Implementation and evaluation of a nurse-led decision-coaching program for healthy breast cancer susceptibility gene (BRCA1/2) mutation carriers: a study protocol for the randomized controlled EDCP-BRCA study.

BACKGROUND: Female BRCA mutation carriers have an increased lifetime risk for breast and ovarian cancer compared to the general population. Women who carry this mutation have several options to deal with their cancer risk, such as risk-reducing surgeries or intensified breast cancer screening. Previous research has shown that preferences in this scenario are highly dependent on affected women's personalities and value systems. To support these women in the decision-making process, a structured decision support consisting of decision coaching combined with a decision aid might be helpful. METHODS/DESIGN: A randomized controlled trial will be conducted in order to compare usual care with structured decision support alongside usual care. The decision support program entails nurse-led decision coaching as well as an evidence-based patient decision aid. Nurses are qualified by a 4-day training program in informed decision-making and decision coaching. Six centers for Familial Breast and Ovarian Cancer in Germany will be included in the study, with a planned sample size of 398 women. The primary outcome is the congruence between the preferred and the actual played role in the decision-making process as measured by the Control Preferences Scale. It is hypothesized that the structured decision support will enable women to play the preferred role in the decision-making process. Secondary outcomes include the knowledge and attitudes about preventive options, decisional conflict, depression and anxiety, coping self-efficacy, impact of event, and self-concept. A process evaluation will accompany the study. DISCUSSION: The EDCP-BRCA study is the first study to implement and evaluate decision coaching combined with a decision aid for healthy BRCA mutation carriers worldwide. TRIAL REGISTRATION {2A}: DRKS-ID: DRKS00015527. Registered 30 October 2019.

Playing with Pearson's concept: orthogonally functionalized 1,4-diaza-1,3-butadienes leading to heterobinuclear complexes.

By reacting 1,2-diketones and ortho- diphenylphosphinoyl aniline in the presence of zinc(ii) as a templating agent, cationic zinc(ii) complexes of novel phosphine oxide functionalized 1,4-diaza-1,3-butadiene ligands are acessible. Herein the zinc(ii) site is bound to all four donor atoms of the ligand. Depending on the flexibility of the 1,4-diaza-1,3-butadiene backbone, the bonds to zinc(ii) from the 1,4-diaza-1,3-butadiene donors can be broken. Reaction with oxalate cleaves the zinc(ii) coordination completely and makes accessible the free ligands possessing orthogonal (N,N: soft; O,O: hard) sets of donor sites. This allows for the specific coordination of soft and hard Lewis acids and thus for the generation of heterobimetallic complexes, here exemplarily shown for the combination of palladium(ii) (soft) and zinc(ii) (hard) centres.

[Acute compartment syndrome after a bowling game]. / Kompartmentsyndrom nach Bowlingspiel.

A 28-year-old male patient was initially conservatively treated by a general physician for muscle strain of the right calf after a bowling game. Due to increasing pain and swelling of the lower leg 5 days later, the differential diagnosis of a deep vein thrombosis was considered. Furthermore, the onset of neurological deficits and problems with raising the foot prompted inclusion of compartment syndrome in the differential diagnosis for the first time. Admission to hospital for surgical intervention was scheduled for the following day. At this point in time the laboratory results showed a negative d-dimer value and greatly increased C-reactive protein level. On day 6 a dermatofasciotomy was performed which revealed extensive muscular necrosis with complete palsy of the peroneal nerve. In the following lawsuit the patient accused the surgeon of having misdiagnosed the slow-onset compartment syndrome and thus delaying correct and mandatory treatment. The arbitration board ruled that the surgeon should have performed fasciotomy immediately on day 5 at the patient's consultation. The clinical presentation of progressive pain, swelling of the lower leg in combination with peroneal palsy must lead to the differential diagnosis of compartment syndrome resulting in adequate therapy. The delay of immediate surgery, therefore, was assessed to be faulty as this knowledge is to be expected of a surgeon.

[Complicated course of a laparoscopic cholecystectomy]. / Komplizierter Verlauf einer laparoskopischen Cholezystektomie.

