Failure to Diagnose Neck Fracture

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Failure to Diagnose Neck Fracture
A California woman in her 60s slipped and fell on a wheelchair ramp outside her home. At the emergency department (ED), she was treated and released by Dr. A., who made a diagnosis of neck sprain. Two days later, she presented to the office of her family physician, Dr. B., where she was seen by a nurse; again, she was diagnosed with a sprained neck.

A CT performed one month later revealed a fractured vertebra in the woman’s neck. By the time the fracture was discovered, the vertebra had already begun to heal in a misaligned position. No further treatment was possible. The patient could no longer turn her head to the left and her ability to turn to the right was limited.

The plaintiff alleged negligence by the defendants in the failure to diagnose her fractured neck.

The defendants claimed that even timely intervention would not have changed the outcome.

Outcome
According to a published account, Dr. A. settled for $9,000 before trial, and Dr. B. settled for $29,999. A defense verdict was returned.

Comment
The facts of the case as presented do not include specifics regarding initial presentation or clinician work-up. When clinicians are confronted with neck pain following trauma, they must decide whether or not to image. Decision rules such as the Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) can help clinicians make this determination.

The CCR standard requires the patient to (i) be alert and not intoxicated, (ii) not have a distracting injury, (iii) not be considered high-risk, (iv) have at least one low-risk factor, allowing safe assessment of the cervical range of motion, and (v) be able to actively rotate the neck 45° left and right.

High-risk factors include age greater than 65, a dangerous mechanism, or paresthesias in the extremities.

Low-risk factors include a simple rear-end motor vehicle collision, sitting position in the ED, ability to ambulate at any time, delayed onset of neck pain, and absence of midline cervical spinal tenderness.

A dangerous mechanism includes a fall from an elevation greater than 3 ft or five stairs; an axial load to the head (eg, diving); a motor vehicle collision at high speed (> 100 km/h) or involving rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision.

NEXUS requires cervical spine radiography unless the patient meets all of the following criteria: (i) no posterior midline cervical-spine tenderness, (ii) no evidence of intoxication, (iii) a normal level of alertness, (iv) no focal neurologic deficit, and (v) no painful distracting injuries. The NEXUS standard may be recalled using the helpful mnemonic NSAID: Neuro deficit, Spinal tenderness (midline), Altered mental status or loss of consciousness, Intoxication, Distracting injury.

In this case, we don’t know whether the patient was older than 65 and can assume the wheelchair ramp was not so steep as to produce a 3-ft drop. There is no evidence the patient had a distracting injury or exhibited midline cervical tenderness, paresthesias, or other neurologic impairment.

Given the omissions from the case description, it is likely that the patient’s presentation was reassuring. If she was older than 65, following the CCR may have led to a decision to image, whereas applying NEXUS would not.

In this case, the modest $39,000 settlement against two defendants may reflect a decision to settle made by the insurance company, not the clinicians. Some medical malpractice policies give the insurance company authority to settle, allowing a settlement without the clinician’s consent. Insurers will often settle even “nuisance” suits for the cost of the trial, but the settlement will net the clinician an adverse National Practitioner Data Bank record.

Does your malpractice policy give you settlement authority—or the insurance company? This may be an important (or at least interesting) discussion to have with your colleagues!

In sum, when assessing patients with neck pain and trauma, it is advisable to know and apply evidence-based rules, such as CCR or NEXUS. Record your application of the selected rule in the medical record. It may be your best defense if you are challenged after a decision not to image. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Failure to Diagnose Neck Fracture
A California woman in her 60s slipped and fell on a wheelchair ramp outside her home. At the emergency department (ED), she was treated and released by Dr. A., who made a diagnosis of neck sprain. Two days later, she presented to the office of her family physician, Dr. B., where she was seen by a nurse; again, she was diagnosed with a sprained neck.

A CT performed one month later revealed a fractured vertebra in the woman’s neck. By the time the fracture was discovered, the vertebra had already begun to heal in a misaligned position. No further treatment was possible. The patient could no longer turn her head to the left and her ability to turn to the right was limited.

The plaintiff alleged negligence by the defendants in the failure to diagnose her fractured neck.

The defendants claimed that even timely intervention would not have changed the outcome.

Outcome
According to a published account, Dr. A. settled for $9,000 before trial, and Dr. B. settled for $29,999. A defense verdict was returned.

Comment
The facts of the case as presented do not include specifics regarding initial presentation or clinician work-up. When clinicians are confronted with neck pain following trauma, they must decide whether or not to image. Decision rules such as the Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) can help clinicians make this determination.

The CCR standard requires the patient to (i) be alert and not intoxicated, (ii) not have a distracting injury, (iii) not be considered high-risk, (iv) have at least one low-risk factor, allowing safe assessment of the cervical range of motion, and (v) be able to actively rotate the neck 45° left and right.

High-risk factors include age greater than 65, a dangerous mechanism, or paresthesias in the extremities.

Low-risk factors include a simple rear-end motor vehicle collision, sitting position in the ED, ability to ambulate at any time, delayed onset of neck pain, and absence of midline cervical spinal tenderness.

