[Malpractice in the treatment of supracondylar humeral fractures in children - experience of the arbitration office of the Northern German Medical Boards].

INTRODUCTION: Arbitration offices ("Schlichtungsstellen") in Germany are expert panels for the extrajudicial resolution of malpractice claims. The performance of arbitration panel proceedings ("Schlichtungsverfahren") is based on the German medical and insurance jurisdiction. In Germany, and in the United States likewise, malpractice claims involving children concern in most cases fracture treatment followed by appendicitis. Out of 242 panel proceedings with the background of fracture treatment in children malpractice was confirmed in 144 cases (60%). The overall ratio: number of confirmed malpractices to number of all proceedings is 30%. There are remarkable differences between the natural occurrence of the different fracture localisations and the fracture localisation related claims. This ratio amounts for example: clavicula 7 : 1, forearm 2 : 1, femur 1 : 5, elbow region (articular) 1 : 5, humerus supracondylar 1 : 3.

METHOD: 32 arbitration panel proceedings concerning alleged malpractice in the treatment of supracondylar humeral fractures in children were evaluated in regards to diagnosis of fracture type and degree of dislocation, conservative and operative fracture treatment, complications, and malpractice related permanent disabilities.

RESULTS: In 20 cases (63%) malpractice was confirmed. The different failures could be classified in: 1) Incorrect interpretation of the X-ray findings, classified as fractures without or with minimal displacement, no reduction, healing with intolerable dislocation; n = 3. 2) Insufficient closed or open fracture reduction, stabilisation and healing with intolerable dislocation; n = 10. 3) Correct primary closed or open reduction, unstable osteosynthesis (loss of pin fixation of the ulnar epicondylus), secondary postoperative rotatory dislocation, cubitus varus; n = 3. 4) Delayed detection of a compartment syndrome of the forearm, no or delayed fasciotomy; n = 3, in two cases resulting in severe Volkmann's contracture. 5) Extensive skin necrosis caused by uncontrolled tourniquet under operation. All malunited fractures, except one, led to cubitus varus, often combined with a restriction (extension/flexion) of the mobility of the elbow joint. No cubitus valgus was found in our series. In eight cases a cubitus varus was treated by valgus osteotomy later on. In other cases this procedure was planned. Adverse events which could not be proven as caused by malpractice, included fracture consolidation in minimal tolerable displacement, n = 3; delayed recurrence of the normal mobility of the elbow joint, n = 2; traumatic cubitus varus caused by primary damage of the humero-ulnar epiphysis, n = 3; pin track infection, n = 1; nerve injuries, n = 10. The concomitant nerve injuries concerned: n. medianus 3, n. ulnaris 2, n. radialis 1, nn. radialis and ulnaris 3, nn. medianus and ulnaris 1. In all these cases the claim was based only or together with other reproaches on the nerve injury, but in no case could a malpractice be confirmed. However it should be mentioned that in some cases a iatrogenic nerve injury could not be excluded definitively. Therefore we always recommend the exploration and documentation of the function of the arm nerves at admittance and immediately after treatment. The applied methods of osteosynthesis were pin fixation, crossed or unilateral radial, n = 30; radial screw, n = 1; elastic stable intramedullary nailing fixation (ESIN), n = 1; fixateur externe (reoperation), n = 1. In no case the method of osteosynthesis was proven as inapplicable or as the cause for the adverse event. Permanent disabilities were considered to be slight in 12 cases (deficient mobility of the elbow joint) and severe in two cases (Volkmann's contracture). Physiotherapy was not found to be beneficial for the restitution of normal mobility of the elbow joint after supracondylar fracture. In at least 7 cases painful physiotherapy was applied, although the X-ray films clearly demonstrated the displaced fracture as the cause of the restricted mobility. In 5 casuistic representations of adverse events after treatment of a supracondylar humeral fracture, the final decision of the arbitration board on the basis of expert reports is illustrated.

CONCLUSION: The results are discussed in order to avoid mistakes in the treatment of supracondylar humeral fracture in children. The appropriate treatment requires exact assessment of the degree and direction of the fracture dislocation, clear definition of the cases in which active treatment, i.e. closed or open reduction and stabilisation, is obligatory, and experience in the operative treatment. A beginning compartment syndrome of the forearm should be detected early by the initial symptoms and immediately treated by fasciotomy.