Here we bring to you a pre-operative misdiagnosis case that led to a legal procedure. The learnings help in understanding the importance of a thorough evaluation of any case and also conclude that missing out on diagnosis may not necessarily miss legal trouble.

The case

An adult patient sustained injuries on his body in a road accident. He was referred to a private hospital in Delhi. The orthopaedic consultant examined him and diagnosed it as a fracture of the femur (thigh bone) on the right side. He was operated on, and a rod was implanted from the loin to the thigh and he was discharged in a few days.

The doctor informed about the successful operation. During the follow-up after one month, an X-ray of the operated site was taken and seen by the concerned doctors of the same hospital. The doctors assured that it would take some more time for getting everything cured. It was alleged that even after 6 months the patient was unable to walk due to pain.

Due to unbearable pain in the operated leg, the patient contacted another doctor who examined the patient and took X-rays. He opined that there was a fracture in the loin bone, and advised the patient to approach the same hospital where he was first operated on earlier.

Series of events thereafter

1. The complainant then met the doctor who had done the surgery and was told that the fracture might have occurred due to a fall somewhere else. The patient was advised for bone grafting as there was an unsatisfactory union of bones. However, the patient was not willing to undergo bone grafting.
2. The patient came back to the hospital with the complaint of pain in the right hip and thigh.
3. The X-ray revealed displaced intra-capsular fracture of neck femur and was advised to undergo osteosynthesis- a valgus osteotomy and fixation with angled blade plate. 
4. Due to financial hardship, the complainant did not opt for further surgery and approached the nearby government hospital where he was later operated on.
5. Being aggrieved by the alleged negligent treatment at the private hospital, the complainant filed the complaint before the district forum.

As per the order pronounced by National Consumer Disputes Redressal Commission:

The Commission declared after reviewing the patient's medical records and medical literature:

"We conclude that the procedure for intramedullary nailing of shaft femur was conducted without any defect by a trained orthopaedic surgeon. Pre-operative misdiagnosis may be due to a failure to obtain proper X-rays with external rotation of the femur shaft to rule out the possibility of a sub-clinical occult fracture. It's critical to realise that in patients with a fractured femoral shaft, particularly those who have been polytraumatised, the greatest degree of suspicion for the occurrence of an ipsilateral femoral neck fracture must be maintained. This might assist to minimise the number of femoral neck fractures that go unnoticed."

The hospital and physicians were found to be negligent for failing to use diagnostic tools to determine the existence of an ipsilateral femoral neck fracture.

"While an error of judgement or failure to diagnose a difficult ailment does not constitute negligence in and of itself, it may be claimed that missing a fracture neck femur, which is missed in 50% of instances, is an act of carelessness."

Learnings from the case 

After stabilisation of fracture of shaft femur due to stress, iatrogenic fracture neck of the femur may occur. Therefore, the presence of a sub-clinical occult fracture and failure to take necessary X-rays in external rotation of the shaft of the femur may account for pre-operative misdiagnosis.

The pre-operative CT scan of the femur neck for all such patients was to be done before doing closed intramedullary nailing for shaft fracture. The CT scan is repeated after closed nailing to confirm the state of the femoral neck unless a fracture was seen on a plain film or during intra-operative fluoroscopy.

In the present case, the patient was evaluated with a pre-operative X-ray AP pelvis, which was negative. It was unclear whether a lateral view of the hip taken could have been more sensitive in detecting the femoral neck fracture.

The anteroposterior internal rotation hip X-ray if taken intra-operatively or immediately after the reduction of the femoral shaft fracture, could have helped in detecting the minimally displaced fracture of the femoral neck. Thus the intra-operative manoeuvres and radiographs should be used to rule out concomitant femoral neck fractures.

Source: Order pronounced by National Consumer Disputes Redressal Commission on 8th July 2021.

For any further reading, kindly go through the original judgement order. 

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.