2021_Book_TextbookOfPatientSafetyAndClin

19 Patient Safety in Orthopedics and Traumatology
locations reported in the literature and no clear
guidelines regarding the management of such
injuries. Therefore the treatment of delayed presentations
of such cases is very difficult and the
patient now needs a risky and complex surgical
intervention. The diagnosis of cervical spine
injuries remains a significant problem for many
blunt trauma patients. Correct and early diagnosis
of these injuries is imperative, as delayed or
missed diagnoses result in increased morbidity
and mortality.
The first error of diagnosis was radiologic: the
sensitivity of the CT scan to cervical trauma is
98% but may fail to identify ligamentous injuries.
Only an MRI can detect this type of lesion before
the subluxation.
This case report underscores the importance
of integrating all aspects of patient history, precise
physical examination, diagnostic imaging,
and clinical judgment. Re-evaluation is necessary
when the CT scan does not correlate with physical
examination. The diligent integration of both
physical examination and the review of images
obtained will undoubtedly lead to a decrease in
claims of medical malpractice.
19.5.2 Case 2
The patient is a 16-year-old girl with no known
family history of neurofibromatosis. She had
noticed some deformity in her spine when she
was 8 years old, and was diagnosed with neurofibromatosis
type I (NF-1) and followed up by a
neurologist. She had a scoliotic deformity of the
spine, more pronounced during a forward Adam’s
test. During the neurologist’s initial follow-up,
serial plain radiographs that had been performed
every 2 years revealed progression of the scoliosis.
Then, 5 years ago, when she was 11 years
old, the patient was treated with a brace. However,
the curve rapidly progressed as she entered the
adolescent growth spurt, with scoliosis measuring
50° Cobb, kyphosis 56°, and Risser 1
(Fig. 19.2). Even so, the brace treatment was continued.
When the patient presented herself at our
283
hospital, she was Risser 5 and the radiological
imaging showed a classic dystrophic kyphoscoliosis
with Cobb angles measuring 88° scoliosis
(T5–T8) and 85° kyphosis (T2–T101) (Fig. 19.3).
Neurofibromatosis is an autosomal, dominant
chromosomal disorder and scoliosis is the most
common skeletal presentation, with incidence
ranging from 10% to 60%. Our patient had a
kyphoscoliotic curve of the proximal thoracic
spine, with severe apical rotation from T5 to T8.
The clinical presentation and radiological imaging
in this patient were very suggestive of dystrophic
features and included: (a) short segment and
acute angular deformity; (b) early occurrence at
the young age of 8 years old; (c) sagittal plane
kyphoscoliosis; (c) pencilling of the ribs; and (d)
defective pedicles. Early surgical stabilization
was indicated in this patient at an early age of
onset because of the risk of substantial progression
of the curve. However, the doctor had opted
for nonsurgical treatment in the initial stages,
using a brace: this is an error of treatment and it
was not surprising that bracing had failed nor that
the curve had rapidly progressed. Now the patient
needs multiple, complex, and risky surgical
interventions.
19.6 Recommendations
To conclude, two important elements must be
mentioned in orthopedic risk management. The
first is that the biggest danger comes not from the
risk itself but from ignorance, as many orthopedists
do not fully appreciate the level of risk and
so do not feel the need for more scrutiny.
The second is that a good doctor-patient relationship
is as essential as both professional competence
and compliance with protocols and
guidelines. When approaching clinical practice,
the principles of classical medicine, from the
Hippocratic oath onwards, must always be kept
in mind. According to Nebel [26], the best prevention
against both adverse events and their
legal implications can be summed up by the
ancient precept “love thy patient.”