Delay in diagnosing fractured radial head

Presentation and physician action

During a football game on a Friday night, a 17-year-old girl was performing cheerleading stunts when she fell approximately 7 feet. The team physician, Orthopedic Surgeon A, examined her on the sidelines.

He noted that she had landed on her left arm and had pain in her left elbow. Orthopedic Surgeon A believed she had possibly dislocated or fractured the radial head. He advised her to follow up with him in the office on Monday.

The girl and her mother came to the office on Monday, September 6. An exam under fluoroscopy revealed a dislocated and fractured radial head. Orthopedic Surgeon A performed a closed reduction under anesthesia and sent the patient home in a splint.

On September 15, the radial head was dislocated again. Orthopedic Surgeon A referred her to Orthopedic Surgeon B in his group for a second opinion and for continued care while he was out of town.

Orthopedic Surgeon B performed an open reduction and internal fixation of the radial head with repair of the annular ligament on October 19. During surgery, he discovered fragments that could be the cause of instability and proceeded to use screws to reduce the fracture and hold the fragments in place.

The patient continued to follow up with Orthopedic Surgeon B. X-rays indicated that the position looked good with the exception of a small gap. By November 19, Orthopedic Surgeon B recommended more aggressive follow-up care and noted range of motion problems.

The dictated note for the follow-up visit of December 16 was missing. During a January visit, Orthopedic Surgeon B noted that the range of movement was “slow going” but improving, and that the patient was satisfied with her care. She was to return in one month, but at her mother’s request, she sought a second opinion.

The medical records from subsequent treaters indicate that Orthopedic Surgeon B suggested a capsular release at the January visit and this prompted the patient to seek a second opinion.

On February 21, Orthopedic Surgeon C examined the patient. His initial impression was a “severe stiffness problem” almost six months after the injury. He ultimately recommended therapy with a certified hand therapist and referred the patient to an orthopedic hand specialist in another city.

The patient saw the hand specialist on April 1. At this visit the patient stated her main issue was limited motion. She did not report significant pain. The exam indicated minimal tenderness over the radial head with range of motion from an FFC of 55 degrees to flexion of 100 degrees. He noted the screws appeared to be “reasonably good” despite a 1 mm gap. Ultimately, he diagnosed a “very stiff elbow following a serious injury,” and recommended continued use of a turnbuckle splint.

While under the treatment of the hand specialist, the patient was evaluated by a musculoskeletal radiologist. He diagnosed the problem as “heterotopic bone and incongruity of the proximal radial ulnar joint with relative sparing of the interosseous membrane.” The hand specialist performed an excision of the radial head and a capsular release in April. During a follow-up visit with the hand specialist two months later, he noted a significant loss in range of motion and more heterotopic bone.

Allegations

A lawsuit was filed against Orthopedic Surgeon A and B and their group. The plaintiff alleged that Orthopedic Surgeon A should have diagnosed a radial head fracture on the sidelines at the football game and sent her to the emergency department immediately. Other allegations included ordering inappropriate self-care and failure to appropriately treat the injury.

Allegations against Orthopedic Surgeon B included failure to achieve anatomic reduction in surgery and failure to use appropriate internal fixation devices. The plaintiff also alleged that both physicians did not use or document appropriate x-ray management of the injury and follow-up care.

Legal implications

One main issue in this case was whether or not the alleged “delay” by Orthopedic Surgeon A caused or contributed to the severity of the injury. The plaintiff’s orthopedic expert stated that based on reasonable medical probability, the delay and the subsequent treatment resulted in contracture of the surrounding soft tissues, loss of cartilage, joint incongruity, and misalignment causing severe limitation of motion.

However, the defense expert testified that the seriousness of the fall and the resulting fracture made full recovery or return to full range of motion difficult even under optimal conditions. The actions of the defendants did not contribute to the severity of the injury or change the patient’s eventual outcome.

Regarding causation, the hand specialist performed an excision of the radial head and did extensive capsulectomies to achieve better range of motion. His operative report states that the limited range of motion was due to heterotopic ossification in the radial ulnar joint. Even after the excision, the patient developed more heterotopic bone that was not present before the surgery.

The medical records from the subsequent physicians did not contain any references to inadequate care by either defendant. Orthopedic Surgeon C noted “fixed radial head” during the February 21 exam. The hand specialist also noted that the radial head was “well reduced.” The primary focus of both subsequent physicians was on the severity of the underlying injury and the developing scar tissue and heterotopic bone condition.

Disposition

This case was taken to trial and the jury returned a verdict in favor of the defendants.

Risk management considerations

While the eventual outcome was a victory for the physicians, the medical records kept by the defendants did not assist their defense. The documentation was described as “basic,” and there was a missing dictated note in the patient’s follow-up care. Further, the physicians did not maintain any of the x-rays related to the diagnosis and treatment of the patient. This allowed the plaintiff to claim that the physicians did not use appropriate x-ray therapy or treatment.

The Orthopedic Surgeon A stated during the investigation of the claim that he did not have a clear memory of what he discussed with the patient on the sidelines at the football game. While it would have been ideal for the surgeon to “document” this encounter with the patient that Friday night, he could also have mentioned the incident in the medical record that Monday when the patient came for treatment. A brief note about the Friday night encounter that described the patient’s condition, the physician’s actions, and the reason for those actions would have provided a more accurate record of events.

Current, complete medical records are helpful to diagnosis and treatment and can also assist in the defense of a malpractice claim. Charting information contemporaneously or as soon as possible after a patient encounter promotes accuracy and completeness of documentation. In addition, the information will be available to you and other members of the health care team to assist with treatment.

Receive two hours of CME and a risk management discount for completing the Case Closed: Trial Victories course, please visit http://tmlt.inreachce.com