ORTHOPEDIC MALPRACTICE

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ICC offers a course in Medical Mal-Practice to orthopedic surgeons. If you are concerned  about your practice our defense course maybe for you to help you reduce your insurance premiums  .  The following are a few examples of what physicians  fail to do which triggers  Mal Practice claims.   Through  ICC's  Medical Mal- Practice Prevention  course  surgeons  learn to avoid these pitfalls.   ICC course generally take 3 months to complete  which the surgeon at the end of the course  the surgeon  will receive a professional designation  in medical mal-practice prevention. 

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II. ORTHOPEDIC MALPRACTICE

ORTHOPEDIC MALPRACTICE

1. Orthopedic surgeons face problems common to those of Emergency room physicians and other surgical specialists in addition to those unique to Orthopedic surgery.

(a) Treatment is largely associated with trauma, adding a high exposure to the inherent risks of surgical intervention.

(b) The physician-patient relationship is usually non-existent at the time of trauma, with confidence and trust developing only over time. Frequently the orthopedist is consulted from an on call list and is not personally known by the patient.

(c) Significant traumatic injuries often result in an unfavorable outcome without regard to the treatment rendered, but the patient may seek to blame someone by bringing a malpractice action.

(d) Treatment is usually long, painful, and inconvenient causing the patient discouragement and monetary loss.

(e) The patient often has an attorney bringing claim for the tort which caused the injury. If the original tort occurrence cannot provide recovery, the attorney may look to the surgeon for recovery.

B. Legal Standards

1. Most Orthopedic surgeons practice in a group setting, with each surgeon responsible for his or her own actions and for the actions of his or her employees. The exposure of the group to liability, for the most part, lies with the qualification of its members and with the conduct of its employees acting within the scope of their duties. Hospital employees are generally held to their own standard of care except when an improper order on the part of the physician is involved. In this setting, the physician may be held liable if an injury results.

C. Areas of Vulnerability

1. Diagnostic Error or Omission

(a) In diagnosing a fracture, it is very important to obtain a good history and physical examination as well as a careful roentgenographic examination.

(b) Particular attention should be given in the presence of certain symptoms or signs:

(1) Pain as a prominent symptom, especially pain which is out of proportion to other findings and pain which fails to abate.

(2) Loss of function of the involved part, unless the fracture is incomplete or impacted.

(3) Findings of swelling, tenderness, deformity, abnormal motion, and crepitus.

(4) In the presence of paresthesia, pallor, or pulselessness of an involved limb, compartment syndrome must be considered and ruled out.

2. Careless Handling of a Patient

(a) Careless handling of a patient with a fracture may aggravate a simple problem:

(1) a closed wound may be converted into an open wound.(2) a clean wound may be contaminated.(3) an intact spinal cord may be severed.(4) major blood vessels or nerves may be severed.

3. Malunion and Nonunion

(a) Poor surgical judgment and poor technique may contribute to delayed or nonunion when there is devitalized tissue, excessive or unnecessary periosteal stripping, or failure to achieve maximal internal fixation. Certain factors that may contribute to delayed or nonunion are amenable to control by the orthopedic surgeon such as:

(1) Poor medical judgment in selection of treatment for a given fracture, as when open reduction is chosen in a setting in which closed reduction would be adequate.

(2) Failure to achieve adequate reduction.

(3) Failure to eliminate the action of shearing or rotary forces on the fracture site.

(4) Inadequate fixation, whether resulting from poor design of a plaster cast, from insufficient duration of otherwise adequate immobilization, or from insufficient external support of a fracture.

(5) Distraction of fragments, as occurs if excessive weight is applied to a limb in traction.

(6) Improper choice or improper use of metal plates and screws, thereby presenting rather than facilitating union.

(7) Infection, especially if related to inadequate wound debridement or disruption of vascular channels.

(8) Delayed in reduction of the fragments.

(9) Interposition of soft tissue which prevents adequate reduction of the fragments.

(10) Persisting distraction of the fragments.

(11) Inadequate immobilization of the fragments.

4. Circulatory Complications

(a) The orthopedic surgeon must evaluate the initial status of the circulation of the extremity involved by fracture or dislocation and he or she must continue to monitor the circulation carefully following therapy.

(b) The following incidents are common occurrences that require careful attention:

  •  

  • (1) Early and appropriate assessment of trauma to the vasculature. At times an artery may be stretched at the time of fracture so that an intimal tear occurs. This is especially dangerous because the patient may present without obvious circulatory deficit only to have disappearance of the pulse in the affected limb over the following few hours as a thrombus forms.

