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Welcome to another edition of clinical nursing cases. We should be putting these out at least monthly from here on in. More often if time allows (or if we receive positive feedback from you).
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This case may be cited as:
Lopez, Andrew. September 4, 2001. Pathologic Fracture, or Patient Injured in Fall. Clinical Nursing Case Studies. Retrieved (insert current date) from the World Wide Web: http://www.nursefriendly.com/nursing/clinical.cases/2001/090401.htm
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Pathologic Fracture, or Patient Injured in Fall
Woodham v. Elyria Memorial Hospital, 2001 WL 753268 N.E.2d Ohio
Summary: The patient in this case had an extensive Oncologic history including multiple metastases and a predisposition to pathological fractures. When the patient fell while transferring a wheelchair, the cause of the broken hip found after the fall was put into question.
The advanced lung cancer patient was admitted to Elyria Memorial Hospital for chemotherapy and subsequent treatment of dehydration.
“More Americans die each year from lung cancer than from breast, prostate, and colorectal cancers combined.
Lung cancer kills more men annually than prostate cancer and more women than breast cancer.
Every three minutes another person is diagnosed with lung cancer. 18 people will die each hour from lung cancer.
The American Cancer Society estimates that 164,100 Americans will be diagnosed with lung cancer and 156,900 will die from the disease in the year 2000.”2
The patient had known lung carcinoma with multiple metastases to her bones and other portions of her body.
“Bone is the third most common site of metastatic disease. Cancers most likely to metastasize to bone include breast, lung, prostate, thyroid and kidney. Carcinomas are much more likely to metastasize to bone than sarcomas. The axial skeleton is seeded more than the appendicular skeleton, partly due to the persistence of red bone marrow in the former. The ribs, pelvis and spine are normally the first bones involved and distal bones are rarely affected.”3
One of the known complications of metastatic cancer to bone is a condition called “Pathological Fractures.”
This is when bones are unable to handle the normal stress of everyday activities. They may break under simple or normal physical demands or with trauma.
“Treatment for bone metastasis is normally palliative. An assessment of the risk of pathological fracture must be made by an experienced orthopaedic surgeon. Lesions that do not represent a risk for fracture may be treated with radiation or by appropriate chemotherapy directed at the tumor. Lesions that are regarded as a risk for pathologic fracture should be surgically stabilized on an elective basis before a fracture occurs.”3
This would become pertinent when a fractured hip in a patient was discovered after she tried to get up from bed to a chair and fell.
The nurse on duty that day was assisting the patient from her bed to a wheelchair for her discharge from the hospital. When the patient got up with assistance the nurse brought her to a standing position. While the nurse reached over to lock the wheelchair, the patient fell to the ground.
On examination following the patient's fall, a fractured hip would be discovered. On review of the radiological evidence and the clinical presentation of the patient, it was unclear if the fall caused the fracture, or a pathological fracture caused the fall.
The patient would soon die from her disease. Her estate administrator chose to sue for damages related to the fall.
The court would rule that there was no clear evidence that the fractured hip was caused by the fall. A directed verdict was given in favor of the nurse and hospital.
The estate administrator would appeal.
Questions to be answered:
1. Could it be clearly determined that either the fall caused the fracture, or that the fractured caused the fall.
2. Was the Nurse or her actions/inactions the proximate cause of the patient's fall or the hip fracture.
3. Was the lower court in error in it's directed verdict.
Expert testimony would opine that it was impossible to tell whether the fracture was caused by the fall or if the hip had fractured spontaneously and precipitated the fall. The orthopedic surgeon giving the testimony clearly stated that patients at risk for pathologic fracture are notoriously difficult to identify.
"Lytic bone metastases must be greater than 1 cm and have destroyed 30-50% of the bone density in order to be seen by x-ray. It is also difficult to distinguish between metastases and benign lesions such as Paget's disease or osteoporosis on plain film. On bone scan, radiolabeled bisphosphonates are taken up by in areas of bone formation but not by the tumor cells. CT is more specific than bone scan and can distinguish between osteolytic and osteoblastic lesions. MRI is the most sensitive method of detection bone metastases because cells can spotted before local bone reaction has occurred."3
The role of the nurse was closely examined to determine if a case could be made for a ruling under Respondeat Superior. Under this doctrine, an employer is responsible for the negligent acts of its employees.
To make this case, the plaintiff would have had to prove via expert witness testimony that the nurse was explicitly the cause of the patient's injuries.
Since the true cause of the fracture was never clearly identified, the nurse's role in the situation was not a pivotal factor.
On appeal, the evidence offered was re-examined. It was clear to the appeals court that the burden of proof was clearly insufficient to make a case for the plaintiff.
For the plaintiff's case to be successful, it would have needed to be proven conclusively, that the nurse caused the patient's injuries. The best the plaintiff's expert testimony could offer was a “maybe” that the nurse was responsible.
This was not enough to sway the appeals court. The verdict was affirmed.
Related Link Sections:
Cancer & Oncology (over 800+ links)
Clinical Charting and Documentation, Nurses Notes:
Direct Patient Care Links
Falls, Injuries & Prevention, Direct (Bedside Nursing) Patient Care Links
Mechanical & Physical Restraints:
Medical Legal Consulting Nurse Entrepreneurs:
Nurse Practice Acts
Nursing Expert Witnesses:
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August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgment Call
1. 42 NLRR 2 (July 2001)
2. Alliance For Lung Cancer. August 23, 2001. Lung Cancer Fact Sheet. Retrieved August 30, 2001 from the World Wide Web: http://www.alcase.org/factsabout_lungcancer.html
3. Bonecancer.org. No date given. Bone Metastasis. Retrieved August 30, 2001 from the World Wide Web: http://www.bonetumor.org/page67.html
This page was created on Tuesday August 28, 2001
Last updated by Andrew Lopez, RN on March 23, 2017
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