The case presented deals with the complicated course of a laparoscopic cholecystectomy in a 45-year-old female patient due to cholecystolithiasis. The patient complained that during the operation an injury to the small intestine occurred, which was only operatively treated at midday of the despite massive pain and insufficient pain treatment. The intervention was claimed to have resulted in mental and physical suffering. The case is assessed by two independent experts in the sense of a "scientifically founded comment" with respect to the decision of the arbitration board and taking the surgical standards into consideration.

[Operation well performed but insufficiently documented and not indicated]. / Operation lege artis, jedoch mangelhaft dokumentiert und nicht indiziert.

A 50-year-old patient presented with a lump in the main joint of the fourth finger of the left hand, which was suspected of being malignant, for an operation. Following surgery the lump was still present and, furthermore, the patient reported a wound resulting from surgery on the third finger accompanied by swelling, pain and a loss of mobility. The patient accused the physician of performing surgery without indications on the wrong finger together with failure to remove the lump. The surgeon stated that lysis had been performed on the flexor tendon in the area of the lump. An external expert admonished the cursory surgery report; however, the expert stated that removal of the lump at the tendon would have been medically indicated and the operation was performed according to professional surgical standards. The decision of the arbitration board differed from the expert opinion as the insufficient documentation presented at first could have been understood to mean that a tendon node on the fourth finger was to be removed which was not the case. Furthermore, the operation performed would only have been indicated if a "trigger finger" were present; therefore, the surgery as well as the resulting afflictions and follow-up treatment were to be assessed as faulty. The handwritten surgery report had several shortcomings as well and led to a reversal of the burden of proof.

[Conservative treatment of distal radius fracture. Consequences of an uncritical follow-up]. / Konservative Behandlung einer distalen Radiusfraktur : Folgen einer unkritischen Verlaufskontrolle.

A 74-year-old woman sustained a fracture of the distal radius with an additional fracture of the styloid process of the ulna due to a fall. After reduction under local anesthesia immobilization treatment in a forearm cast was initiated. Despite increasing secondary dislocation during radiological x-ray follow-up control, the bone was described as correctly aligned by the treating physician and non-operative treatment was continued. After a total treatment period of 9 months including 7 months of physiotherapy the patient still presented a limited range of motion and local soft tissue swelling of the right wrist. The patient filed a complaint for wrong treatment of the distal radius fracture resulting in severe pain and considerable deformity of the right wrist leading to a significant handicap during activities of daily living. The expert opinion of the arbitration board ascertained a case of medical malpractice in terms of the indications. Due to the initial presence of criteria of radiological instability, an operative treatment had already been indicated at the first presentation. In addition, secondary dislocation during radiological follow-up examination should have led to conversion of treatment in favor of surgery. The arbitration board furthermore concluded that iatrogenic malpractice led to a severe deformity of the right wrist which would result in a loss of grip strength and future arthritic deformation of the wrist. Legal aspects of the case are discussed.

[Foreign body retention after soft tissue laceration. A case of insufficient inspection and documentation]. / Augenbrauenplatzwunde mit übersehenem Fremdkörper. Unzureichende Inspektion und Dokumentation.

A 52-year-old man sustained a laceration to his left eyebrow after a fall in his bathroom. His plastic glasses shattered upon impact. The patient was referred to a local emergency department. After a quick exploration by the physician on call, the wound was closed by a nurse using the Steri-Strip Wound Closure system. No further exploration or imaging was performed. Four weeks after the incident the patient presented to a dermatologist with a "foreign body sensation" at the site of the laceration. Assuming a foreign body granuloma, he was referred to a maxillofacial surgeon who removed plastic debris (parts of the glasses worn by the patient). The wound subsequently healed without further complications.The patient filed a complaint for inadequate treatment in the emergency department. No detailed patient and accident history had been obtained, the wound exploration performed by the physician was superficial, and the wound closure was performed by a nurse. The expert opinion of the arbitration board ascertained a medical malpractice in terms of insufficient history, examination, and a lack of documentation. Specific questioning of the accident history would have led to the suspicion of possible foreign bodies, thus, leading to a more thorough exploration and likely further imaging. The arbitration board concluded that obtaining a detailed accident history and an accurate examination would have revealed the foreign bodies and/or led to further imaging. Complying with this, the patient could have been spared further harm and secondary surgery would have been unnecessary.

[Incomplete paraplegia after delayed diagnostics of motor function deficits. Severe malpractice?]. / Inkomplette Querschnittlähmung nach verzögerter Abklärung motorischer Ausfallserscheinungen. Schwerer Behandlungsfehler?

