Need a Pedes Ortho PA-C expert (not an MD) to review the following claim:
Six-year-old child visiting Orlando from Brazil fell on the playground resulting in right arm injury. Patient taken to local hospital emergency department for evaluation and treatment. ED MD's exam found decreased ROM and tenderness of right elbow. X-rays of the right forearm showed non-displaced oblique fracture through the proximal ulna. There was also questionable cortical irregularity of the supracondylar humerus as well as abnormal radiocapitellar alignment concerning for subluxation/dislocation, but evaluation was significantly limited due to positioning.
ED MD consulted with pediatric orthopedist who reviewed the films and felt that the quality of the radiographs was not good enough to confirm a radial head subluxation and recommended repeated films and to follow-up as an outpatient within 1-2 days. A long posterior splint was applied, and the patient was discharged home.
Patient followed up as instructed at a local pedes ortho clinic where she was seen and evaluated by a PA-C who noted that the patient fell off the monkey bars at a playground landing directly onto her right elbow. The PA-C found decreased range of motion due to pain with tenderness in the olecranon process on physical exam and noted that he reviewed outside films and radiology reports before diagnosing the patient with a fracture to her right proximal ulna. No repeat imaging was done. The patient was placed in a long arm cast with instructions to follow up with an orthopedic provider in Brazil in 4 weeks.
The patient followed up with a provider in Brazil as instructed. X-rays were done of the right elbow revealing signs of dislocation of the radial head. A few days later, repeat x-rays were done of the right elbow revealing an anterior and lateral dislocation of the radial head in relation to the humerus with soft tissue swelling. Based on the x-rays, it was determined that the patient had suffered a Monteggia fracture with fluid inside the elbow joint due to her traumatic injury.
The patient's family alleges that the PA-C deviated from the standard of care during the outpatient visit resulting in a delayed diagnosis of the Monteggia fracture. There are no claims against the ED MD or the initial pedes ortho who was consulted by the ED MD.
Files:
No questions yet!
Do you believe there might have been medical error?
The PA that saw the patient in follow up should have reviewed the ER note which would have discussed the possibility of radial head dislocation and the poor quality of the radiographs. Furthermore, the PA would have reviewed the radiographs and realized that they are of poor quality and non diagnostic. Therefore new radiographs with appropriate positioning should have been obtained which would have allowed for diagnosis of a Monteggia fracture. Standard treatment is closed reduction and it is well known that complications arise if treatment is delayed beyond 2-3 weeks. This treatment was not performed and followed up was not scheduled for at least 4 weeks in the patient’s home country. It is my opinion that the PA’s care fell below the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Standard treatment of a Monteggia fracture is closed reduction. Failure rates increase significantly if treatment is delayed beyond 2-3 weeks. This would most likely lead to requiring operative repair and long-term pain and complications.
What makes you a good expert for this case?
I am an orthopedic PA with 20 years of clinical experience, 7 of those being in orthopedics and 12 years in emergency medicine. I have also served as an expert witness in many cases for both plaintiff and defense with deposition experience for both sides.
How often do you encounter cases similar to this one in your practice?
I commonly see pediatric injuries including fractures (with and without dislocation). In my practice, I am required to review my own X-rays without direct oversight by a physician.
Do you believe there might have been medical error?
