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Paul Sankey: Missed Fractures in Accident and Emergency

I have dealt with several cases recently where ankle fractures have been missed in Accident and Emergency Departments. In some cases where they have had to use crutches anyway, not too much damage has been done. In others, trying to walk on the fracture for some time has led to a very poor recovery.

There are guidelines known as ‘The Ottawa Ankle Rules’ which should assist Casualty staff in managing patients with ankle injuries. The Rules are designed to avoid people being x-rayed unnecessarily but also ensure that fractures are not missed.

Less than 15% of patients who present with ankle injuries in Accident and Emergency actually have fractures. The Rules are designed to target investigations on the right patients.The Rules require that patients should undergo x-rays if they have ankle pain and either cannot bear weight on their ankle or on examination the bony areas of the ankle are tender.

In my experience there are several mistakes commonly made. First, some patients have x-rays but the fracture is simply missed. This is most likely to happen when the injury is fresh. As time passed the new bone is formed around the fracture site, the fracture becomes more obvious. However even if Casualty Doctors cannot spot the fracture, the x-rays should be reviewed later by more specialist radiologists who should normally be able to interpret them correctly.

Secondly, staff sometimes perform an inadequate examination and fail to note that the bony areas are painful.

Thirdly, staff sometimes interpret the Rules as requiring an x-ray where there is both bony tenderness and patients cannot weight bear.

In fact one of these should be enough.In one of my most serious cases a man fractured both his knee and his ankle. Having found the knee fracture, staff ignored his ankle. The fracture was missed for over a year, by which time it was destined not to unite and some of the bone around the joint had died. He had to undergo numerous operations and struggled to walk.

It seems to me that medical mistakes here occur surprisingly often despite the fact that the Rules provide reliable guidance. Unfortunately for many people these errors can prove very costly.

Paul Sankey is a solicitor specialising in clinical negligence. If you or a member of your family have a clinical negligence enquiry please call our expert clinical negligence solicitors on 0800 916 9049, fill in our short online claim form and one of our specialist clinical negligence team will be in touch.