Risk management in acute paediatric orthopaedics

24.4 Risk management in acute paediatric orthopaedics



Robyn Brady




Essentials



1 Inadequate identification and management of unstable or displaced injuries such as lateral condylar elbow fractures, Monteggia fracture dislocations, and slipped upper femoral epiphysis (SUFE), can cause serious long-term deformity and malfunction.

2 Immobilisation complications, from loss of position to skin ulceration or compartment syndromes, demand scrupulous departmental risk management protocols, as they often relate to ‘weakest link’ situations.

3 The importance of adequate initial clinical evaluation and follow up of patient or clinician concerns cannot be over-stressed.

4 A variety of departmental risk-management strategies provide a safety net for doctor and patient.


Introduction


Emergency medicine is an area of medical practice with a high rate of litigation, and orthopaedic conditions (especially missed fractures) make up a high proportion of successful claims. Many factors intrinsic to emergency medicine contribute to this danger, including high staff turnover, 24-hour practice with multiple hand-overs, wide-ranging procedural demands, and workload flux.


Just as many of the problems are systemic, so too are many of the solutions. Adverse outcomes can occur when the clinical problems discussed in this section are not recognised or dealt with adequately, and there are clear emergency department (ED) systemic interventions that can minimise their occurrence.



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.






Table 24.4.1 Adverse events in acute paediatric orthopaedics
Missed displaced fracture/dislocations
• Elbow

Supra-condylar fractures

Lateral condyle fractures

Monteggia fracture dislocations

Medial epicondylar joint entrapment

• Knee

Tibial spine

• Phalangeal fractures with angulation

• Hip

Slipped upper femoral epiphysis (SUFE)

• Open injuries

• Fracture complications, e.g. compartment syndrome, neurovascular compromise

• High-risk patients

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Risk management in acute paediatric orthopaedics

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