A 72-year-old female patient was transferred to a rehabilitation centre after surgical stabilization of a subtrochanteric femoral fracture. However, adequate mobilization was not possible there and 5 days after transfer deficits in the motor function of both lower extremities were documented for the first time and an initial paraplegia was diagnosed the following day by a neurologist. Magnetic resonance imaging (MRI) revealed the suspicion of an unstable fracture of the seventh thoracic vertebral body 8 days after the initial symptoms, which was confirmed by computed tomography after another 3 days. Surgical decompression and stabilization were performed at a department for neurosurgery 4 days later but incomplete paraplegia persisted permanently. The patient complained about insufficient diagnostic measures at the rehabilitation centre. The expert opinion concluded that it would have been mandatory to investigate the matter of the newly occurring neurological symptoms immediately but this had only been performed after undue delay, which had to be interpreted as a case of medical malpractice. The expert pointed out that it was not possible to provide clear evidence that emergent diagnosis and surgery would have enabled a significantly better outcome.The arbitration board ascertained a lack of examination and argued that prompt and adequate diagnostic measures would have revealed the relevant pathological finding and thus surgery would have been performed immediately. According to the reversal of evidence in favor of the patient it could be assumed that no permanent neurological damage existed when the first neurological symptoms occurred and that emergent surgery at least had the potential to prevent permanent paraplegia. This opinion of the arbitration board is supported by numerous references in the literature.

[Trends in inpatient treatment in ophthalmology in Germany]. / Entwicklung der stationären augenärztlichen Versorgung in Deutschland.

BACKGROUND: Over the last decade inpatient treatment has been reduced in favor of outpatient care or markedly shortened inpatient stays in most organ-specific surgical specialties such as ophthalmology in Germany. METHODS: Data from the federal statistics agency on the international classification of disease (ICD), diagnosis-related groups (DRG) and performed operations and procedures from 2000 to 2010 as well as data from the Institute for Reimbursements of Hospitals (InEK) on average costs per DRG in every German DRG (G-DRG) version from 2004 to 2010 were analyzed for ophthalmology. RESULTS: From 2000 to 2010, the number of cases with a main ophthalmological diagnosis decreased (-19 %), which was mostly due to a reduction in the number of cataract inpatients (-56 %). All subspecialties such as glaucoma (+82 %) and retina (+68 %) with the exception of primary strabismus diagnoses (-15 %) gained in number of cases. Inpatient cataract surgery was the most common surgery in 2004 but numbers decreased to 2010 (-9 %). The most often performed inpatient procedure was vitreoretinal surgery in 2007 and 2010 (increase 2004-2010 + 46 %). Average hospital stay decreased between 2005 and 2010 from 3.9 to 3.4 days and the average cost per case increased by 3.6 % overall and by 13.4 % for surgical cases. CONCLUSION: Ophthalmic healthcare provided as inpatient services decreased with a trend towards more complex cases being treated as inpatients from 2000 to 2010.

[Curriculum "patient safety" for undergraduate medical students at the department of surgery, University of Greifswald]. / Curriculum "Patientensicherheit" im Blockpraktikum Chirurgie an der Universität Greifswald.

BACKGROUND: Risk reducing measures like the surgical checklist have been proven to reduce effectively adverse events and improve patient safety and teamwork among surgical staff members. Nevertheless, many physicians still refuse to use even simple safety tools like the WHO checklist. A progress in patient safety can only be achieved by changing the operating proceedings and mentality of medical students. This is best performed by teaching patient safety already very early in the medical education. METHOD: The present study demonstrates the implementation and evaluation of the curriculum "patient safety" for undergraduate medical students in the 4th year of medical school at the Department of Surgery, University of Greifswald. 141 students evaluated a total of six lectures from April to October 2011. RESULTS: The results indicate that young medical students show great enthusiasm in safety matters and are willing to adopt the principles. Especially the importance of the issue and the didactic design were evaluated as being very high. CONCLUSION: The curriculum "patient safety" as part of the training program in medical school is a powerful and effective educational tool that is able to raise the student's awareness of patient safety affairs. Thereby it is crucial to start early within medical education during the phase of socialisation. We recommend the general implementation of a patient safety curriculum in medical school.

