> 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
This email has been scanned for viruses by NAI AVD however we are unable to
accept responsibility for any damage caused by the contents.
The opinions expressed in this email represent the views of the sender, not
South Warwickshire General Hospitals NHS Trust unless explicitly stated.
If you have received this email in error please notify the sender.
The information contained in this email may be subject to public disclosure
under the NHS Code of Openness or the Freedom of Information Act 2000.
Unless the information is legally exempt from disclosure, the
confidentiality of this e-mail and your reply cannot be guaranteed.
|