Oh, and well done on changing the name of this confounded thread (or was
that Matt or Rowley?). Anyway I was getting tired of opining on "Sacphoids".
AF
----- Original Message -----
From: "Bruce Finlayson" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, September 01, 2005 11:28 PM
Subject: Re: Scaphoids
> From a lurker....
> How many orthopaedic consultants, or for that matter hand surgeons or any
> other 'experts', do you know that actually see scaphoid fractures ACUTELY?
> It irritates me that the 'expert' opinion so often comes from an
> individual with absolutely no experience of the acute presentation beyond
> 6 months spent in A&E.
>
> ----- Original Message -----
> From: "Dunn Matthew Dr. (RJC) A & E - SwarkHosp-TR"
> <[log in to unmask]>
> To: "Bruce Finlayson" <[log in to unmask]>
> Sent: Thursday, September 01, 2005 10:18 AM
> Subject: Re: Scaphoids
>
>
>>> As we're getting into the legal bit now maybe what I should
>>> be asking you wealth of Expert knowledge out there is - if
>>> YOU were the Expert in such a case would you be satisfied
>>> that the doctor had documented an absence of scaphoid # signs
>>> and say something like 'the doctor made adequate clinical
>>> tests for a fracture but no signs were present' OR would you
>>> say ' a fracture has been shown to be present, therefore the
>>> scaphoid must have been tender, and the doctor's examination
>>> must have been inadequate' - how do we counter that latter
>>> argument? Does anyone know of any evidence that this can
>>> happen? - or is this discussion the only evidence there is
>>> whereby a number of us have said that we've seen this happen before?
>>
>> The expert will often be an orthopaedic consultant. I would guess that a
>> number of them out there will say that there must have been tenderness
>> but
>> examination was inadequate. The way to counter this would be by quoting
>> published papers reporting fractures with no tenderness at the time
>> examined. Of course if there are a lot of these cases, then you may get
>> the
>> argument that the doctor should have been aware of this and it was not
>> acceptable to exclude a fracture on clinical examination.
>> Personally if I were to give evidence, I'd cite the papers showing
>> sensitivity of asb tenderness to be around 90%, which is about the
>> percentage you want; and I'd look at original data a bit more to work out
>> a
>> negative predictive value. A bit of faffing around looking at notes to
>> look
>> at general documentation and how believable they were as well.
>> As to which way a court would decide, who knows.
>> In answer to the original question, scaphoid fracture in the absence of
>> asb
>> tenderness is well recognised. However the negative predictive value of
>> absence of tenderness and the uncertainty of the benefits of more
>> aggressive
>> management on prognosis suggest that it is a reasonable course of action
>> not
>> to proceed to MRI scan (I had one of these done on a patient once, but
>> I've
>> only been a consultant for seven years, so the rest are still in the
>> pipeline) or bone scan.
>> I note that BAEM is in the process of revising guidelines on this
>> subject.
>>
>> Matt Dunn
>> Warwick
>>
>>
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