June 1998 Bulletin

Study finds 58% claims abandoned, settled

Failure to diagnose claims due mainly to missed diagnoses of fracture or tumor

A Committee on Professional Liability study of 72 malpractice claims of alleged failure to diagnose, filed between 1983 and 1997, found 42 (58 percent) of the claims were abandoned or settled without any payment. Twenty-eight claims (39 percent) were settled with payment.

Only two cases went to trial. One resulted in a defense verdict and the other in a plaintiff verdict. In the defense verdict, the defendant orthopaedist was found not liable for the death of a 39-year-old person who died of colon cancer some time after being evaluated by the orthopaedist for sciatica. For the plaintiff's verdict case, the jury awarded the estate of the plaintiff $700,000 for the failure to diagnose a pulmonary embolus which caused an 18-year-old person's death.

For the 72 claims, defense costs totaled $2,425,000. The average cost was $34,000 and the median cost was $18,000. The defense costs ranged from zero to $172,000. The Committee on Professional Liability's team of reviewers believed that there was no negligence by the orthopaedic surgeon in 46 of the claims (64 percent) and perhaps some negligence in 11 of the claims (15 percent).

Failure to diagnose claims most commonly arose from missed diagnoses of fracture or tumor. Sixty percent of claims involved fractures; 20 percent involved tumors. The remainder of the diagnoses encountered included infection, failure to recognize complications under casts, pulmonary embolus, cervical HNP, rotator cuff tear, partial nerve laceration and vascular injuries.

The findings of the study underscore the importance of attention to detail and a thorough history and physical examination. The clinical "pearls" gleaned from the study are identical to those found in previous closed claim studies targeting fractures or specific anatomic sites.

Risk management comments related to fracture failure to diagnose are summarized here. Each of these missed diagnoses were encountered in the committee's closed claim review.

• Beware of the diagnosis of wrist sprain. There were missed or delayed diagnoses of scapholunate dissociation, navicular fracture and Kienbo¨ck's.
• Check the wrist and elbow in forearm fractures. The reviewers discovered missed diagnoses of Monteggia or Galeazzi fractures and missed humeral condylar fractures.
• Lisfranc injuries, talar neck fracture, calcaneal fracture and femoral neck fractures all made the "hit parade" of missed diagnoses. Quality X-rays in at least two planes are essential. X-rays, including initial ER films, should be personally reviewed by the treating orthopaedist. Additional diagnostic studies should be considered, such as MRI, CT or bone scan if the above diagnoses are suspected and X-rays are negative.
• Beware of the head-injured, senile or otherwise mentally impaired patient. Several missed fractures occurred in this group. One patient with advanced senility complained that doctors were shortening her leg. Several weeks later an X-ray showed a displaced femoral neck fracture.
• Additional X-ray views or CT with reconstruction may help assess complex intra-articular fractures. One case involved failure to diagnose and address a capitellar shear component of a complex distal humerus fracture. A corollary is to check post-op permanent films in the operating room and not rely on image intensifier views. X-rays in the recovery room are of little use because they are too late to identifiy needed operative changes even if they do document the final result.
• Beware of pain under casts. There are no hypochondriacs with casts. Several cases of failure to diagnose cast problems in tibia fractures included skin slough, gangrene and nerve palsy. Failure to take these complaints seriously resulted in catastrophic complications (several cases had documented multiple calls to the physician's office complaining of cast pain inappropriately treated with pain medication.)
• A review of several cases makes it necessary to point out the orthopaedist should be available or arrange alternative cover for assigned ER on-call days. Two of the cases litigated involved compromised trauma care due to irresponsible call coverage. In addition, prompt personal evaluation of high energy injuries can avert life- and limb-threatening complications.
• Discuss even minor radiograph findings with the patient. Minor capsular or ligamentous avulsion fractures should be shown to the patient. Treatment may be the same as for a sprain, but the patient may question his care if a subsequent practitioner shows him a "missed fracture."
• Consider general surgery consultation in the spine-injured patient with paraplegia. Intra-abdominal or retroperitoneal injuries may be missed (e.g., duodenal injuries.)
• Beware of knee pain in children. Document the physical exam of the hip in these cases, and take appropriate radiographic studies.

Diagnoses that failed to identify tumors were problematic in several cases. Committee reviewers found little to criticize and only a few cases involving what they considered to be negligent care. Soft tissue sarcoma and lymphoma were commonly missed. Clinical errors encountered were failure to follow up on abnormal tests; and failure to pursue work-up of atypical and refractory pain.