CASE VIGNETTE – APRIL 2020

Fracture/Dislocations of Joints Can be Exceedingly Challenging

Consider the case of the society matron (only 61 years of age) who sustained a fracture/dislocation of her dominant thumb. The joint involved was between the first metacarpal and the proximal phalanx of the thumb. As you look at your thumb, it’s not the end joint but the one next to the end joint.

Her hand became caught in the stock as she fell whilst skiing and the force applied bent the thumb well away from the index finger. One of the bones in the joint was fractured and was quite markedly displaced.

Upon returning to Australia (from her favourite location in Aspen), the society matron underwent an operation. The Orthopaedic Surgeon reduced and fixed the fracture, and held the thumb in a splint for six weeks.

Although the fracture healed, upon removal of the splint, it was apparent that one of the ligaments that was stabilising the joint was no longer functioning satisfactorily and the thumb itself became very unstable. This is sometimes referred to as “a gamekeeper’s thumb”. In times gone by, gamekeepers used to snap the necks of pheasants and other game birds by holding each bird against the chest with one hand and pushing forcibly downwards on the neck and head to extinguish life from the captured game with the other. The force applied to that same joint in the thumb was very similar to the force that had been applied to the thumb of the society matron when she fell in Aspen.

She was eventually subjected to a second operation, with additional costs. Unfortunately, that endeavour was complicated by sepsis which necessitated hospitalisation and intravenous antibiotic therapy. Her prolonged immobility resulted in deep venous thrombi forming in one of her lower limbs, with embolisation of the clots to her lungs. As is sometimes the case, one of the emboli was of sufficient magnitude to block the bifurcation of the main pulmonary artery, resulting in sudden death.

You can imagine the anguish experienced by the family. What seemed to be a simple thumb injury whilst skiing during the Christmas holidays resulted in the loss of their wife, mother and grandmother.

The subsequent claim was successful. The Court found that had the injury been dealt with properly in the first instance, and that the ligament had been repaired as well as the fracture being internally fixed, the eventual sequence of events was much more likely than not to have been less dramatic.

Whatever your view on the matter, it is incumbent upon the Orthopaedic Surgeon to manage fracture/dislocations totally and completely, and not just the fracture in isolation.