General Advice – October 2021

Qualities You Should Look for in an Expert

Since I have spoken about the need for some form of quality control with medicolegal reports, it is also appropriate that I list some of the qualities that I believe are necessary in a good reporter.  In no special order, they are:

• Sufficient intellect (and usually, most medical practitioners possess this).
• Adequate education (especially in the subspecialty chosen).
• An analytical ability that allows the expert to sift through the evidence and make a true and accurate determination on causation and loss.
• Adequate experience both of and in the subspecialty chosen.
• Erudition in reporting.
• The ability to maintain focus and communicate in a concise manner.
• Expressing unequivocal decisions whenever possible.
• Remaining emotionless.  I sometimes see colleagues expressing frustration in their reports after dealing with a seemingly difficult plaintiff.
• The report should be devoid of bias.  This can be very difficult.  Not all bias is recognised by the reporter.
• Objectivity is paramount.
• Transparency is also essential.  Reasoning should always be explained.
• Completeness, with all questions being answered, all the time.

My great mentor, the Hon Des Derrington, retired Justice of the Supreme Court of Queensland, has been an invaluable source of advice for me for almost four decades.  I will always be indebted to him.

Lead Article – September 2021

Orthopaedic Injuries Can Make You Mad

I am using the word “mad” quite loosely.  I am not suggesting that the orthopaedic injury will give rise to psychiatric or mental illness but instead, can be irritating, frustrating, give rise to anger and anguish and generally making you “mad”.  We all feel this type of frustration from time to time.  Some inciting agents are more provocative than others.

There is another dimension to explore.  That relates to the patient who has had an orthopaedic injury but follows a course contrary to the expected natural history.  Minor soft tissue injuries, strains and sprains typically heal quite promptly.  To see a patient five years later with a symptom spectrum unchanged, suggests that there is far more to it than just the simple orthopaedic condition.

These patients may be truly mad, suffering with some form of psychiatric illness.  Importantly, the relatively minor orthopaedic accident may have been the precipitant for the psychiatric demise.  Had it not been for the accident, the patient may have continued on a seemingly normal course indefinitely.

I see these patients from time to time.  I outline my views on the likely contribution of the orthopaedic injury to the circumstance but also make reference to the need for psychiatric investigation and care.

Typically, I hear no more about the case.  I genuinely hope that the advice has been followed and that some form of respite is eventually achieved.

Case Vignette – September 2021

Can You See the Funny Side?

Whilst my sympathy for injured individuals is genuine and maintained, I can also sometimes see an element of humour.  At the risk of causing offence, I keep my mirth to myself.  I can recall a recent case however that should be shared.

Two workers were on a construction site in the central business district of Brisbane.  They were dismantling a steel structure.  The structure had two upright steel poles, about three metres apart.  Spanning the gap between the poles, and about three metres above ground level, was a third pole.

One worker was standing on a stepladder with a grinder and was in the process of cutting the junction between one of the uprights and the horizontal beam.  It was quite obvious that when the cut had been completed, the horizontal beam would collapse.

I was taking a history for a medicolegal report from the other worker.  He was standing beneath the beam.  Lo and behold, when the beam and the upright were finally rendered separate, the beam fell and struck him heavily over his shoulder, giving rise to a serious fracture dislocation.

At the end of the consultation, and departing from my usual routine, I asked him why he was standing there.

With a straight face, and without any hesitation, he said “My boss told me to stand there”.

What more can I say?

General Advice – September 2021

Try Not to Pre-empt the Consultation

Plaintiffs presenting for medicolegal examinations will have various expectations.  Some think that the whole process may take several hours.  Others will believe that the examiner will hurt them (either by design or accidentally).  Some won’t know what to think.

Not infrequently, patients express surprise than an orthopaedic examination can be accomplished efficiently and without causing any great discomfort.  I am not sure why they think this.  Maybe it is because of prior experience?

In essence though, it is possible to perform a thorough orthopaedic examination efficiently and almost painlessly.  Careful attention to detail, being aware of patients’ reactions and exercising proper professional skill can usually elicit all the necessary findings with a painless process.

Lead Article – August 2021

You Can’t Be Serious!

You will all recall this famous phrase, commonly attributed to John McEnroe. Whilst I would never publicly condone poor sportsmanship, especially in the public arena, I did derive great pleasure from the antics McEnroe displayed when a probably blameless umpire was the subject of his wrath.

Some plaintiffs feel the same. Many have been subjected to quite significant injuries which have had a major life-altering effect for a period of months and possibly years.

Mother Nature and her biological assistants are very clever however. Even serious injuries can heal with little or no adverse effect and a decade or two later, it can be quite difficult to discern any discrepancy in function.

Whilst decades of observation have led me to this belief, it is impossible to convince a plaintiff in the early phases of rehabilitation that such an outcome will eventuate. Understandably, the plaintiff or his/her legal advisor will express incredulity.

Whilst I have great sympathy for the situation, the natural history of many injuries is such that near-normal function can be restored. In fairness to all stakeholders, it is only reasonable that the compensation cart rewards the long-term reality.

Case Vignette – August 2021

Horses are Heavy

A 28-year-old secretary was visiting a local winery on a Sunday afternoon. By all accounts, she enjoyed herself enormously. The food was excellent, the wine flowed copiously and although she was able to walk to her car, considerable aid was required.

