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Management of young child with pulled elbow (01HDC01097)

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01HDC01097, 20 September 2002

Right to services of an appropriate standard ~ Reasonable care and skill ~ Surgical registrar ~ Emergency medicine ~ Paediatrics ~ Dislocation ~ X-ray ~ Public hospital ~ Right 4(1)

A complaint was made by the mother and grandmother of a two-year-old girl about the care she received from a surgical registrar at an Accident and Emergency Department of a public hospital. The complaint was that the registrar did not provide the appropriate standard of health care to the child and that in particular he caused unnecessary distress and pain by failing to diagnose a dislocated elbow joint.

The facts were that the child presented with symptoms suggesting a dislocated elbow. Attempts were made to reduce the elbow by both a GP at his surgery and later by an RMO and a surgical registrar at a public hospital. The child remained in distress and the decision was made to make no further attempt to reduce the elbow but to offer the accompanying grandparent and father a sling in order to treat the injury conservatively. The child remained in pain and two days later was taken to a second public hospital where the elbow responded to reduction, thereby relieving the child from any further pain.

The Commissioner reasoned, after receiving independent expert advice from an emergency medicine specialist, that:

(1) the registrar's decision to make no further attempt to reduce the elbow but to offer a sling was probably prompted by the belief that the elbow had already been successfully reduced, supported by a normal X-ray;

(2) an X-ray may not detect dislocations in young children where the bones have not ossified;

(2) it is not always obvious when a reduction has been successful as a child can continue to feel discomfort and be reluctant to move the elbow following repeated manipulations; and

(3) a sling is the next appropriate step in treatment whether the elbow joint has been reduced or not, as the majority of such injuries will spontaneously reduce within 48 hours.

The Commissioner held that the surgical registrar did not breach Right 4(1) in that even though it is more probable than not that the child's elbow remained dislocated, his treatment was of an appropriate standard, for the following reasons:

(1) after reviewing the X-rays, the registrar did consider whether the child might have a dislocated elbow and examined her accordingly; and

(2) his decision not to attempt any further treatment of the child's arm was appropriate in light of her pain and discomfort and the fact that most dislocations will spontaneously reduce.

The Commissioner commented that if the registrar's communication with the family had been satisfactory a complaint would not have been made.