Category Archives: July 2017

General Advice

Hysterical Orthopaedics

3 (b)

The word “hysteria” has specific psychiatric connotations.  Patients who are thought to suffer with hysteria sometimes present with so-called conversion disorders.

In the orthopaedic paradigm, patients may present with fixed contractures, for example of a hand or fingers, as a result of complete non-use for a protracted period.  That period can be in the form of years.  As a result of holding the hand in a curled-up position across the front of the torso, permanent contractures form and the digits can simply not be extended.  I have seen such a case.


How Does it Arise?


Although there may have been a precipitating injury, it is often of relatively minor extent.  It is not the sort of injury that would result in such a devastating outcome.  Instead, rather than being of a physical origin, the malady is more likely to be of a psychiatric origin.

That does not mean that the patient is not impaired and neither does it mean that the patient is not seriously disabled.  It simply means that the causative inciting agent has complex overtones other than those of a purely orthopaedic nature.

You should be seeking the advices of your favourite clinical psychiatrist in fully assessing these cases.

Lead Article

Social and Recreational Activities


Whilst most attention in personal injury and medical negligence claims focusses upon impairment assessments, causation, economic loss and future therapeutic needs, it is also reasonable to assess losses of social and recreational enjoyment that may follow a traumatic incident.


Some plaintiffs are extremely active and were so up until the time of their subject injury.  Many are outstanding golfers, engage in triathlons or regularly have overseas jaunts for snow skiing and touring.  A serious injury with ongoing impairments and disabilities may permanently diminish or even remove the ability for the injured plaintiff to return to some semblance of lifestyle activity.

Your orthopaedic expert is well positioned to assist with this analysis.  Whilst some injuries are truly irretrievable, the adverse effects of others can be diminished quite significantly by the provision of splints, braces, orthoses and prostheses.  A stiff, painful ankle could be splinted, allowing a return to some limited bush walking and hiking.  Advice can also be offered on modified techniques to accomplish tasks which were previously taken for granted.  The provision of a motorised golf buggy for example may allow a previously keen golfer to make at least a limited return to that favoured recreational pursuit.

At a personal level, I believe that addressing this important issue of social and recreational capacity is a vital part of any medicolegal report.

It is vital that the expert listens to the plaintiff.  Establishing an easy rapport facilitates the gleaning of these personal details.  Some patients are more adaptable than others.  Relatively trivial injuries to some may invoke major lifestyle changes for others.

Separating genuine complaints from self-serving exaggeration is equally vital.  You will benefit from engaging an expert who is experienced, sympathetic and realistic.

Case Vignettes

But He Didn’t Hurt His Ankle!

long leg cast

The plaintiff sustained a fracture involving the upper end of his shin bone.  It was managed successfully, it had united without difficulty and the expectation was that he would return to symptomatic normality.

His claim however centred upon his ipsilateral ankle.  He complained of pain, swelling and stiffness which interfered with his ambulatory capacity and compromised his future economic prospects as a labourer.  READ MORE


“You Can’t be Serious!”


The insurer was incredulous.  How is it that this upper shin fracture has given rise to such a debilitating problem with the ankle?

Well, the therapeutic regimen was of a non-operative nature and it included the application of a long leg cast for a four month period.  The cast was not well applied and the ankle was fixed in a downward position (plantar flexion) for that entire duration.  Secondary capsular contractures formed and inadequate attention was paid to the problem following removal of the cast by the physiotherapist.

At the end of an 18 month period, the ankle joint remained quite stiff and the capsular contractures appeared to be solid.

Whilst uncommon, this is a recognised sequel to the inappropriate positioning of the joint for a prolonged period without proper rehabilitation.  Although the ankle itself may not have been injured at the time, the sequence of events which has followed renders the ankle malady as being of a compensable nature.  The causative link is indirect but real.