    •

  •  

  • (2) Circulatory impairment may result when swelling in an extremity causes an overlying circular cast to become too tight. In this instance, the cast should be bivalved completely and all bandages and padding cut down to the skin for the full length of the cast. Clearly, malpractice in this setting is most likely to arise when follow-up care of patients after surgery or reduction is inadequate.

    •

  •  

  • (3) Circulatory impairment may result from hemorrhage and edema into closed compartments of the extremities. Such circulatory embarrassment can be seen in fractures of the leg, forearm and elbow. Signs of such a compartment syndrome have been enumerated under the rule of the four "p's:" loss or diminution of pulse, pallor proceeding to cyanosis, pain out of proportion to that expected from fracture alone and paresthesia and paralysis due to anoxia of the nerves and muscles. When these signs appear there may be irreversible damage to the involved nerves and muscles and in fact gangrene may ensue if appropriate measures are not taken rapidly.

    •

    5. Postoperative Infection

    (a) Infection is seen most commonly in open fractures or in closed fractures in which open reduction and internal fixation has been carried out. In general, all open wounds should be considered as emergencies. Every hour lost following injury predisposes the patient to serious infection. The goal of treatment should be the removal of all contaminated and devitalized tissue and conversion of the dirty wound to a clean one. Culture and sensitivity testing of the wound to determine appropriate antimicrobial therapy is important, but initiation of antibiotic administration should not be delayed until these results are available.

    (b) Other means of minimizing the risk of infection include control of the surgical environment, attention to scrub technique, reduction of operating room traffic, and observation of infection control practices.

    (c) Careful follow-up for the development of post-operative abscess formation and for the development of osteomyelitis is important in all patients who have undergone orthopedic surgery, including those who have undergone insertion of a prosthetic device.

    D. Recommendations

    1. Clinical diagnosis must be confirmed by adequate and appropriate x-ray examinations. A single plane view is often insufficient to make an accurate diagnosis.

    (a) X-ray in two planes, including the joints above and below the fracture, may prevent failure to diagnose an associated joint dislocation.

    (b) In addition to the usual anterior-posterior and lateral radiographs, consider obtaining special views for any suspected injury of the cervical spine.

    (c) A posterior dislocation of the shoulder may be missed unless an axillary view is obtained.

    (d) Special radiographic studies, such as CT or plain tomograms may be needed to evaluate a bone injury properly.

    (e) A repeat x-ray in one or two weeks may be necessary to diagnose a fracture, as the fracture line may not be visible until some measure of healing starts.

    2. Careful neurological examination of the involved extremity as well as thorough vascular assessments must be made and documented on an ongoing basis.

    3. Know the indications for open operative reduction of fractures.

         4. Know the contraindications to open reduction of a fracture:

    (a) Presence of an active infection or osteomyelitis.

    (b) Presence of a fracture fragment of insufficient size for attachment of rigid fixation.

    (c) Presence of bone that is so weak or soft that internal fixation devices would not be secure.

    (d) Presence of surrounding soft tissue that is so abnormal or that has such poor healing capacity that the risk of surgery is greatly increased.

    (e) Presence of medical conditions or illnesses that are a contraindication to anesthesia.

    (f) Presence of nondisplaced fractures or impacted fractures already in good position.

    5. When rigid immobilization of a fracture is necessary to achieve union, assure that it is applied such that:

    (a) Pain is relieved.

    (b) No shearing or rotational stress occurs at the fracture site.

    (c) Displacement or angulation of the fragments is precluded.

    (d) The optimal positioning of the fragments is maintained.

    6. Have a tickler system in use to follow up on all studies.

    7. Never release original x-rays. A patient may obtain copies of any films or may have the original films reviewed at the custodial facility.

    8. Do not improvise.

    9. Document the history, physical examination, studies obtained and results, in addition to any consultations. Moreover, carefully document plans and a discussion of the prognosis held with the patient and/or family of the patient. These measures provide one of the best defenses against a malpractice claim and in particular will protect you from a claim that you allegedly guaranteed a cure.

    10. Keep the patient informed. In pediatric cases, keep the parents of the patient well informed and document the content of all discussions held with them.

    11. Maintain vigilance for danger signals as discussed above.

    12. Be aware of patients and attorneys seeking compensation for Workers' Compensation. As Workers' Compensation does not pay for pain and suffering, a plaintiff's attorney may pursue malpractice litigation as a means to obtain fiscal reward.

     NOTICE  .

    One  Course outside class  room generally take 3 months  to complete 

    Cost of each course  is $1,300.00 Plus book fee

    Courses  starts  April 2, 2007  and  May  7, 2007 

    Corporate  discounts available  for  10 or more students  

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