Failure to diagnose mandible fracture

Presentation
On June 1, a 35-year-old woman fell while stepping off a boat, injuring her chin, jaw, wrist, and hand. She went to an urgent-care clinic for treatment that evening and was diagnosed there with left mandibular fracture and chin laceration. The physician at the clinic referred the patient to the emergency department (ED) of a local hospital, suggesting that she have a Panorex x-ray, laceration repair, and possibly a CT scan.

Physician action
The emergency medicine physician treating this patient ordered a facial x-ray series, read that same evening as negative. These same x-rays were reviewed the next morning by the defendant radiologist, who also interpreted them as negative. The ED physician did not order a Panorex x-ray or CT scan of the face, but discharged the patient home with instructions to follow up in 5-7 days.

On June 2, the patient was evaluated by her dentist. He noted a long cusp fracture and TMJ problem. The dentist did not note fracture or reference malocclusion in his notes. The patient then saw her family physician on June 8 for removal of the sutures from the chin laceration. At this visit, she complained of a sore and swollen jaw. No Panorex films or x-rays were ordered.

The patient returned to her dentist and complained of TMJ problems. She was referred to Oral Surgeon A, who evaluated the patient on June 22. He reviewed the hospital x-rays and ordered a Panorex. He diagnosed the patient with a left high subcondylar fracture. Oral Surgeon A told her to exercise and increase the range of motion in the mandibular region.

On July 3, the patient was evaluated by Oral Surgeon B. He noted that the initial films from June 1 showed a left sided subcondylar fracture. The patient continued to experience problems with malocclusion and TMJ over the next two years. She received regular care from her dentist, Oral Surgeon B, and an Orthodontist. She underwent range of motion exercises and had rubber bands and braces placed to help improve her bite, but had continued discomfort.

Oral Surgeon B noted that the patient’s occlusion was as good as it was going to be without surgery. The patient indicated she had concerns with her speech, and Oral Surgeon B recommended consultation with a speech pathologist.

In April 2002 the patient sought a second opinion from Oral Surgeon C. He assessed decreased mandibular mobility and malocclusion. An MRI was interpreted as showing a malunion of the left condyle; anteromedial disc displacement without reduction; and secondary arthritic changes of both condylar heads. Oral Surgeon C discussed the possibility of a coronoidectomy and bilateral TMJ arthrocentesis after extraction of bicuspids and pre-surgical orthodontics. The patient has not had the repair surgery.

Allegations
A lawsuit was filed against the ED physician who treated the patient on June 1 and the radiologist who reviewed her x-rays on June 2. The allegations against the radiologist included:

• failure to properly and adequately evaluate patient’s facial injuries;
• failure to properly interpret the x-ray;
• failure to diagnose mandible fracture
• failure to administer proper and adequate medical care treatment; and
• failure to timely obtain or refer the patient to an oral surgeon.

Legal implications
The plaintiff’s radiology expert testified that the defendant was negligent for not identifying the mandible fracture. This expert said he detected a mandibular fracture of the symphysis on the PA view. He also testified that the standard of care for a symptomatic patient with a chin laceration, pain in the preauricular region, clinical suspicion of a mandibular fracture, and a chipped tooth is to have a Panorex. If a Panorex is not available, a facial CT should be performed.

However, this expert conceded that he too had missed some abnormalities in films, and that radiologists often do not have the information that treating physicians have regarding what happened with the injury.

The defense radiology expert did not believe a violation of the standard of care occurred regarding the radiological assessment of the mandibular injury. He disagreed that the symphyseal fracture is obvious on the facial series x-ray. He stated that every fracture is obvious when you know where it is and where to look for it. If he had been reviewing these films under similar circumstances, there was a fair chance he would not have noticed any abnormality.

A maxillofacial surgeon testifying for the defense stated there was no subcondylar fracture and no symphyseal fracture evident in the films. He also reviewed the subsequent Panorex film, and said there was no symphyseal fracture.

Disposition
This case was taken to trial and the jury reached a verdict in favor of the defendant radiologist. In the case against the ED physician, the jury reached a verdict in favor of the plaintiff.

Risk management considerations
In reviewing this case for the defense, one radiologist said that upon first glance she did not see the fracture on the films. However, after reviewing the patient’s chart and re-reading the films, the fracture can be seen. In this case, it may have been preferable for the ED physician to include a list of the patient’s symptoms along with the order for the x-rays. This may have better guided the radiologist in understanding the patient’s condition.