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

BACKGROUND: Delayed presentation of injury cases is common in developing countries like India. It is prudent to study reasons for delayed presentations to focus preventive measures towards responsible factors. Since foot and ankle orthopaedics is in its infancy in India, it was deemed to be worthwhile to study reasons for delayed presentations of foot and ankle injuries.

METHODS: Retrospective analysis of prospectively collected data from 482 foot and ankle injuries treated at our three foot and ankle centres over past three years was undertaken. Delayed presentation was defined as cases presenting to us at or after 3 weeks of injury, but with complete records. Reasons for delayed presentations were analysed.

RESULTS: There were ninety eight such cases who fulfilled the delayed presentation criteria and within this group there were twenty different varieties of foot and ankle injuries. Of these twenty six cases were never treated by qualified orthopaedic surgeons and were labelled as direct delayed presentations, and the remaining 72 cases who were treated by qualified orthopaedic surgeons, but could not be diagnosed and presented late, were labelled as indirect delayed presentations. Failure to suspect injury (5 cases) or failure to diagnose injury (67 cases) were reasons for indirect delayed presentations. Failure to diagnose injury on part of clinicians was either due to failure of clinical and radiological analysis (analytical failure - 15 cases) or due to failure to investigate case with further radiological investigations (investigative failure - 10 cases). Forty-two cases had combined failures.

CONCLUSIONS: In developing countries like India, patients did neglect their foot and ankle injuries and presented late. In fact, by way of delayed diagnosis, clinicians were more responsible for indirect delayed presentations of foot and ankle injuries. This is contrary to the common belief that in developing countries like India, only patients would be solely responsible for delayed presentations after injury. Because delayed diagnosis by clinicians seemed more alarming than delayed presentation by patients, focus of prevention of foot and ankle injuries in developing countries should shift more towards educating clinicians than patients.