In November 2022, Paul Cahill settled a medical malpractice claim on behalf of a 65-year-old man who lost his lower leg after his ankle fracture went approximately 40 days without orthopedic follow-up. The initial closed reduction and casting had been appropriate management for the injury as it had been understood at the time. The failure was downstream: the system that was supposed to bring the patient back for the timely follow-up imaging and re-evaluation that an unstable ankle fracture requires did not function. By the time imaging was finally performed, the fracture had displaced into a different and more serious pattern, the joint had been disrupted, and infection had taken hold. The ankle was no longer salvageable. A below-knee amputation was required. The defendant hospital and physicians settled the claim before trial.
This case is doctrinally useful as an illustration of two related propositions. The first is that the management of an ankle fracture does not end when the cast goes on. The second is that the duty of care extends to the systems a clinician and a hospital have in place to ensure that follow-up actually occurs. When those systems fail, the consequences can be catastrophic and irreversible, even where the initial clinical decision-making was within the standard of care.
The clinical context
The ankle is the joint formed where the talus (the bone of the foot that sits beneath the tibia) meets a socket created by the medial malleolus (the inner ankle prominence formed by the distal tibia), the lateral malleolus (the outer ankle prominence formed by the distal fibula), and the posterior malleolus (the back wall of the distal tibia). The socket is called the ankle mortise. The talus fits into this socket in a precise alignment. The stability of the joint depends on the integrity of the bony walls of the mortise and on the ligaments that hold the talus in place.
A bimalleolar fracture is a fracture involving two of the three malleoli, typically the medial and lateral. A trimalleolar fracture involves all three. In general, bimalleolar fractures are considered unstable because the loss of two of the three bony supports compromises the ability of the mortise to hold the talus in alignment. Without intervention, the talus can shift out of position (a phenomenon called displacement or subluxation), the joint surfaces no longer articulate properly, and the long-term result is pain, stiffness, post-traumatic arthritis, and, in severe cases, joint failure.
The orthopaedic management of an unstable ankle fracture depends on the clinical picture. Closed reduction (manually moving the bones back into anatomical alignment) and cast immobilization is a reasonable option in some cases, particularly where the fracture pattern allows the bones to be held in place by the cast alone and where the patient is at higher surgical risk. Where closed reduction is the chosen treatment, the published orthopaedic literature (including, in Canada, the practice guidance available through the Canadian Orthopaedic Association and the AO Foundation trauma protocols that most Ontario orthopaedic surgeons follow) recognizes that close follow-up is essential. The bones can shift out of alignment during the early weeks of healing. Without repeat imaging to confirm that the reduction has been maintained, a loss of reduction can go undetected until it becomes irreversible.
The general consensus in orthopaedic practice is that a patient with an unstable ankle fracture treated by closed reduction requires repeat imaging at approximately one week, two weeks, and four to six weeks after the initial reduction. If displacement is identified at any of these intervals, surgical fixation (open reduction with internal fixation, or “ORIF”) becomes the appropriate next step. The window for successful surgical correction is short. Once the soft tissues around the joint have organized around a displaced position, and once the joint surfaces have begun to remodel in a malaligned position, the option of restoring anatomical alignment is largely lost.
The infection risk follows separately. When fracture fragments shift, they can disrupt the joint capsule and the surrounding soft tissues. The combination of disrupted soft tissue, compromised vascular supply, and an immobilized limb in a cast creates conditions in which bacteria can establish a foothold. Septic arthritis is a bacterial infection of the joint itself. Osteomyelitis is a bacterial infection of the bone. Both are serious clinical conditions in their own right. In the context of an already disrupted ankle joint, they can render a limb unsalvageable. Gas in the joint on imaging is a recognized radiological sign that infection has progressed to a level requiring urgent surgical attention.
The patient and the injury
The patient was a 65-year-old man. He sustained an ankle fracture that was identified, on initial imaging, as a bimalleolar pattern. He underwent closed reduction and cast immobilization. The choice of closed reduction was a reasonable orthopaedic decision on the information available at the time. The patient was discharged with the expectation, on the part of the treating clinicians and on the part of the patient, that orthopaedic follow-up would be arranged.
The follow-up did not occur. The records reflect a period of approximately 40 days during which no orthopaedic clinician saw the patient and no follow-up imaging was performed. By the time the patient finally underwent repeat imaging, the X-ray demonstrated a disrupted ankle mortise with posterior displacement of the tibiotalar joint. A CT scan was performed the same day. The CT revealed a displaced trimalleolar fracture and gas within the joint space, a constellation of findings consistent with septic arthritis and osteomyelitis. The original bimalleolar fracture pattern had progressed in two ways simultaneously: a third fragment (the posterior malleolus) had displaced, converting the fracture pattern to trimalleolar, and bacterial infection had taken hold in the disrupted joint.
By that point, the orthopaedic options for salvaging the ankle had been lost. The combination of significant displacement, established infection in the joint and the bone, and the duration over which the deterioration had progressed meant that surgical reconstruction was no longer viable. The treating team proceeded to a below-knee amputation.
The standard of care for orthopaedic follow-up
The standard of care for orthopaedic follow-up after closed reduction of an unstable ankle fracture is a matter on which expert orthopaedic evidence is required in litigation. Description here is general background and should not be taken as a substitute for that evidence in any particular case. With that caveat, the general consensus in Canadian orthopaedic practice can be sketched.
A patient discharged from hospital after closed reduction of an unstable ankle fracture requires a clearly arranged follow-up appointment with an orthopaedic surgeon, typically within seven to fourteen days of the initial reduction. The first follow-up serves two purposes. The first is to obtain repeat X-rays through the cast to confirm that the reduction has been maintained. The second is to assess the patient clinically for signs of compartment syndrome, vascular compromise, infection, or other complications that may develop during the first one to two weeks. If the first follow-up is reassuring, additional follow-ups are typically scheduled at four weeks, six weeks, and twelve weeks, with imaging at each visit to monitor healing.