[Malpractice in the treatment of diaphyseal fractures in children - experience of the Arbitration Office of the Northern German Medical Boards]. / Fehler bei der Behandlung diaphysärer Frakturen der langen Röhrenknochen bei Kindern - Erfahrungen der norddeutschen Schlichtungsstelle.

BACKGROUND: Statistics of the Arbitration Office of the North German Medical Boards for extrajudicial claim resolution show that nearly 30 % of all panel proceedings confirm medical malpractice. In proceedings concerning fractures in children the percentage rises to 63 % with significant differences in various fracture localisations. METHODS: Between 2000 and 2011 the Arbitration Office dealt with 272 panel proceedings regarding the fracture treatment in children. In this study 83 proceedings concerning the treatment of diaphyseal fractures of the long bones are evaluated. RESULTS: The claims were related to the following specialities (p = number of proceedings, m = number of malpractices): orthopaedics/traumatology p = 46, m = 38; general surgery p = 17, m = 21; paediatric surgery p = 16, m = 13; anaesthesia p = 1, m = 1; general practitioner p = 2, m = 2. In 7 cases concerning obstetrics (4) and paediatrics (3) no malpractices could be established. In 5 cases two facilities/doctors were included in the same proceeding. On 17 occasions, 2 errors were made that were unrelated to each other. The overall frequency of malpractice was 69 % with no significant differences between the involved facilities. The diaphyseal fracture locations were: humerus p = 5, m = 2; radius and/or ulna (Monteggia fractures excluded): p = 29, m = 20; femur p = 29, m = 20; tibia (with or without fracture of the fibula): p = 20, m = 14. In conservative fracture treatment the following negligent adverse events were confirmed: severe skin lesions owing to either plaster extension or removal of the cast (11), omitted or insufficient reduction followed by consolidation in intolerable malposition (8), no inducement of corrective measures after consolidation in intolerable displacement (11). Following malpractices in the surgical treatment were classified as: no indication for surgical treatment (2), no osteosynthesis in spite of clear indication (3), technical failures in primary osteosynthesis (16), technical failures in repeated osteosynthesis (4), aspiration pneumonia due to missed intubation (1). The applied methods of osteosynthesis were intramedullary nailing, mainly ESIN p = 24, m = 12; plate p = 24, m = 5; fixateur externe p = 7, m = 5. The results of maltreated diaphyseal fractures were altogether moderate: transitional impairment due to delayed or repeated therapeutic measures with prolonged fracture healing, no functional loss 70 %, slight deformation of the forearm, minimal loss of mobility 21 %, remarkable deformation of the forearm with considerable impairment of mobility, especially pronation/supination, deformation of the radio-ulno-carpal joint unit 7 %. DISCUSSION: There are three main categories in the maltreatment of diaphyseal fractures: 1) Omission of fracture reduction with or without internal stabilisation in cases of relevant axial deviation by unjustified expectation of "spontaneous correction". 2) Omission of fracture reduction in cases of unmotivated or neglected secondary displacement. 3) Technical failures in performing of osteosynthesis resulting in instability or the creation of intolerable malposition requiring re-osteosynthesis. The high number of plate osteosyntheses in our series (44 %) is not representative for the general treatment of children's fractures in Germany. Most cases of plate osteosynthesis are related to corrective measures with clear indication. In nine casuistic representations the errors in treatment are explained. CONCLUSION: The evaluation of malpractice in the treatment of diaphyseal fractures in children confirms the consensus: correct assessment of fracture type, early adequate treatment and fracture control, early corrective measures after insufficient primary reduction or secondary dislocation, lead to fracture healing without any anatomic or functional deficiency. Reverse argument: fracture healing leading to anatomic and/or functional loss gives a very probable indication of malpractice.

Gut microbiota correlates with energy gain from dietary fibre and appears to be associated with acute and chronic intestinal diseases.

