr. Iorio testified that the accepted period in which to perform open reduction and internal fixation on a fracture like the plaintiff's is between 7-14 days after injury.

Dr. Michael Miranda also testified as an expert witness for the defendant.   Dr. Miranda graduated from UConn Medical School in 1988.   After a residency in orthopedics at Hartford Hospital and UConn Medical Center, Dr. Miranda did a one-year fellowship in Orthopedic trauma.   His medical practice focuses on complex joint fractures.   He travels in North America and Europe, giving lectures on how to manage complex fractures and is a member of the North American Musculoskeletal trauma committee.

Dr. Miranda was Board certified by the American Board of Orthopedic surgery 1999.   He has treated approximately 200 acute ankle fractures in the last 15 years.  “Acute” ankle fracture means a recent fracture.

Dr. Miranda testified that where the patient has an open fracture, there is a danger of infection.   Therefore, those patients are usually operated on right away.   In addition, if there is no blood flow into the foot, immediate surgery is generally warranted.

Dr. Miranda opined that the prevailing standard of care did not require the plaintiff to undergo surgery on her ankle within 24 hours of the injury because she had a closed fracture and no neurovascular compromise.   Dr. Miranda agreed with Dr. Iorio that surgery within 24 hours was not only not required, but was contraindicated because at the 24-hour mark the doctor does not know how severe the swelling will be.   According to Dr. Miranda, a physician “would be in real trouble” if he performed surgery too soon after the injury, then there was extensive swelling, which could prevent the physician from being able to close the skin at the surgical site.

Dr. Miranda further testified that a review of Dr. Carangelo's surgical note did not indicate that there was any healing or fibrous tissue at the fracture site and contained no indication that the surgery he performed was made more difficult by the passage of time.   Dr. Miranda was familiar with the Konrath study referred to above.   He testified that the conventional medical wisdom in the 1980s and 1990s was that a trimalleolar fracture should be treated within 24 hours.   However, studies like the Konrath study changed that view.

The court finds that the prevailing standard of care in 2006 did not require that surgery be performed within 24 hours of the injury.   The defendant was appropriately treated by the defendant at the UCONN emergency room.   The doctors at the emergency room referred the plaintiff to Dr. Kevin Shea the day following the injury.   That referral did not violate the standard of care.   Dr. Shea offered to perform surgery on the plaintiff two days after the injury, but the plaintiff refused to undergo the surgical procedure.

The court further finds that the standard of care in 2006 indicated that the optimum time for surgery on a fracture such as the one sustained by the plaintiff was within 7-14 days of the injury.   The defendant through Dr. Shea could have performed surgery on the plaintiff, but she went to another physician.

Ultimately, the plaintiff did have an open reduction internal fixation of her right ankle 11 days after her injury.   The 11-day interval, being within the prevailing standard of care, did not impede her surgery in any way.

Based on the foregoing, the plaintiff has failed to prove beyond a reasonable doubt that the defendant State of Connecticut or its agents or employees violated the prevailing standard of care with respect to the treatment of her trimalleolar ankle fracture.   Judgment may enter in favor of the defendant.

By the court,

Aurigemma, J.

FOOTNOTES

FN1. The plaintiff introduced this study from the Journal of Orthopaedic Trauma, Vol. 9, No. 5, pp. 377-80, 1995..  FN1. The plaintiff introduced this study from the Journal of Orthopaedic Trauma, Vol. 9, No. 5, pp. 377-80, 1995.

Aurigemma, Julia L., J.