The Doctor’s Advocate | Third Quarter 2013
Director's Forum

A Perfect Storm

by David B. Troxel, MD, Medical Director, Board of Governors

Dr. Troxel

A 55-year-old female was referred by her primary care physician (PCP) to an orthopedist for evaluation of a two-year history of low back pain that radiated down the back of her right leg toward the knee. She reported that a previous MRI showed disc degeneration and herniation.

The orthopedist ordered x-rays of the lumbar spine and pelvis. The x-rays showed a questionable lytic lesion measuring 6–7 cm in the right iliac bone just superior to the acetabulum.

The radiologist recommended a CT scan with bone windows. The orthopedist’s routine was to personally review his patients’ x-rays, which he did in this case, but he did not see the lytic lesion. The CT scan was performed one month later, but the report made no mention of pelvic abnormalities.

Both radiology reports were sent to the orthopedist’s office and filed without his review. There was no office policy in place to ensure that reports were filed only after he had initialed and dated them. The patient’s PCP was copied on the radiology reports. The PCP reviewed and initialed the reports, but he did not follow up to discuss the findings with the orthopedist or the radiologist.

An x-ray taken two years later again showed an irregular lucency above the right acetabulum, possibly a lytic lesion. The orthopedist reviewed the films, but he did not appreciate the presence of a lytic lesion. A CT scan was recommended and done one week later, but the report did not mention the lytic lesion. Both radiology reports were sent to the orthopedist’s office and filed without his review.

The patient’s back and right leg pain worsened, and an x-ray taken eight months later again showed a large lytic lesion of the right lower ileum just superior to the acetabulum extending down toward the ischium. The report stated, “A neoplasm could give this appearance.” The orthopedist reviewed the films, and he again missed the lytic lesion. The radiology report was not in the orthopedist’s file. Because of worsening pain, an MRI was performed two months later, but the report made no mention of a pelvic abnormality.

Four months later, the orthopedist performed an L5 laminectomy, and the patient’s back pain improved. Follow-up x-rays of the lumbar spine and right hip four months after surgery again noted the expansile lytic lesion involving the right iliac bone, ileum, and acetabulum. The report stated, “A chondroid lesion cannot be excluded.” These films were reviewed by the orthopedist, who again failed to see the lytic lesion. The radiologist’s report was faxed to his office and filed; it had not been brought to his attention.

An MRI done one month later showed a lobulated, expansile lesion measuring 13 x 7.5 x 4.5 cm, suspicious for low-grade chondrosarcoma. The radiologist phoned the orthopedist to discuss the findings—it was the first time he knew that an abnormality was present.

The patient was immediately referred to a major medical center, where she underwent partial resection of her pelvis and hip with amputation of the right leg. Her recovery was complicated by infection and difficulty healing. She is now considered cancer free.

A claim was filed alleging failure to appreciate the presence and significance of a lesion diagnosed as chondrosarcoma more than three and a half years after it was first noted in the filed radiology reports.

Expert Opinion: Defense

An orthopedic oncologist who reviewed the initial pelvic x-rays opined that the chondrosarcoma involved the acetabulum when the patient initially presented. In addition, the pain radiating down the back of her leg toward the knee suggested sciatic nerve involvement. Because the acetabulum and, probably, the sciatic nerve were involved, he did not believe limb salvage would have been an option when she presented. He felt that if surgery had been performed at that time, it would have been essentially the same procedure that was performed when the chondrosarcoma was diagnosed, i.e., external hemipelvectomy with leg amputation.

Two other orthopedic oncologists agreed that an earlier diagnosis wouldn’t have changed the eventual surgical treatment. Each stated that the orthopedist’s repeated failure to see the lesion on x-ray and his failure to read the radiology reports were below the standard of care. Furthermore, his chart notes didn’t document any meaningful physical examination(s) during the course of these events.

Expert Opinion: Plaintiff

An orthopedic surgeon was highly critical of the orthopedist for not appreciating the sarcoma on x-ray, for not having an office policy to bring the radiology reports to his attention, for misdiagnosing the cause of the patient’s back pain, and for treating her incorrectly with lumbar spine surgery.

He believed her leg could have been salvaged, had a timely diagnosis been made. The PCP breached the standard of care by failing to follow up on the radiology report he received on the initial pelvic x-ray. The radiologist’s failure to call the orthopedist about an unexpected lytic lesion in the initial pelvic x-ray was below the standard of care, as was his failure to identify the lesion in the subsequent MRIs.


The patient’s PCP stated he did not follow up with the orthopedist or radiologist to discuss the findings on the initial radiology reports because he did not understand what a questionable lytic lesion was and didn’t know what purpose a CT scan with bone windows would serve. The radiologist was criticized for not calling the orthopedist about the unexpected findings. He did not think the lytic lesion in the initial pelvic x-ray required a phone call because it was only “questionable.” He acknowledged the finding was not expected, but he assumed the orthopedist and PCP would read and understand his report.


Physicians must be certain there is a process in place to ensure that no imaging, laboratory, or consultant’s report is ever filed unless it has been dated and initialed by the physician as proof that it was reviewed. Many medical liability claims would be prevented by this simple policy.

It is also important to create a suspense file or computerized follow-up list for all ordered imaging studies, laboratory tests, diagnostic procedures, and consultations—both to ensure that they were completed and that the physician reviewed the reports.

Sometimes requested tests are not performed due to failure of office or hospital personnel to order them or because of patient noncompliance. For example, a delay in diagnosis of prostate cancer may be indefensible if a screening PSA was ordered but not performed because the test request was never received by the laboratory or it was incorrectly requisitioned by office staff. Furthermore, if the test was performed and an elevated PSA result was charted without the physicians’ review, an allegation of negligence will be made.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

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