CASE VIGNETTE – OCTOBER 2018

A Case From 1979

I clearly remember being an Orthopaedic Registrar at the Royal Brisbane Hospital in 1979.  I was still an unaccredited Trainee, hoping to enter the esteemed echelons of the Orthopaedic Training Programme and embark properly upon a career as an Orthopaedic Surgeon.

As was often the case, Junior Registrars such as I seemed to find ourselves rostered for weekend work. I had scored a Sunday.

It was just before midday when a 16 year old girl was brought into the Accident and Emergency Department of the Royal Brisbane Hospital in Herston in the arms of her father. The girl was obviously greatly distressed. The mother was whimpering in sympathy and the father was far from impressed.

The girl was carefully placed upon a trolley in the corridor and she was reviewed by the Resident Medical Officer on duty. He was able to glean the following history:

Miss AY was a 16 year old high school student who had been involved in a relatively high speed motor cycle accident with her boyfriend on the preceding afternoon (the Saturday). Apparently, the motor cyclist had lost control of the cycle on a corner in remote bushland just to the north of the Brisbane metropolitan region. Neither rider nor his pillion (Miss AY) lost consciousness but both were unable to stand, walk or seek help. Instead, they lay in this near-forest environment for 90 minutes before a passing motor cyclist found them. This was before mobile phones!! The Queensland Ambulance Service was summonsed and both were transported to the Royal Brisbane Hospital.

Miss AY was assessed and was found to be suffering with considerable knee pain. A clinical examination was performed that Saturday afternoon (the day before I saw her), a radiographic examination was arranged and she was told that there was no obvious problem in the region of the knee joint. She was discharged into the care of her parents. Her father remembered carrying her out to the car and both parents attempted to nurse her during that Saturday evening and the early hours of the Sunday morning. The girl was in great pain, equally distressed and the dissatisfaction showed in all three faces when they returned the following morning.
The treating Resident Medical Officer reviewed the x-rays that had been taken the preceding afternoon. In those days, hard films were available. Although the knee joint appeared to be normal, the radiograph itself looked suspicious. It appears again just below. See if you can identify the problem.

I wonder if you picked the problem. If you look at the top of the x-ray, near the name plate, you will see something protruding downwards and to the left just adjacent to the name plate.

Now look at the x-rays that were taken on that Sunday morning when she re-presented. You can see that she had a transverse fracture of the femur (the thigh bone) with considerable overlap. The lower end of the upper segment was protruding down and laterally, and that is what the young doctor saw on that Sunday morning. He could see the lower end of the upper part of the thigh bone protruding beside the name plate. Unfortunately, the x-ray taken on that Saturday did not extend high enough for it to be obvious to those reviewing her at the time.

In reality therefore, this poor girl had a transverse fracture of the thigh bone that was untreated for the next 20 hours or so. She was sent home in the care of her parents without adequate analgesia and without crutches and without splintage. Her parents were obliged to deal with her bodily functions in the bed overnight and the next morning. As the bones protruded into the soft tissues in the thigh, extreme pain would have been experienced. All this because an inadequate physical examination had been performed and an inadequate radiographic examination had been arranged.

It beggars belief that even a cursory examination of the thigh would have failed to identify this complete fracture of the femur.

I learnt a very valuable lesson that day. I have always subscribed to the theory that “there but for the grace of God go I”. I also believe that “good orthopaedic surgery comes from experience and experience comes from bad orthopaedic surgery”. It’s best that my experience comes from the mistakes of others and not from me. This was a particularly valuable learning experience for all of us.