JOURNAL ARTICLE
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[Malpractice in the treatment of fractures and dislocations of the elbow joint in children--experience of the arbitration office of the North German Medical Boards].

BACKGROUND: Statistics of the arbitration office of the North German Medical Boards show that 30% of all panel proceedings confirm medical malpractices. In panel proceedings concerning the treatment of fractures in children, the percentage rose to 60% with significant differences in the individual fracture localisations.

METHODS: Between the years 2000 and 2010, the arbitration office dealt with 257 panel proceedings regarding the fracture treatment of children. This study evaluates the decisions of 53 proceedings concerning the treatment of fractures and dislocations of the elbow joint.

RESULTS: All cases except one concerned the following surgical specialities: 1. orthopaedics/traumatology, n = 14; 2. general surgery, n = 13; 3. paediatric surgery, n = 5. On 7 occasions 2 treatment facilities were involved in the same proceeding. The following types of fractures/dislocations were present (each with the number of proceedings [p] and the confirmed malpractices [m]): fracture of the radial humeral condyle and transcondylar Y-fractures, p = 12, m = 11; fracture of the ulnar epicondyle, p = 2, m = 2; sole dislocation of the radial head as well as in combination with Monteggia lesion, p = 19, m = 17; displaced fracture of the radial head and radial neck, respectively, p = 8, m = 4; fractures of the olecranon, p = 3, m = 2; fracture of the coronoid processus, p = 1, m = 1; dislocations and dislocation fractures of the elbow joint without Monteggia lesion, p = 8, m = 5.

DISCUSSION: 42 of these cases (79 %) confirmed malpractice of which 27 (64%) resulted in permanent restriction of the elbow joint mobility. Due to the diversity of injuries, the types of treatment errors were also very variable. In most cases the treatment errors were initiated through the false interpretation of X-ray findings which resulted in false and inadequate therapy measures, for example, the overlooked and not reduced dislocation of the radial head. Three transcondylar Y-fractures were missed on both the X-ray findings and during the operation. In cases where the dislocation of the radial head was not diagnosed in the first instance but operated on within four months (n = 3), a satisfactory result was still achieved. However, if the operation took place at a later time (in our cases 9 months to 8 years after the injury, n = 14) there was no improvement achieved and in many cases the elbow joint mobility deteriorated significantly. In three cases of dislocation of the elbow joint, an intraarticular entrapment of the disjointed ulnar epicondyle was overlooked and therefore not corrected which resulted in deleterious effects on the joint movement. There were five cases with a dislocation combined with a displaced fracture of the radial neck (Mason IV). This fracture was insufficiently reduced/stabilised on two occasions and in one instance the reconstruction of the disrupted joint ligaments was not carried out which resulted in permanent instability of the elbow joint and subluxation. In five casuistic representations the final decision of the arbitration board on the basis of expert reports is illustrated.

CONCLUSION: From a traumatological point of view, the elbow region of a child constitutes a distinct problem zone due to the rarity and diversity of the fractures and dislocations in this area. Relevant experiences in diagnostics and therapy of injuries in this region cannot always be expected. Every doctor who happens to come across a case in which a child suffers from such injuries should be responsible for the timely referral to a treatment facility that has the relevant experience to treat such cases.

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