Improvements in high-throughput sequencing technologies have spurred a large number of studies aimed at obtaining a better understanding of the composition and the dynamics in gut microbiota and its associations with various human diseases, especially those in the intestinal tract. Here we briefly summarize results from three different such studies from our group, all of which used 454 based high-throughput 16S rRNA sequence analysis combined with other microbiota profiling methods to determine faecal microbiota composition. In the first study, a controlled feeding trial, we establish that energy gain from the consumption of up to 50 g/day of a resistant maltodextrin depends on the prevalent microbiota composition. Over time, resistant maltodextrin supplementation increased the proportion of total faecal bacteria as well as potentially beneficial bifidobacteria. Thus, energy gain from resistant maltodextrin in an individual appears to vary over time and depend on the adaptation of gut microbiota. We then illustrate the power of molecular tools for identifying (i) distortions in early microbiota development in pre-term infants and the presence of potentially novel pathogens contributing to necrotizing enterocolitis and (ii) a specific microbiota signature, based on discriminant analysis of the 16S rRNA sequences, that correlates with the prevalence of an early risk marker associated with colorectal carcinogenesis, intestinal adenoma, in elderly adults.

[Infection after anterior cruciate ligament reconstruction: grave error in treatment?]. / Infektion nach arthroskopischer Kreuzbandersatzplastik: schwerer Behandlungsfehler?

A 28-year-old patient showed clear signs of knee joint infection 8 days after arthroscopic reconstruction of the anterior cruciate ligament. The treating physicians recommended further observation although they stated that a knee joint infection could not be reliably excluded. One week later arthroscopic revision was performed and intraoperative smear tests showed infection by Pseudomonas aeruginosa. Therefore, another 6 days later the obviously infected transplant had to be removed. In the long run painful and limited range of motion of the affected knee joint persisted. The patient complained about medical malpractice concerning management of the complication. The expert opinion stated that due to the fateful course of infection the tendon graft could not be retrieved after the eighth day post surgery anyway. Thus, only flawed delay of treatment was criticized. The arbitration board argued, however, that scientific data concerning the fate of infected tendon grafts do not support the expert opinion and that immediate arthroscopy and antibiotic treatment at least had the potential to influence the course of infection in a positive manner. Evidence clearly shows that survival of an infected tendon graft depends on early diagnosis and emergency treatment rather than just on fate. Due to the fact that, although having in mind the possibility of a knee joint infection, the necessary therapy was delayed for 8 days, the arbitration board considered the described medical malpractice a severe treatment error, leading to reversal of evidence in favour of the patient.

[Malpractice in the treatment of fractures and dislocations of the elbow joint in children--experience of the arbitration office of the North German Medical Boards]. / Schlichtungsverfahren bei Kindern mit Frakturen und Luxationen des Ellenbogengelenks--Erfahrungen der norddeutschen Schlichtungsstelle.

BACKGROUND: Statistics of the arbitration office of the North German Medical Boards show that 30% of all panel proceedings confirm medical malpractices. In panel proceedings concerning the treatment of fractures in children, the percentage rose to 60% with significant differences in the individual fracture localisations. METHODS: Between the years 2000 and 2010, the arbitration office dealt with 257 panel proceedings regarding the fracture treatment of children. This study evaluates the decisions of 53 proceedings concerning the treatment of fractures and dislocations of the elbow joint. RESULTS: All cases except one concerned the following surgical specialities: 1. orthopaedics/traumatology, n = 14; 2. general surgery, n = 13; 3. paediatric surgery, n = 5. On 7 occasions 2 treatment facilities were involved in the same proceeding. The following types of fractures/dislocations were present (each with the number of proceedings [p] and the confirmed malpractices [m]): fracture of the radial humeral condyle and transcondylar Y-fractures, p = 12, m = 11; fracture of the ulnar epicondyle, p = 2, m = 2; sole dislocation of the radial head as well as in combination with Monteggia lesion, p = 19, m = 17; displaced fracture of the radial head and radial neck, respectively, p = 8, m = 4; fractures of the olecranon, p = 3, m = 2; fracture of the coronoid processus, p = 1, m = 1; dislocations and dislocation fractures of the elbow joint without Monteggia lesion, p = 8, m = 5. DISCUSSION: 42 of these cases (79 %) confirmed malpractice of which 27 (64%) resulted in permanent restriction of the elbow joint mobility. Due to the diversity of injuries, the types of treatment errors were also very variable. In most cases the treatment errors were initiated through the false interpretation of X-ray findings which resulted in false and inadequate therapy measures, for example, the overlooked and not reduced dislocation of the radial head. Three transcondylar Y-fractures were missed on both the X-ray findings and during the operation. In cases where the dislocation of the radial head was not diagnosed in the first instance but operated on within four months (n = 3), a satisfactory result was still achieved. However, if the operation took place at a later time (in our cases 9 months to 8 years after the injury, n = 14) there was no improvement achieved and in many cases the elbow joint mobility deteriorated significantly. In three cases of dislocation of the elbow joint, an intraarticular entrapment of the disjointed ulnar epicondyle was overlooked and therefore not corrected which resulted in deleterious effects on the joint movement. There were five cases with a dislocation combined with a displaced fracture of the radial neck (Mason IV). This fracture was insufficiently reduced/stabilised on two occasions and in one instance the reconstruction of the disrupted joint ligaments was not carried out which resulted in permanent instability of the elbow joint and subluxation. In five casuistic representations the final decision of the arbitration board on the basis of expert reports is illustrated. CONCLUSION: From a traumatological point of view, the elbow region of a child constitutes a distinct problem zone due to the rarity and diversity of the fractures and dislocations in this area. Relevant experiences in diagnostics and therapy of injuries in this region cannot always be expected. Every doctor who happens to come across a case in which a child suffers from such injuries should be responsible for the timely referral to a treatment facility that has the relevant experience to treat such cases.

