Failure to diagnose fracture
by Laura Hale Brockway, ELS, Vice President, Marketing, and
Winnie Alobuia, Risk Management Representative
An eight-year-old boy came with his mother to a local emergency department (ED). He reported pain in his lower left leg (“hamstring pain”) from a fall earlier that day.
The patient’s care in the ED was directed by a physician assistant (PA). An emergency medicine physician was listed as the attending physician, but there was no documentation of his involvement in the case.
The PA examined the patient and noted decreased range of motion (ROM), pain, and tenderness of the left leg. The patient’s pain level and degree of loss of ROM was not described. The PA ordered and interpreted “femur left x-ray” as showing no fracture or dislocation. The patient was prescribed ibuprofen, rest, and crutches. He was discharged from the ED after crutch training and instructed to follow up with his pediatrician in two to three days.
The next morning, Radiologist A interpreted the x-ray images as showing no abnormality.
Pediatrician A saw the patient five days later and noted “continues with pain” and that he had difficulty walking and putting pressure on the leg. Pediatrician A noted that he was “better today.” His physical exam described “tender left groin” and “hips okay.” He concurred with the previous diagnosis of muscle pain and recommended symptomatic care. The patient was told to return as needed. The patient did not return to Pediatrician A.
Two years passed and the patient saw Pediatrician B for a well check. Pediatrician B found that the patient’s right leg was longer than his left leg and referred her to a pediatric orthopedic surgeon.
During the first visit with the pediatric orthopedic surgeon, the patient’s mother provided the patient’s history of the previous injury and reported that it took two months for him to recover from the pain in his leg. The pediatric orthopedic surgeon found that there was a difference in the height of the patient’s femurs and he had a Trendelenburg gait. X-rays showed a short femoral neck fracture and a high trochanter compared to the right hip.
The pediatric orthopedic surgeon reviewed the x-ray from three years earlier and stated that the patient had a femoral neck fracture that was not recognized by Radiologist A. His findings and options for treatment — including leg lengthening surgery or trochanteric transfer — were discussed with the patient’s mother. The mother said she would consider the options.
An MRI was performed the next day. It confirmed evidence of a prior femoral neck fracture with subsequent angulation of the metaphysis and epiphysis causing posterior angulation by 63 degrees.
Two months later, the patient and his mother met with the pediatric orthopedic surgeon to discuss options, including 1.) lengthening the left leg via osteotomy and a Precice nail; 2.) shortening the right leg; and 3.) no surgery until the patient experiences pain or difficulty walking. The surgeon noted, “We reviewed the risks and benefits of each option . . . they would like to monitor and consider surgery in the future if he becomes symptomatic.” At this meeting, the patient denied any pain and reported that he was wearing a shoe lift in his left shoe that helped him feel “more level.”
During the next year, the patient remained asymptomatic. It was maintained that surgery may become necessary in the future as the patient was still growing and his condition could progress.
A lawsuit was filed against Radiologist A, alleging misdiagnosis of the patient’s injury that resulted in a leg length discrepancy that will require surgery to repair. The plaintiffs also alleged that had the fracture been treated at the time of the injury, “his risk of malunion and avascular necrosis would have been substantially lower.”
This was a difficult case to defend. Radiologists consulting for this case reviewed the x-rays that made the basis for this claim and identified the fracture. These original x-rays demonstrated “significant angulation of the left femoral neck, consistent with a poorly visualized fracture.”
Further, “The fracture line is not clear because it is a femur study and not a hip study so positioning is not optimal. The wrong test was ordered. The radiologist should have recommended a hip study be ordered.”
Radiologists reviewing this case also noted the patient’s injuries “were not appropriately diagnosed and managed by the ED and radiology staff.”
Physicians who reviewed this case were also critical of Pediatrician A for not setting a more established follow-up date rather than telling the patient to return “as needed.” It was also noted that Pediatrician A’s patient history and overall documentation were poor and failed to reflect an adequate exam.
This case was settled on behalf of Radiologist A.
Risk management considerations
Defense radiology consultants were critical of Radiologist A for “failing to diagnose the fracture and in failing to report the fracture to the referring physician at the time of interpretation.” According to one defense consultant, “the femoral neck should be evaluated as part of an x-ray of the entire femur” and a request for additional imaging of the hip was warranted. Other radiology consultants also identified the fracture on the x-ray and were critical of the radiologist for not reviewing the entire image.
Opinions expressed by the defense consultants are consistent with a 1995 study that noted “from a practical point of view once an abnormality on a radiograph is pointed out and becomes so obvious that lay persons sitting as jurors can see it, it is not easy to convince them that a radiologist who is trained and paid for seeing the lesion should be exonerated for missing it.” This study also pointed out that is especially true when diagnosis and treatment are delayed due to an x-ray not being fully reviewed. (1)
The study further describes some contributing factors of radiology errors that include technical errors, system issues, frequent interruptions, and more. For instance, technical errors such as the specific imaging protocols used could influence a radiologist’s ability to appropriately identify or interpret abnormalities.(1)
Systems issues may include staff shortage, work overload, inadequate equipment, staff inexperience, or even the reporting environment. Other considerations include limited clinical information, or inappropriate expectations and capabilities of various radiological techniques. Frequent interruptions may also lead to loss of concentration and failure to report identified abnormalities (1).
Poor documentation and communication between providers also contributed to the outcome in this case. The patient’s record did not include any documented consultation between the PA and Radiologist A. Radiologist A may have been helped in his interpretation of the films if he had been told about the patient’s symptoms and the PA’s impression along with the x-ray order. Maintaining clear, complete, and contemporaneous documentation can benefit the physician in the event of a claim and increase the quality and continuity of patient care.
Brady, A. P. Error and discrepancy in radiology: inevitable or avoidable? Insights into Imaging 2017. Volume 8, article 1, pages 171–182. Available at https://link.springer.com/article/10.1007/s13244-016-0534-1. Accessed August 12, 2021.
Laura Brockway can be reached at firstname.lastname@example.org.