ARTIGO DE REVISÃO
Iatrogeny in traumatology
Fernando Baldy dos ReisI; Akira IshidaII; José Laredo FilhoIII
IFull Professor, Trauma Group Head
IIFull Professor, Departament Head
IIIAdministration Pro-Rector, Chairman
Traumatology evolution took place at the same time as scientific and technologic development of humanity. Were very important for this specialty development of anesthesiology, microbiology, radiology and metallurgy. The first two areas gave their contribution to development of surgery, in a whole, while the other two directly affected bone and joint traumatology.
The discovery of X Rays by Roentgen in 1895 allowed more precision and certainty in diagnosing fractures. Thus, clinical application for study and control of reductions as well as their follow-up became an immediate consequence. A great push on conservative treatment, and understand on bone callus formation took place. Image diagnosis took another push with development of CT scans and more recently, MRI.
The use of image intensifiers allowed an improvement on quality of closed reductions, bringing benefits in regard of time of surgeries. Some open reductions could now have the possibility of being performed percutaneously, and to minimize damage to adjacent soft tissues.
Last, the biocompatibility aspect had a satisfactory solution, allowing the development of a number of models, and synthesis material applications. Technological development of metallurgy, with special metallic alloys reduced organic reactions to metal.
Iatrogeny is a sequela or complication of a treatment which is caused essential and exclusively by a medical mistake in regard of conducting and orientating a diagnosis or a therapy, whether conservative or surgical.
When facing iatrogenic lesions, several aspects should be considered that lead the orthopedic specialist to make such mistakes, always avoiding to make impolite and tendentious comments, that sometimes do not reflect the real patient's condition.
Currently, with the sub-specialties, there are orthopedic specialties involving all the locomotor system, and within each one of them, specifically, Trauma. The Traumatologist should be able to take care not only of isolated fractures, but a poly traumatized and poly fractured patient, taking the individual as a whole, prioritizing the vital systems and rationally planning the treatment of the several fractures. This way, forced by work place pressure, we at the large orthopedic centers are forming professionals who get more and more sub specialized, taking care of "parts of the patient", with possibility for mistakes.
Current trend is sub specialization in certain areas, what can bring benefits to the patient, nevertheless it doesn't mean to always take place. In regard of the care of a poly traumatized and poly fractured patient, traumatologists should be trained and updated, mainly because in the small cities of the country, 80% of the orthopedic patients have fractures.
Healing of fractures is a natural process that should be helped by a doctor. Intempestive attitudes, due to lack of knowledge, or for mal practice, can prejudice the natural evolution.
Even though it can look to be evident, a correct diagnosis is not always correctly done; several cases of patients whose initial diagnosis was inadequate, end to present several complications. It is known that a physical examination is fundamental, however many times an orthopedist decides a diagnosis only by radiographs. So, we could state: "Take care of the patient, not the radiograph".
Anamnesis aiming to diagnose concurrent lesions differentiates the orthopedist. It is known that the same fracture at different ages should be took care differently.
An initial radiographic image can not be conclusive. Patients, at the time they are seen at urgency frequently have poorly elucidative exams. In femoral shaft fractures, for example, it was found that in 10% of the cases the initial radiographic image did not correspond to intra operative or planigraphic images(1).
For a better elucidation of diagnosis, some fractures may need additional exams, such as CT scan in calcaneum fractures, 3D imagery in fractures of the pelvian ring, and even osteocondral fractures can be early diagnosed by MRI.
Associated injuries can frequently be ignored, being their sequelae generally of higher importance than the fracture itself, that, for being evident, was diagnosed. This can be seen in calcaneus fractures associated to spine fractures; these, are frequently not diagnosed. If unstable, can lead to very important neurologic lesions(2).
So, an Orthopedist should have knowledge enough to know, after a clinical suspect, what exams he/she should request to perform an adequate diagnosis, as well as do not forget anatomical aspects of each fracture, since vascular injuries may be associated, leading to fragment necrosis or even necrosis of joint surfaces such as in femoral neck, scaphoid and talus.
After a careful study was performed, it is possible to know the "personality of the fractures", analyzing all involved aspects, not forgetting to take into consideration the set of injuries and the patient's general condition, and so, to choose the best treatment for each given fracture and patient, using metallic implants specific for that case and even complex mounts of external fixation.
Previous planning(3), specially of the operative time, allow a better performance of the orthopedic surgeon, and consequently, better results. We can not forget the biological aspects in treatment of fractures, and to perform it in gentlest way to soft tissues, so vital for fracture consolidation.
When an orthopedic surgeon is inexperienced in a chosen surgical method, and doesn't have local conditions for performing it at his/hers workplace, it is very important to send the patient to a center with adequate conditions. When it is not possible to send the patient, it would be preferable to choose a non operative method or even another method that could be locally feasible.
In rehabilitation, it is observed that, due to lack of assurance, or sometimes due to lack of knowledge or experience, some colleagues delay to start rehabilitation, thus bringing prejudice to the performed treatment. It is worthy to remind that functional rehabilitation after a surgery, will finish the disease called fracture(3).
SOCIAL AND ECONOMICAL ISSUES
The above discussed aspects are closely related to social and economical situation involving our country. Lack of conditions for an adequate professional practice is as well responsible for iatrogenic lesions.
Lack of adequate hospitalar conditions, and difficulty to use adequate implants are possible factors causing bad results.
The traumatologist is responsible for sequelae such as lack of consolidation, infection, residual deformities (angular, rotational and shortening). As we usually take care of healthy individuals, mortality rate is very low.
Nevertheless the Brazilian society of Orthopedics and Traumatology has been insisting in update of its affiliates, and that we do not have to legally account by lesions caused by malpractice, in the fore coming years the orthopedist will face a legal liability.
MEDICO-LEGAL ASPECTS "PRIMUM NON NOCERE"
Under the above statement, much could be said, since at first, a physician should not harm. What to say about issues as:
1 - Omission?
2 - Negligence?
3 - Malpractice?
4 - Unpreparedness?
These are the most important responsible for daily practice iatrogenies, and more responsibilities than it could be wondered are liable to the doctor.
For example, having not performed a good evaluation of a accident patient, leading to sequelae suggests omission, negligence and malpractice.
To argue that the sequela took place due to Health System not giving necessary resources for treatment does not exempt the doctor of being co responsible, becoming an agent of unpreparedness and of malpractice in treating a given disease.
Performing a surgery without being adequately trained or prepared in technique or instruments can mean unpre-paredness or malpractice.
We see that iatrogeny is free among us, and with the best methods of evaluation, and patients criticism can worsen the civil and criminal responsibilities of the doctors for an increased incidence of iatrogenies.
1. Brumback, R.J.; Reilly, J.P.; Poka, A, et al: Intramedullary nailing of femoral shaft fractures. Part I: Decision-making errors with interlocking fixations. J. Bone Joint Surg, 70 A: 1441-1452,1988.
2. Harkess, J.W.; Ramsey, W.C.: Principles of fractures dislocations. In: Rockwood, C.A. & Green, D.P.: Fractures in adults, 3 ed. New York, Lippincott, 1991, pag 1 a 180.
3. M¸ller, M.E., Allgower, M.; Schneider, R.; Willenegger, H: Manual of internal fixation fo fractures. Technique recommended by the AO-ASIF group, 3rd ed. Berlin, Springer Verlag, 1991.
*Work performed at Ortopedics and Traumatology Departament, UNIFESP/EPM
Publication in this collection
27 Sept 2005
Date of issue