She demanded a detour en route to the car park. She had spied three chestnut geldings in a nearby paddock. Imbued with both liquor and love for animals, her approach was too close. The nearside front hoof of one of the big fellas trod on her sandalled toes.

Her state of inebriation was such that she probably didn’t feel a lot, although three of her digits were amputated immediately and the remaining two looked quite dusky. Over the next several weeks, one of those two toes required amputation but the fifth digit (her hallux or great toe) was saved.

Many months of rehabilitation followed and her claim included Post Traumatic Stress Disorder.

Although there was no padlock on the gate to the horses’ paddock, it was firmly closed and required two hands to disengage the catch. There was also a small sign warning guests about entering the paddock and identifying it both as private property and a container of danger.

Whilst everybody was very sympathetic, her claim was ultimately unsuccessful. It just goes to show – not all long lunches end well.

General Advice – August 2021

You Get What You Pay For

I have touched on this subject before.

I recently received a request to perform a medicolegal examination (dealing with alleged medical negligence) by a medical defence organisation. Accompanying the letter of instruction was a memorandum dealing with fees.

That memorandum quoted a fee structure that the soliciting agent would find acceptable and also expressed a direction that all fees would be at the “lower end of the scale”.

Every purchaser has a right to deem what is fair and reasonable. That opinion however does not oblige a supplier to comply.

I foresaw problems with this particular agent and therefore declined to be involved. I assume they found some “cut price” reporter around another corner.

Lead Article – July 2021

“Over a Period of Time” Injuries

It is timely that we revisit this particular topic. Claims are becoming more frequent, the cases are more complex and the outcomes are even less certain.

Causation is so much easier to identify when a single specific accident results in a constellation of injuries. For example, a worker falling from the eleventh storey of a construction site is reasonably likely to sustain multiple injuries involving both the appendicular and central skeletons. Soft tissue wounds are likely to occasion that smorgasbord of fractures.

Conversely, a worker who performs relatively menial, sedentary tasks over a period of a decade yet complains of neck pain, lumbar pain, wrist pain, shoulder pain and elbow discomfort as a result of those work practices is far more difficult to assess.

I suppose it is possible that some of those practices may give rise to discomfort but it becomes far less likely that true orthopaedic pathology will be witnessed.

Frequently, a thorough orthopaedic examination identifies some underlying constitutional, non-work related explanation for the symptomatic pattern. Whilst plaintiffs and their lawyers may cling to the concept that the entire malady has been caused by the decade at work, reality is unlikely to support them.

Whilst I expect “over a period of time” injuries to continue to present, requesting solicitors should be aware of the attendant difficulties and select their cases carefully. “No win, no fee” lawyers should be especially on guard.

Case Vignette – July 2021

Osteoporosis of Pregnancy

Osteoporosis refers to demineralisation of the collagen structure in bone. It presents clinically as fractures caused by minimal force and radiographically by bones that are far less radio-dense than normal. Whilst the condition is often associated with age, and in particular in females, it can also rarely be associated with the third trimester of pregnancy in quite young women. Mothers at or about the age of 30 years appear to be particularly vulnerable and it is during the third trimester that hip pain (either unilateral or bilateral) is noted.

The diagnosis initially requires a high index of suspicion and this is not always present with all obstetricians. The diagnosis is best made with an MRI scan examination and the treatment modalities will differ according to the extent of the lesion that is identified.

Ideally, the condition is identified in its earliest phases, before a fracture of the femoral neck occurs and before anything more than rest and observation are required.

Sometimes, if the diagnosis is delayed, a fracture of the femoral neck may ensue. If that fracture is incomplete or undisplaced, it can be managed relatively easily with internal fixation. This is an orthopaedic endeavour that is not usually very difficult. Most fractures will then go on to sound osseous union with little or no long-term sequelae.

The most undesirable state however is when the diagnosis is delayed, a fracture occurs, the fracture becomes displaced and the risk of non-union, delayed union or avascular necrosis of the femoral head increases exponentially. If the fracture is displaced, many of these patients will eventually require a total hip replacement.

Whilst the hip replacement will solve the problem initially, it is an undesirable operative intervention in somebody who is in their early thirties. Hip replacements have a finite life span and theoretically, 10% of those patients will require a revision by the time they are in their early fifties. Of those, a further 20% will require a second revision in their seventies. Even a third revision may be required in the patient’s eighties, given actuarial longitudinal life studies that exist today.

It is important therefore that all clinicians involved in obstetric care have at least a high index of suspicion for this unusual and uncommon condition. Early diagnosis, proper orthopaedic care and judicious rehabilitation can effect an excellent outcome. If any or all of those elements are absent, the outcome can be far from desirable.

General Advice – July 2021

Patient Demeanour

All of us are subject to bias. Even the most revered of judges in the Supreme Court will have some preconceptions based upon past experiences in life.  Orthopaedic surgeons are no different.

Patients who whinge, whine, carry on to the extreme and embellish extraordinaire are less likely to be taken seriously than an individual who presents in a mainstream manner.

Very occasionally, patients are seen at the opposite end of that spectrum. They have been subjected to exceedingly severe injuries yet complaints literally have to be dragged out of them. It is this latter group, as rare as it is, that often evokes the most sympathetic reports from even the most hardened orthopaedic surgeons.

I am not suggesting that you advise your plaintiffs to “toughen up” excessively, but embellishment should also be discouraged.