The duty to arrange the follow-up is shared. The orthopaedic team that performed the initial reduction is generally responsible for ensuring that a follow-up appointment is scheduled before the patient is discharged. The hospital, through its discharge processes, is generally responsible for ensuring that the appointment information is communicated to the patient and that the booking systems function as designed. The patient is generally responsible for attending the appointment. Where the system fails at any of these points, the consequence can be a patient lost to follow-up.
The 40-day gap in this case was not a missed first follow-up. It was the complete absence of any orthopaedic follow-up, over a period during which the patient would normally have been seen at least twice and would have had at least two sets of follow-up imaging. The failure was, on the available facts, a systemic failure of the discharge and follow-up arrangements rather than an isolated missed appointment.
The legal framework
A medical malpractice claim in Ontario requires the plaintiff to establish, on a balance of probabilities, the four elements of the standard negligence framework. These are (1) duty of care, (2) breach of the applicable standard of care, (3) damages, and (4) causation linking the breach to the damages.
Duty of care. The duty of care owed by orthopaedic surgeons and hospitals to a patient discharged from acute care with an unstable fracture extends beyond the initial reduction. The duty includes ensuring that the patient has access to the follow-up assessment, imaging, and intervention that the fracture pattern requires. The duty extends to the systems that are supposed to bring the patient back. Both the treating physicians and the hospital have roles to play in those systems.
Standard of care. The applicable standard of care, as noted above, would have required follow-up assessment and imaging within seven to fourteen days of the initial reduction, with further follow-ups at standard intervals over the subsequent months. A 40-day gap without any follow-up falls outside that standard. The expert evidence at trial would have addressed both the substance of the standard and the question of which clinician or which institutional process bore which share of responsibility for the gap.
Damages. The damages were severe. A below-knee amputation in a 65-year-old man produces lasting consequences: the need for a prosthesis, the loss of mobility, the increased risk of falls, the cardiovascular and metabolic effects of significantly reduced physical activity, and the psychological consequences of limb loss. The damages in a case of this kind are typically substantial and include past and future medical costs (prosthetic fitting and replacement over time, mobility aids, home modifications), past and future loss of income or housekeeping capacity, attendant care costs as the patient ages, and pain and suffering. The agreement on damages, while confidential, would have reflected this constellation of harms.
Causation. The causation analysis would have addressed whether the failure to follow up was a “but for” cause of the amputation under the framework in Clements v Clements, 2012 SCC 32. The relevant counterfactual is what would have happened if standard follow-up imaging had been performed at the expected intervals. The plaintiff’s case would have rested on expert orthopaedic evidence that a displacement identified at the first or second follow-up would have been amenable to surgical correction (ORIF), that the joint would have remained intact, that infection would not have developed in the disrupted joint, and that the patient would have retained his ankle and his lower leg. The defence position would have explored whether any of these counterfactual steps was reliable on the balance of probabilities. The case was settled before trial, so the causation issues were not litigated to verdict.
The resolution
The matter resolved by settlement in November 2022. The settlement was reached before trial. The terms are confidential. The settlement reflects the parties’ assessment of the strengths and weaknesses of the respective positions on the standard of care, causation, and damages, weighed against the risks and costs of trial.
Why this matters
For patients recovering from an ankle fracture treated by closed reduction, the lesson is that follow-up is not optional. If a patient leaves the hospital after a closed reduction of an unstable ankle fracture without a scheduled follow-up appointment in hand, that is a warning sign. A patient with an unstable fracture who has not been seen by an orthopaedic clinician within two weeks of the reduction should contact the treating hospital or seek a second opinion. Symptoms that warrant urgent re-evaluation regardless of the scheduled timeline include increasing pain, swelling, warmth, fever, or any sense that the cast no longer fits properly.
For orthopaedic clinicians and the hospitals where they work, the case illustrates that the duty of care extends to the institutional systems that are supposed to bring patients back. Discharge planning, appointment booking, reminder protocols, and the procedures for following up on missed appointments are not administrative afterthoughts. When those systems fail in the context of an unstable fracture, the clinical consequence can be a limb. The case is a reminder that the practice of orthopaedic surgery in a public-system setting carries a parallel responsibility for the system that supports the practice.
For the broader practice of medical malpractice litigation in Ontario, the case is one of a series of cases on the live notable-cases page in which a system failure (rather than an isolated clinical error) produced a catastrophic outcome. Other entries in this category include the October 2016 CPAP oxygen tubing disconnection case, where a hospital equipment connection failed; the esophageal intubation case, where the response time of anesthesia coverage was a contributor; and the hepatitis B surveillance case, where a family practice surveillance schedule was not maintained. These cases share a common analytical structure: the breach is not a discrete moment of clinical misjudgment but a failure of the system designed to deliver the care that the standard required.
For prospective clients who have lost a limb or experienced a serious orthopaedic complication after a fracture, the relevant question is whether the follow-up process functioned as it should have. If a fracture was treated by closed reduction and a complication developed that might have been preventable with timely repeat imaging or surgical intervention, the records of the discharge planning, the booking history, and the follow-up communications are the place to start. The two-year limitation period in Ontario runs from the date the patient knew or ought to have known that an injury had occurred and was caused by an act or omission by the defendant.
Settlement Date: November 2022
Settlement Type: Confidential settlement before trial
Defendants: Hospital and physicians (not named)
Counsel for the plaintiff: Paul J. Cahill
