Zusammenfassung
Studienziel, Methode: Während in der wissenschaftlichen Literatur zur Problematik der Behandlung von suprakondylären
Humerusfrakturen im Kindesalter zahlreiche Angaben zu Komplikationen und ihren Ursachen
zu finden sind, fehlen Aussagen zu deren haftungsrechtlichen Konsequenzen weitgehend.
Deshalb wurden aus 242 Schlichtungsverfahren zur Frakturbehandlung im Kindesalter
32 Verfahren zu suprakondylären Humerusfrakturen ausgewertet. Ergebnisse: In 20 Fällen (63 %) wurden Behandlungsfehler festgestellt. In 14 dieser 20 Fälle
hatten die Behandlungsfehler zu Dauerschäden geführt. Die häufigsten Behandlungsfehler
waren eine unzureichende Reposition mit nachfolgender Osteosynthese in intolerabler
Fehlposition (10 Fälle), die unterlassene Reposition (3 Fälle) und eine instabile
Osteosynthese des ulnaren Pfeilers mit typischer Rotationsdislokation und Übergang
zum Cubitus varus (3 Fälle). In 3 Fällen war ein Kompartmentsyndrom zu spät diagnostiziert
und behandelt worden, 2-mal davon mit dem Resultat einer Volkmann'schen Kontraktur.
Für 10 Nervenschäden (8‐mal temporär und 2‐mal dauerhaft) konnte in keinem Fall eine
Fehlbehandlung bestätigt werden. Als nicht frakturtypischer Schaden trat 1-mal eine
ausgedehnte Weichteilnekrose oberhalb des Ellenbogens infolge Druck des Gipsverbands
auf. Die verwendeten Stabilisierungsverfahren: Kirschner-Drähte gekreuzt, parallel,
kombiniert (n = 18), Kirschner-Draht und Schraube (n = 1), ESIN (n = 1), kein Fixateur
externe, waren in keinem Fall zu beanstanden. Für die Frakturbehandlung sind 2 Fehlertypen
zu erkennen: 1. Falsche Einschätzung des primären Frakturmusters, unterlassene Reposition
und Stabilisierung. 2. Fehlerhafte Durchführung der Osteosynthese, entweder Stabilisierung
in intolerabler Fehlstellung oder instabile Osteosynthese mit nachfolgender Redislokation.
Die Dauerschäden durch fehlerhafte Frakturbehandlung bestanden im Cubitus varus und/oder
einer Streck-/Beugebehinderung des Ellenbogens. Schlussfolgerungen: Die Analyse der einzelnen Behandlungsabläufe lässt in manchen Fällen auf mangelnde
Erfahrung der betroffenen Ärzte schließen.
Abstract
Introduction: Arbitration offices (“Schlichtungsstellen”) in Germany are expert panels for the
extrajudicial resolution of malpractice claims. The performance of arbitration panel
proceedings (“Schlichtungsverfahren”) is based on the German medical and insurance
jurisdiction. In Germany, and in the United States likewise, malpractice claims involving
children concern in most cases fracture treatment followed by appendicitis. Out of
242 panel proceedings with the background of fracture treatment in children malpractice
was confirmed in 144 cases (60 %). The overall ratio: number of confirmed malpractices
to number of all proceedings is 30 %. There are remarkable differences between the
natural occurrence of the different fracture localisations and the fracture localisation
related claims. This ratio amounts for example: clavicula 7 : 1, forearm 2 : 1, femur
1 : 5, elbow region (articular) 1 : 5, humerus supracondylar 1 : 3. Method: 32 arbitration panel proceedings concerning alledged malpractice in the treatment
of supracondylar humeral fractures in children were evaluated in regards to diagnosis
of fracture type and degree of dislocation, conservative and operative fracture treatment,
complications, and malpractice related permanent disabilities. Results: In 20 cases (63 %) malpractice was confirmed. The different failures could be classified
in: 1) Incorrect interpretation of the X‐ray findings, classified as fractures without
or with minimal displacement, no reduction, healing with intolerable dislocation;
n = 3. 2) Insufficient closed or open fracture reduction, stabilisation and healing
with intolerable dislocation; n = 10. 3) Correct primary closed or open reduction,
unstable osteosynthesis (loss of pin fixation of the ulnar epicondylus), secondary
postoperative rotatory dislocation, cubitus varus; n = 3. 4) Delayed detection of
a compartment syndrome of the forearm, no or delayed fasciotomy; n = 3, in two cases
resulting in severe Volkmann's contracture. 5) Extensive skin necrosis caused by uncontrolled
tourniquet under operation. All malunited fractures, except one, led to cubitus varus,
often combined with a restriction (extension/flexion) of the mobility of the elbow
joint. No cubitus valgus was found in our series. In eight cases a cubitus varus was
treated by valgus osteotomy later on. In other cases this procedure was planned. Adverse
events which could not be proven as caused by malpractice, included fracture consolidation
in minimal tolerable displacement, n = 3; delayed recurrence of the normal mobility
of the elbow joint, n = 2; traumatic cubitus varus caused by primary damage of the
humero-ulnar epiphysis, n = 3; pin track infection, n = 1; nerve injuries, n = 10.
The concomitant nerve injuries concerned: n. medianus 3, n. ulnaris 2, n. radialis
1, nn. radialis and ulnaris 3, nn. medianus and ulnaris 1. In all these cases the
claim was based only or together with other reproaches on the nerve injury, but in
no case could a malpractice be confirmed. However it should be mentioned that in some
cases a iatrogenic nerve injury could not be excluded definitively. Therefore we always
recommend the exploration and documentation of the function of the arm nerves at admittance
and immediately after treatment. The applied methods of osteosynthesis were pin fixation,
crossed or unilateral radial, n = 30; radial screw, n = 1; elastic stable intramedullary
nailing fixation (ESIN), n = 1; fixateur externe (reoperation), n = 1. In no case
the method of osteosynthesis was proven as inapplicable or as the cause for the adverse
event. Permanent disabilities were considered to be slight in 12 cases (deficient
mobility of the elbow joint) and severe in two cases (Volkmann's contracture). Physiotherapy
was not found to be beneficial for the restitution of normal mobility of the elbow
joint after supracondylar fracture. In at least 7 cases painful physiotherapy was
applied, although the X‐ray films clearly demonstrated the displaced fracture as the
cause of the restricted mobility. In 5 casuistic representations of adverse events
after treatment of a supracondylar humeral fracture, the final decision of the arbitration
board on the basis of expert reports is illustrated. Conclusion: The results are discussed in order to avoid mistakes in the treatment of supracondylar
humeral fracture in children. The appropriate treatment requires exact assessment
of the degree and direction of the fracture dislocation, clear definition of the cases
in which active treatment, i.e. closed or open reduction and stabilisation, is obligatory,
and experience in the operative treatment. A beginning compartment syndrome of the
forearm should be detected early by the initial symptoms and immediately treated by
fasciotomy.
Schlüsselwörter
Arzthaftung - Frakturbehandlung bei Kindern - Behandlungsfehler - suprakondyläre Humerusfraktur
- Schlichtungsverfahren
Key words
adverse event - fracture treatment in children - malpractice - supracondylar humeral
fracture - extrajudicial claim resolution
