The Expert: Dr. Brent Moelleken, a reconstructive surgery expert, testifies concerning the damage to plaintiff’s foot.
Testifying in a 2020 California personal injury trial, Dr. Brent Moelleken, a reconstructive plastic surgeon from Los Angeles, gives his opinion surrounding the damage a motorcycle crash caused to a plaintiff’s foot.
The doctor who had examined the plaintiff said that originally the patient was having symptoms confined to his toe, but after almost a year he began having problems in the front of his heel, also. This is related to the tibial nerve which gives a branch to the big toe and also the front of the heel, the medial plantar nerve. This second area being involved after such a delay led him to believe that this was actually a type of phantom pain that resulted from continuous toe pain overwhelming the brain.
This severe and spreading pain causes the release of hormones that constrict the blood vessels supplying the foot. This was a foot that already had impaired blood flow in the small arterioles due to diabetes, and now the larger arteries to the foot were similarly affected due to the pain.
Moelleken explains that the plaintiff’s pain and dysfunction led to a curling of the toes as the flexed position totally dominated the patient’s ability to extend the toes. The doctor refers to this condition as “hammertoe.” An ulcer developed on a joint of the second toe because of this hammertoe, rubbing against a shoe. In a patient with a poor blood supply, this not only provides an environment conducive to infection, but threatens the entire foot. Ordinarily, hammertoe is treated surgically by removing a segment of bone or removing the joint. However, this is problematic: first, because it results in a flaccid toe, and in this case there is extreme risk due to the poor blood supply to this area.
The expert explains that a prosthetic would protect the second toe from curling over the adjacent toe, but does nothing for hammertoe. It will not allow the intrinsic or extrinsic muscles to lift a toe impacted like this, or allow the toe to push off the ground.
Discussing more fully the role played by prosthetics in amputations, the doctor’s testimony explains that no prosthetic will assist in the foot pushing off of the ground. The lack of a functional toe therefore prohibits one from pushing off and affects the overall balance.
When amputations are performed, there will always be some degree of functional deficit. It is important to be able to inform the patient of expected limitations. Consideration of the level of the amputation is extremely important to the patient for the rest of their lives. “Every day that he’s missing his toes is a day that he cannot balance properly” and it is mentally “upsetting” to look down and see that your toes are gone.
Having followed the plaintiff for more than a year, the reconstructive expert tells the jury that his patient is getting worse, and he expects that he will have to undergo further amputations in the future. Presently, since the first toe is missing, he walks with his foot curved to that side. The second toe is a hammertoe and therefore functionally not a useful toe. He considers that this patient has therefore functionally lost two toes, and remarks that, “Once you lose enough toes, it ceases to be a functional foot.”
The testimony in this clip concludes with a discussion about how the amputation level would be determined in this case. The doctor says that once the toes have been compromised as they have, a transmetatarsal amputation, or amputation of the forefoot across the long bones of the foot would ordinarily be the best level of amputation. But that may not be so in this case because the initial crush injury altered the blood supply through the heel, leaving a post op stump that would be unlikely to heal.
After a seven day trial, the jury awarded the plaintiff $615,000.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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