CASE VIGNETTE – November 20020

The Confounding Effects of Time

I am referring specifically to younger patients (those who have not yet reached skeletal maturity) who might be subjected to a constellation of quite severe injuries of a widespread nature.

I recall a young girl who had been struck by a motor vehicle whilst on a pedestrian crossing outside her local state school. She had been struck from the right. She had sustained a fracture of the clavicle, a fracture dislocation of the shoulder, a fracture of the arm bone (the humerus), a dislocation of her elbow and fractures of both forearm bones (the radius and the ulna). She also had multiple rib fractures with an underlying pneumothorax and required ventilation in an intensive care unit for nearly three weeks. There were also closed pelvic fractures, a compound fracture of the thigh bone (the femur) and compound fractures of both of her shin bones (the tibia and the fibula).

So severe was this list of injuries that she required no fewer than seven operations, was hospitalised for a little over three months and lost one year from primary school. She was quite significantly disfigured as a result of the lacerations sustained at the time of the injuries and the operative scarring that ensued during her therapeutic regimen. She was only seven years old.

I saw her when she was 21, fourteen years later. All of the fractures had united, every joint had regained a full range of motion, there was no evidence of neurological sequelae, motor function was restored, there was no residual muscle wasting and no evidence of peri-articular or intra-articular instability.

In fact, apart from the scarring, she had made a complete recovery.

When measuring her impairment, nothing could be quantified using the relevant chapters of the AMA 5 Guides as a result of her orthopaedic injuries. The only losses that could be quantified were those related to scarring, and these were best dealt with using Chapter 8.

You can imagine the dismay of the parents (and the plaintiff’s solicitor) when there was a 0% impairment rating from an orthopaedic perspective.

I shared this surprise, but there it was. The Guides themselves allow no room for emotion and neither can they be appropriately manipulated according to sympathy.

The effects of time can be quite extraordinary. If only every outcome was so positive!