These type of fractures are uncommon, yet they can be missed 20-50% of the time. Historical details and specific exam physical findings are very important, therefore the PA must rely on a combination of parent/child a acurate reports(i.e timing, hight of fall, MOI etc.) and physical exam clues to ascertain levl of acute compromised. The vignette does not discuss nor provides certain basic management steps. 1. lack of pain management prior to assessment--would have helped with exam. 2. repeat x-rays post analgesic administration might have helped. 3.Lack of a detailed neurovascular exam initially and at follow-up. 4. A wrist x-ray was warranted in this case if this was deemed a Montegia Fx 5. Ortho resident consult for ED reduction and/or assessment would have been pertinent. 6. An Elbow US/MRI was it ever entertained immediately and upon follow-up given the difficult exam presented by the child? 7. What ED/Peds clinic protocol PA followed. 8. What was the experience level of PA managing/recognizing Montegia fractures. 9, Was there any DDX listed in the MDM 10. Serial elbow x-rays timing should have been followed more closely with a lower suspicion given the acute nature of fracture
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Along with the explained potential departures in previous question/answers provided along with loss of reduction due to failing to anticpate/recognize fx type. This child could have benefitted from more timely serial x-rays, advanced imaginng studies. This child might have not been able to maintain the reduction due to possible annular ligament entrapment in the joint space. If a BADO Calsssification system would have been used/discussed in the chart, this could have prevented the compromised outcome.
What makes you a good expert for this case?
Provided ED care services for 11.5 years and Orthopedic Trauma Care for 14.5 years at an inner city Level 1 ACS Trauma Center--see resume.
How often do you encounter cases similar to this one in your practice?
Perhaps 1-2 yearly, usually the MOI was slightly different in terms of force generated and sustained by the child since they can tolerate greater mechanical stressing forces than adults.
Do you believe there might have been medical error?
It is integral into pediatric orthopedic APP onboarding and education to not miss a Monteggia fracture. Any pediatric patient with a proximal ulna fracture after a fall must be thoroughly evaluated for a Monteggia fracture with dedicated forearm and elbow films. If the image positioning is suboptimal due to pain, guarding, etc, as is typical in the ED/Urgent care settings, then it is reasonable to control pain and attempt to repeat images. Oftentimes imaging at time of injury is suboptimal due to pain, positioning, and resource availability. It is the pediatric orthopedic provider's responsibility to ensure orthogonal imaging to rule out subluxation/dislocation of the radial head. Imaging could also be obtained in the immobilization that the patient was in (splint, cast, etc) since the material is radiolucent. This would also help with patient positioning for subsequent images in clinic as pain would be better controlled.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delayed diagnosis of Monteggia fracture/dislocations leads to morbidity of the proximal radiocapitellar joint and causes functional impact on the patient. In this case, it is likely that this patient would have required subsequent operative intervention to reduce the dislocated radial head, which is more challenging when diagnosed in a delayed fashion as opposed to shortly after time of injury. Conversely, if the Monteggia fracture was diagnosed earlier, this injury may have been successfully reduced under conscious sedation, potentially avoiding subsequent surgery.
What makes you a good expert for this case?
I am the Education Lead for our Advanced Practice Provider group of almost 30 APPs in Pediatric Orthopedics. I have designed, implemented, and optimized the APP onboarding curriculum for Pediatric Orthopedics at our large institution, and have integrated mandatory trainings into our onboarding curriculum to ensure that providers are aware of "can't miss" diagnoses. Having almost a decade of Pediatric Orthopedics experience, I routinely treat fractures and complex patients that require a high index of suspicion for subtle abnormalities. Regularly, I teach students, residents, and APPs a systematic approach to x-ray review to ensure subtle injuries are not missed. Furthermore, I sit on a POSNA committee involved in the development of a national standardized onboarding curriculum for Pediatric Orthopedic APPs, and am directly in charge of helping to implement curriculum at institutions to ensure adequate APP education. Routinely, I am faculty at Pediatric Orthopedic education conferences, and teach both new and experienced APPs what not to miss as a nationally recognized speaker. I have previously provided legal consultation for Pediatric Orthopedic cases as well.
How often do you encounter cases similar to this one in your practice?
Fractures such as this are the "bread and butter" of Pediatric Orthopedics. Although a missed diagnosis of Monteggia fracture does not occur often, I treat elbow and forearm injuries weekly. This injury pattern is something I am extremely familiar with.
Want to open a case or submit response?
Comments are accepted only from Physician Assistant experts.