Case Archive
Emergency Medicine, Pediatric Pulmonology
Ref. # 34287

A 15 year old Pennsylvania boy was in a motorcycle accident. His father took him to the ER for extreme right leg pain. A physical exam revealed an open right tibula-fibula fracture and abrasion to the right shoulder. Vital signs, respiratory status and neurologic findings were normal. X-rays of the leg confirmed a right leg fracture. After an orthopedic consult, the patient was taken to the OR for wound debridement and closed fracture reduction. The surgery lasted approximately 90 minutes. Shortly thereafter in post-op recovery, the patient experienced facial and neck swelling. Anesthesia was called. A chest X-ray revealed massive bilateral chest wall subcutaneous emphysema with a large pneumomediastinum and a small right-sided pneumothorax. A general surgeon inserted a chest tube and the patient was transferred to the ICU. Nine days later the chest tube was successfully removed and the patient was discharged the following day. A medQuest ER physician opined there was a negligent failure to order a chest X-ray in the ER in light of the boy's type of trauma. A medQuest pediatric pulmonologist reported that obtaining a chest X-ray in the ER would have revealed a pneumothorax. This could have been treated prior to the massive air leak and extra pulmonary air collection the patient ultimately suffered. The negligence prolonged the patient's post-op recovery and increased his discomfort.

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