Medical Malpractice Insights: Fracture/dislocation of hip results in avascular necrosis

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Fracture/dislocation of hip results in avascular necrosis

Was the ED doc’s early reduction to blame?

Facts:

A police officer in his 30’s is in a training exercise when a fellow officer falls on him, dislocating the first officer’s hip. He is taken to the local ED by EMS. An x-ray done within 20 minutes confirms the diagnosis, but the ED physician fails to document the accompanying 1 x 2 cm fracture fragment inferior to the femoral head reported by the radiologist as a Pipkin Type I (see graphic and reference below). The dislocation is easily reduced under propofol by the EP within 40 minutes of arrival. An orthopedic surgeon arrives after the reduction and consults the regional trauma center. The center reviews the post-reduction CT and recommends transfer for an open procedure to address the bone fragment. Avascular necrosis develops post-op and the officer requires a hip replacement after which further complications develop. The officer then recalls a comment by someone at the trauma center suggesting that a primary open reduction rather than immediate closed reduction was the treatment of choice. He consults an attorney who refers the records to an EM expert before filing a lawsuit.

Plaintiff: The ED physician failed to note the large bone fragment from the femoral head and treated my injury as a simple posterior dislocation. I would not have needed a hip replacement if he would have transferred me to the trauma center before relocating my hip. Now I’m in constant pain, can barely walk, and cannot function as a police officer.

Defense: There is a minority opinion that open reduction in this type of fracture/dislocation might be preferable, but the standard of care remains early reduction. This reduces the incidence of avascular necrosis, which occurs in up to 30% of such dislocations regardless. The care was completely appropriate, and in fact commendable. Defense experts in both emergency medicine and orthopedics would be eager to support the care rendered.

Result: No lawsuit was filed, and the patient was reassured that his care was appropriate.

Takeaway:

• When we do the right thing in a true emergency (even if we don’t document all the findings in our ED note), we should have nothing to fear.
• As often advised, use extreme caution when commenting on care by other physicians and jumping to conclusions about what is and is not the best course of action.
• A “hired gun” plaintiff expert could make life miserable in a case like this, but thankfully our insurers have “bigger guns” and are eager to use them for our defense. This case illustrates how physicians who make themselves available to plaintiff attorneys can – more often than not – keep good docs from getting sued.

References:

1. Pipkin femoral head fracture classification. Weerakkody Y et al. radiopaedia.org. https://radiopaedia.org/articles/pipkin-femoral-head-fracture-classification
2. Traumatic Hip Dislocation: A Review. Sanders S et al. Bull. NYU Hosp Joint Dis. 2010;68(2):91-6 http://presentationgrafix.com/_dev/cake/files/archive/pdfs/281.pdf
3. Hip Dislocation in Emergency Medicine: Treatment & Management. McMillan SR. Medscape eMedicine, Apr 11, 2016. https://emedicine.medscape.com/article/823471-treatment#d10

Diagnostic Error: A diagnosis that was delayed or wrong that occurs when all the clinician needed to make the diagnosis was potentially there, but because either the clinician or the system or both wasn’t functioning at the level of which they’re capable, the diagnosis wasn’t made.

Bob Trowbridge, MD

Director, Division of General internal Medicine

Maine Medical Center