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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