June 1998 Bulletin
Study finds 58% claims abandoned, settled
Failure to diagnose claims due mainly to missed diagnoses of fracture
By Lynn C. Garner, MD; and Dennis B. Brooks, MD
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
- 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
- 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
- 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.