Failure to stabilize a wrist fracture

Presentation

On August 15, a woman fell at work and fractured her left wrist. On referral from her employer, she immediately went to an urgent care clinic that would provide care for occupational injuries. 

X-rays revealed that the patient suffered a left distal radius fracture and ulnar styloid fracture in the left wrist. The patient was instructed to return the following day for an orthopedic evaluation with a hand surgeon.
  

Physician action

The patient was seen the next day by Hand Surgeon A. He examined the patient and reviewed the X-rays. Despite significant swelling and tenderness, the patient had motor strength at 2/5; intact sensation; and no symptoms of compartment syndrome. Hand Surgeon A recommended an open reduction internal fixation (ORIF) with a plate and pins. 

On August 23, Hand Surgeon A took the patient to surgery at a nearby hospital. Based on the pre-operative X-rays, the surgeon planned to use an ORIF kit that contained a standard volar plate in the procedure. 

Once in the operating room, the surgeon discovered the fractures were more severe than they appeared on the pre-operative X-rays. The distal radius was shattered and compressed into the metacarpal bones. There were 5 to 6 intra-articular fragments on the volar aspect of the radius and many smaller fragments on the dorsal side of the radius. Additionally, there was a large distal fragment about 1 to 2 cm in size and an ulnar styloid fracture. 

The standard volar plate was not long enough to stabilize the fractures. A dorsal spanning plate was also needed to fixate the radius, but this plate was not included in the surgery kit. 

Hand Surgeon A reduced and attempted to temporarily secure the fracture with a Kirschner wire (K-wire). He attempted to reduce the dorsal fracture by removing multiple smaller fragments and filling in the remaining bony defects with bone putty. Fluoroscopy confirmed that the fracture had been adequately reduced and the K-wire was in good position. 

Hand Surgeon A planned to perform a second ORIF procedure to insert a dorsal spanning plate to stabilize the fractures. He did not document this plan in the surgical report.

The patient returned the next day, August 24, for a follow-up visit with Hand Surgeon A. She reported intense wrist pain following surgery. Hand Surgeon A noted swelling of the left wrist and removed a few sutures on the volar side of the patient’s wrist. He then removed the K-wire from the wrist with surgical pliers. 

Hand Surgeon A wrapped the wrist and put it back in the splint. He did not replace the removed sutures. His progress notes did not include the need or plan for a second surgery, nor did they include his reasoning for removing the K-wire. The patient was instructed to ice and elevate her left arm and return for a follow-up visit in six days (August 30).

The next morning, the patient went to the ED with intense pain. The EM physicians had difficulty finding palpable pulses in her left hand. The patient was admitted to the hospital and given IV morphine and IV hydromorphone. Hand Surgeon A was informed of the patient’s admission and condition. The next afternoon, August 26, the patient was discharged after her pain improved. 

The patient returned to the hospital and was re-admitted in the early morning hours of August 27. She reported intense pain, swelling, and numbness in the left hand and wrist. Hand Surgeon A evaluated the patient during her admission. She was again discharged after her pain improved with medication. She was instructed to follow up on August 31.

The patient returned to Hand Surgeon A on August 31. Her pain and swelling were improved, but there was diminished sensation in her fingertips. The surgeon discussed a second surgery to insert a dorsal spanning plate. The patient agreed to the surgery and was told to return on September 7.

A scheduler was instructed to schedule a left distal radius fracture ORIF with a dorsal spanning wrist plate. However, the patient’s workers’ compensation carrier required preauthorization. A request was sent to the preauthorization office asking for clearance on September 6, six days after the patient’s appointment.

On September 1, the patient met with a worker’s compensation case manager and said she wanted a second opinion on her wrist. The case manager scheduled an appointment with Hand Surgeon B for September 13, the earliest available appointment. 

The patient and case manager returned to Hand Surgeon A on September 7. The pain and swelling had improved, and the surgeon removed the remaining sutures. Hand Surgeon A said that he was still waiting for approval for surgery from the workers’ compensation carrier. 

On September 13, the patient and case manager met with Hand Surgeon B. She reviewed the patient’s radiographs and stated that the fracture was significant and difficult to repair. She recommended a second ORIF surgery. The patient transferred her care to Hand Surgeon B.

On September 21, Hand Surgeon B performed a dual exposure ORIF surgery with a volar locking plate and a dorsal spanning plate. A complete carpal tunnel release was also performed.

At a follow-up visit in April, Hand Surgeon B documented the patient’s wrist had good pronation but no supination. She was also noted as having 10 degrees of wrist extension but no wrist flexion. She had wrist arthrodesis but was not experiencing pain. 

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Allegations

A lawsuit was filed against Hand Surgeon A, alleging failure to provide adequate fixation to secure the comminuted wrist fracture. This failure resulted in permanent injury and impairment to the patient’s wrist.

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Legal implications

Hand and wrist surgeons who reviewed this case for the plaintiff stated that Hand Surgeon A breached the standard of care by failing to reduce and fixate the fracture during the August 23 surgery. They specifically criticized the surgeon’s failure to insert a plate to secure the fracture. They also claimed the K-wire was an inadequate substitute. 

Hand Surgeon A was also criticized for not accurately describing the procedure in his operative report and for failing to perform a second ORIF procedure in a timely manner. These factors made Hand Surgeon B’s repair surgery more difficult.

Defense consultants disagreed about the emergent nature of a second ORIF procedure. They felt that the second surgery was scheduled appropriately. However, they pointed that Hand Surgeon A did not tell the patient that he did not have the proper fixation equipment to stabilize the fracture. 

The defense of this case was compromised by Hand Surgeon A’s lack of documentation and communication with the patient and other providers. If he had more fully communicated his intention for a second procedure to better stabilize the wrist, she may not have sought a second opinion. The patient’s decision to obtain a second opinion and to transfer her care further delayed the second procedure. 

Documentation was also an issue in this case. Hand Surgeon A’s operative report was not detailed and did not state the reason for using K-wire as a temporary solution. While this may have been his plan, he did not document it or communicate it to the patient. The patient, her husband, and the case manager all testified that Hand Surgeon A did not tell them he was unable to place a plate on August 23. 

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Disposition

This case was settled on behalf of Hand Surgeon A. 

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More about documentation errors

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