A dangerous mechanism includes a fall from an elevation greater than 3 ft or five stairs; an axial load to the head (eg, diving); a motor vehicle collision at high speed (> 100 km/h) or involving rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision.

NEXUS requires cervical spine radiography unless the patient meets all of the following criteria: (i) no posterior midline cervical-spine tenderness, (ii) no evidence of intoxication, (iii) a normal level of alertness, (iv) no focal neurologic deficit, and (v) no painful distracting injuries. The NEXUS standard may be recalled using the helpful mnemonic NSAID: Neuro deficit, Spinal tenderness (midline), Altered mental status or loss of consciousness, Intoxication, Distracting injury.

In this case, we don’t know whether the patient was older than 65 and can assume the wheelchair ramp was not so steep as to produce a 3-ft drop. There is no evidence the patient had a distracting injury or exhibited midline cervical tenderness, paresthesias, or other neurologic impairment.

Given the omissions from the case description, it is likely that the patient’s presentation was reassuring. If she was older than 65, following the CCR may have led to a decision to image, whereas applying NEXUS would not.

In this case, the modest $39,000 settlement against two defendants may reflect a decision to settle made by the insurance company, not the clinicians. Some medical malpractice policies give the insurance company authority to settle, allowing a settlement without the clinician’s consent. Insurers will often settle even “nuisance” suits for the cost of the trial, but the settlement will net the clinician an adverse National Practitioner Data Bank record.

Does your malpractice policy give you settlement authority—or the insurance company? This may be an important (or at least interesting) discussion to have with your colleagues!

In sum, when assessing patients with neck pain and trauma, it is advisable to know and apply evidence-based rules, such as CCR or NEXUS. Record your application of the selected rule in the medical record. It may be your best defense if you are challenged after a decision not to image. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Failure to Diagnose Neck Fracture
A California woman in her 60s slipped and fell on a wheelchair ramp outside her home. At the emergency department (ED), she was treated and released by Dr. A., who made a diagnosis of neck sprain. Two days later, she presented to the office of her family physician, Dr. B., where she was seen by a nurse; again, she was diagnosed with a sprained neck.

A CT performed one month later revealed a fractured vertebra in the woman’s neck. By the time the fracture was discovered, the vertebra had already begun to heal in a misaligned position. No further treatment was possible. The patient could no longer turn her head to the left and her ability to turn to the right was limited.

The plaintiff alleged negligence by the defendants in the failure to diagnose her fractured neck.

The defendants claimed that even timely intervention would not have changed the outcome.

Outcome
According to a published account, Dr. A. settled for $9,000 before trial, and Dr. B. settled for $29,999. A defense verdict was returned.

Comment
The facts of the case as presented do not include specifics regarding initial presentation or clinician work-up. When clinicians are confronted with neck pain following trauma, they must decide whether or not to image. Decision rules such as the Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) can help clinicians make this determination.

The CCR standard requires the patient to (i) be alert and not intoxicated, (ii) not have a distracting injury, (iii) not be considered high-risk, (iv) have at least one low-risk factor, allowing safe assessment of the cervical range of motion, and (v) be able to actively rotate the neck 45° left and right.

High-risk factors include age greater than 65, a dangerous mechanism, or paresthesias in the extremities.

Low-risk factors include a simple rear-end motor vehicle collision, sitting position in the ED, ability to ambulate at any time, delayed onset of neck pain, and absence of midline cervical spinal tenderness.

A dangerous mechanism includes a fall from an elevation greater than 3 ft or five stairs; an axial load to the head (eg, diving); a motor vehicle collision at high speed (> 100 km/h) or involving rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision.

NEXUS requires cervical spine radiography unless the patient meets all of the following criteria: (i) no posterior midline cervical-spine tenderness, (ii) no evidence of intoxication, (iii) a normal level of alertness, (iv) no focal neurologic deficit, and (v) no painful distracting injuries. The NEXUS standard may be recalled using the helpful mnemonic NSAID: Neuro deficit, Spinal tenderness (midline), Altered mental status or loss of consciousness, Intoxication, Distracting injury.

In this case, we don’t know whether the patient was older than 65 and can assume the wheelchair ramp was not so steep as to produce a 3-ft drop. There is no evidence the patient had a distracting injury or exhibited midline cervical tenderness, paresthesias, or other neurologic impairment.

Given the omissions from the case description, it is likely that the patient’s presentation was reassuring. If she was older than 65, following the CCR may have led to a decision to image, whereas applying NEXUS would not.

In this case, the modest $39,000 settlement against two defendants may reflect a decision to settle made by the insurance company, not the clinicians. Some medical malpractice policies give the insurance company authority to settle, allowing a settlement without the clinician’s consent. Insurers will often settle even “nuisance” suits for the cost of the trial, but the settlement will net the clinician an adverse National Practitioner Data Bank record.

Does your malpractice policy give you settlement authority—or the insurance company? This may be an important (or at least interesting) discussion to have with your colleagues!

In sum, when assessing patients with neck pain and trauma, it is advisable to know and apply evidence-based rules, such as CCR or NEXUS. Record your application of the selected rule in the medical record. It may be your best defense if you are challenged after a decision not to image. —DML