24.4 Risk management in acute paediatric orthopaedics
Adverse events in paediatric acute orthopaedics
Non-identification or delayed identification
‘Missed fractures’ are commonly associated with ED litigation, accounting for approximately half of ED negligence claims in the UK and Australia.1 Articles auditing the correlation of ED doctor X-ray analysis with radiologist reporting in recent years show that 1–2% of these reports have a discrepant concordance significant enough to alter management2–6 although in many series there were no long-term adverse events detailed. Fractures can also be missed because of primary assessment failure (failure of thorough history or examination, therefore failure to X-ray). X-rays may be inadequate in coverage or resolution, the abnormality may be missed by the ED physician(s), or by radiologists; this too tends not to show in reported series, which presume radiology reports to be the gold standard, and there may be breakdown between radiologist reporting and ED physician notification and recall of patient. All such oversights have been specifically associated with adverse outcomes7 and the physician responsibility for follow up and communication, which extends to ensuring that a booked follow up does actually occur, must not be overlooked.
Common or serious acute paediatric orthopaedic adverse events are shown in Table 24.4.1.
Regarding missed displaced fractures and dislocations, the following points should be considered:
Anatomical distortions should be clinically apparent to patient and physician. In fact, in a series of 80 injuries with delayed identification,5 there were comments about pain, swelling or loss of function documented in more than 60% of cases, which had not been acted upon. In 20% of cases the doctor was alerted to the possible problem by the patient or his/her relatives.
Fractures about the joint are at disproportionately high risk both for being missed and for adverse events. Although most series of fractures missed in the ED include a large array of different sites (45 fractures at 15 sites and 69 fractures at 27 sites5 in two series not exclusively paediatric), knee injuries (tibial spine and plateau) were disproportionately represented in the former (nine fractures compared with only one missed scaphoid fracture), and elbow injuries were disproportionately represented in paediatric adverse events. However, in all the significant paediatric elbow injuries listed as potentially missed (unstable supracondylar fracture, lateral condyle fracture, Monteggia fracture-dislocation and a trapped medial epicondyle, e.g. after elbow dislocation), elbow examination was grossly abnormal, including an effusion and a limitation of range of motion. Although the radiological Monteggia fracture-dislocation has often been missed by an untrained X-ray viewer, the clinical elbow abnormality should not be. A lack of clinical joint integrity (effusion, asymmetry cf. the other side, reduced range of movement) is an indication for early orthopaedic review even if the X-ray appears normal.
Two special categories of high-risk patients deserve mention. The first is multitrauma patients,7,8 due to several factors including urgency of other clinical problems, the possibility of an altered or distracted conscious state, and hand-over problems. The second group of note is children with complex medical conditions including autistic spectrum disorders, due to difficulties in patient communication, occasional pre-existing anatomical abnormalities, varying pain thresholds, and a need to establish base-line ‘normal’. Both of these categories of patient require senior medical involvement, careful and often repeated systematic assessment and documentation.Procedure-related problems
Problems relating to ED interventions fall into a separate category, and increase proportionally with the number and types of procedural activity undertaken in a department, which varies widely in Australia, particularly for the paediatric population. Strategies to minimise these problems are now so well described in the risk-management literature that any department planning to change procedural practice would do well to follow these guidelines (Table 24.4.2).
1 Gwynne A., Barber P., Taverner F. A review of 105 negligence claims against accident and emergency departments. J Accid Emerg Med. 1997;14:243-245.
2 Klein E.J., Koenig M., et al. Discordant radiograph interpretation between emergency physicians and radiologists in a paediatric emergency department. Pediatr Emerg Care. 1999;4:245-248.
3 Walsh-Kelly C.M., Hennes H.M., Melzer-Lange M.D. False-positive preliminary radiograph interpretations in a pediatric emergency department: Clinical and economic impact. Am J Emerg Med. 1997;15(4):354-356.
4 Simon H.K., Khan N.S., Nordenberg D.F., Wright J.A. Paediatric emergency physician interpretation of plain radiographs: Is routine review by a radiologist necessary and cost-effective? Ann Emerg Med. 1996;27(3):295-298.
5 Kremli M.K. Missed musculoskeletal injuries in a university hospital in Riyadh: Types of missed injuries and responsible factors. Injury. 1996;27(7):503-506.
6 Cameron M.G. Missed fractures in the emergency department. Emerg Med. 1994;6(1):37-39.
7 Alpers A. Key legal principles for hospitalists. Disease Monitor. 2002;48(4):197-206.
8 Connors J.M., Ruddy R.M., McCall J., et al. Delayed diagnosis in paediatric blunt trauma. Pediatr Emerg Care. 2001;17(1):1-4.