[Injury to the median nerve after minimally invasive decompression: discrepancy between the surgical report and actual course of surgery]. / Verletzung des N. medianus nach minimal-invasiver Dekompression: Diskrepanz zwischen Operationsbericht und tatsächlichem Operationsablauf.

A 72-year-old man suffering from carpal tunnel syndrome had undergone minimally invasive decompression by using a SafeGuard® Mini-Open Carpal Tunnel Release System. After the operation the patient presented with a paraesthesia in the median nerve distribution. Two months later an operative revision was performed in another hospital. A partial transection of the median nerve and an incomplete release was seen. The surgeon of the first operation stated that detailed informed consent including the risk of iatrogenic nerve injury had been obtained. Furthermore he referred to the operative report, which mentioned the accuracy of the procedure without any problems or complications during surgery. The Arbitration Board stated that the operative report could not exculpate the surgeon because the findings of the operative revision disagreed with the first operative report. The expert opinion declared that the lesion was a result of an inaccurate operative procedure as the surgeon was not able to demonstrate an anatomical variation of the median nerve.

[Wound closure after irrigation with Octenisept® without possibility for drainage]. / Wundverschluss nach Wundspülung mit Octenisept® ohne Abflussmöglichkeit.

A 39-year-old patient suffered a stab wound of the right thenar prominence after an accident with a screwdriver. In the first hospital the deep wound was irrigated with octenidine dihydrochloride/2-phenoxyethanol and closed by suture. During the further course pressure pain and numbness of the right thenar and swelling of the right hand occurred. Three weeks after the accident an operative revision of the wound in a second hospital was performed. The intraoperative findings showed inflammation and necrosis of the right m. abductor pollicis brevis, but no infection with pus.The patient accused the first hospital of irrigating the tissue of his right hand with Octenisept®. The expert option of the Arbitration Board identified improper care in the first hospital with insufficient excision of the wound and incorrect use of the Octenisept® solution. Against the explicit advice of the manufacturing company the wound had been sutured without the possibility of drainage for the Octenisept® solution.

[Malpractice in the treatment of supracondylar humeral fractures in children - experience of the arbitration office of the Northern German Medical Boards]. / Fehler bei der Behandlung suprakondylärer Humerusfrakturen bei Kindern - Erfahrungen der Norddeutschen Schlichtungsstelle.

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 alleged 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.

[Missed clavicle fracture, deep vein thrombosis following bicycle accident with head and chest trauma]. / Ubersehene Klavikulafraktur, tiefe Beinvenenthrombose nach Fahrradsturz mit Schädel-Hirn- und Thoraxtrauma.

A 57-year-old patient suffered head and chest trauma following a bicycle accident. After 12 days in hospital with early mobilization the patient developed a deep vein thrombosis 5 days after being discharged and the family physician diagnosed a non-displaced clavicle fracture. The patient complained that no thrombosis prophylaxis had been carried out during the stay in hospital and the clavicle fracture had been overlooked. The expert opinion from the arbitration board determined that no health limitations had occurred as a result of the missed clavicle fracture. There were no indications for anticoagulation in accordance with the guidelines due to a lack of risk factors and the event was deemed unpreventable.