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Delayed presentation or delayed diagnosis? A retrospective study of prospectively collected data of 482 foot and ankle injury cases

Category: Trauma Introduction/Purpose: Delayed presentation of injury cases is common in developing countries due to lack of resources as well as lack of awareness. Such cases pose a great management challenge to clinicians. Study aimed to find out every possible responsible factor responsible for delayed presentations would guide towards targeted preventive measures. Foot and ankle orthopaedics being in infancy in developing country like India, foot and ankle injuries do present late. We took up a study to document and analyse the reasons for delayed presentations of foot and ankle injuries. Methods: Retrospective analysis of prospectively collected data from 482 foot and ankle injury cases treated at our three foot and ankle centres over past four years was done. Delayed presentation was defined as cases presenting to us at or after 3 weeks of injury and all these cases formed inclusion criteria. Delayed presenting cases without complete records and cases who were lost to follow up were excluded from this study. Reasons for delayed presentations were charted and further analysed. Results: Ninety eight delayed presenting cases (out of 482 cases) were divided in two groups. First group (28 cases) never got treated by orthopaedic surgeons, was labelled as ‘Direct delayed presentation group’. Second group (72 cases) who got treated by orthopaedic surgeons, but could not be diagnosed initially and presented late was labelled as ‘Indirect delayed presentation group’. Direct group cases initially followed home, quack or family physician’s remedies. Failure to suspect injury (5 cases) and failure to diagnose injury (67 cases) were reason subgroups in indirect group. Failure to diagnose injury was due to failure of clinico-radiological analysis (analytical failure (15 cases)) or due to failure of investigating case further (investigative failure (10 cases)). Forty two cases had combined analytical and investigative failures. Conclusion: In developing countries like India, many patients neglected their foot and ankle injuries and presented late. However clinicians were found to be more responsible for generating indirect delayed presentations by the way of failing to diagnose timely presented injury cases! This is contrary to common belief that in developing countries, patients would be solely responsible for delayed presentations! As delayed diagnosis by clinicians seemed more alarming than delayed presentation by patients, preventive education should also be imparted to clinicians over and above to patients. Study of such a scenario in developed countries would be interesting.