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Management of angulated radial fracture without manipulation (01HDC02275)

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(01HDC02275, 31 October 2002)

General practitioner in Accident and Medical Clinic ~ Standard of care ~ Fracture management ~ Complaints procedure ~ Rights 4(1), 10(3)

A complaint was made by a 60-year-old patient about the care he received from a general practitioner at an Accident and Medical Clinic.

The GP suspected that the patient had sustained a fracture of the distal radius bone in the arm. This was confirmed by X-ray. The GP assessed the angle of the fracture to be less than 15° and, because there was no visible deformity, decided that the angulation was within acceptable limits. He elected to manage the fracture by putting it into a plaster cast without manipulating the fracture, with a plaster check the following day and a follow-up X-ray at 10 days. In the meantime, the GP received and considered the radiologist's report, which stated that there was moderate dorsal angulation of the distal radial articular surface. When the patient presented for the scheduled follow-up appointment, the GP requested another X-ray. The patient declined to have it taken at the clinic. The public hospital's notes record that the patient presented with a post-fracture deformity involving dorsal angulation. After reduction, a satisfactory alignment was achieved.

Independent expert advice was that the distal radial articular surface is anatomically (or normally) in a position of volar angulation, so any dorsal angulation is already dorsally angulated past the normal anatomical position. Dorsal angulation to any degree in this type of fracture is potentially problematic.

The Commissioner held that:
1) the GP and the clinic did not breach Right 10 as the concerns raised by the patient were responded to appropriately when they sought to facilitate resolution of the complaint;
2) the GP breached Right 4(1) in that the initial and subsequent management of the fracture, misdiagnosing the degree of angulation and concluding that manipulation was not required, fell below an acceptable standard for a general practitioner at an Accident and Medical Clinic - either the GP misread the initial X-ray and made an error interpreting the subsequent radiologist's report, or he had a different understanding of what is an acceptable position for the fracture;
3) the GP did not breach the Code with regard to any adverse outcome the patient suffered, as the need for corrective surgery cannot be attributed to the treatment provided by, or any lack of action by, the practitioner;
4) the clinic was not vicariously liable for the GP's breach of the Code, as the matters involved clinical decisions of an individual practitioner, and were not reasonably foreseeable or preventable by the clinic.