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April 2018 – Case Vignette

Case Vignette

Multiple Injuries In The Lumbar Spine

The AMA 5 Guides recommend that expert reporters quantifying impairments use the so-called “Diagnosis Related Estimate Category” method for assessment.  There are several reasons for that recommendation.  One relates to the potential for unreliability when assessing ranges of motion of the lumbar spine.  The assessor may be mistaken or alternatively, the patient may be inconsistent and/or even overreactive.  The use of the Diagnosis Related Estimate Category system assists in levelling the playground for assessment.

 

The Guides however are equally specific in their advice concerning multiple injuries in the same vertebral column segment.  That is to say, if there are two or more discrete injuries in the lumbar spine, it is not the Diagnosis Related Estimate Category that should be used but rather, the Range of Motion method.  For example, if there is a fracture of the transverse process, a fracture of a vertebral body at L3 and a fracture of a lamina at L5, it is the Range of Motion method that should be used.

Multiple lumbar vertebrae fracture

There are two steps to the Range of Motion analysis.  The first relates to measuring the losses as a result of the specific fractures according to Table 15-7. There are separate sections within that Table that make reference to fractures of posterior elements, a vertebral body, disc lesions or forward slippage of one vertebral body on the other (spondylolisthesis).

l5 s1 mri

In addition to quantifying the loss related to the two or more discrete injuries in that lumbar spine, the reporter must also measure the ranges of motion in the sagittal and coronal planes.  Rotation should also be measured, especially in the thoracic spine.

 

The losses measurable using Table 15-7 and the losses measurable related to the restrictions in range of motion are then combined using appropriate Combined Values Tables to yield a final functional whole person impairment.

 

This can lead to confusion amongst reporters.  It is confusion that causes disagreement and usually, it is disagreement that compounds the processes of mediation and Court trials.

l5-s1 xray mild

It is most useful for all involved if your expert reporter is not only familiar with disorders of the vertebral column, but also the proper use of the AMA 5 Guides.

 

April 2018 – General Advice

GENERAL ADVICE

Where Does Medicolegal Experience Come From?

 

The answer is pretty obvious.  From all sorts of places, really.

 

From the medical perspective, competence is directly proportional to experience.  That is not to say that the two equal each other but as medicolegal reporters age and gain experience, so do they refine their process and diminish or even eliminate obvious errors, commissions or omissions.  There is an adage that “Good medicolegal reporting comes from experience, experience comes from bad medicolegal reporting”.  It would be a very unusual medical practitioner who engages in medicolegal reporting who has not make a few mistakes.  It should be hoped that the reporter has learnt.

Nero

From the legal perspective, experience is also important.  Whilst the legal aspects of managing a claim are well outside the medicolegal reporter’s domain, so is a precise understanding of anatomy, physiology and pathology quite difficult for many lawyers.  Whilst I am surprised at just how much medicine some of my senior legal colleagues know and understand, there will always be some voids and deficits.  There is a number of relatively easily digested texts that deal with medicolegal issues and which explain some of the nuances of injury, impairment and disability.  Another useful port of call is to telephone your friendly medicolegal consultant.  This type of dialogue assists both sides.  There is no property in a witness.  There is no reason why these frank discussions cannot occur.  Provided the rules of evidence are obeyed, considerable mutual assistance can be gleaned.

Penguins

April 2018 – Lead Article

LEAD ARTICLE – APRIL 2018

How Useful Are Past Medical Records?

 

I usually answer “vital” but there are some obvious exceptions.

 

When assessing a functional loss or quantifying an impairment, and attributing that loss or a component of the loss to a compensable event, it is important to measure any loss that may have predated the subject accident.  This process of apportionment is often overlooked and can lead to unrealistic expectations and wasteful expensive litigation.

 

Conversely, past medical records can be misleading.  I recall appearing as an expert witness in the District Court in Mackay many years ago.  I had flown up the evening before and dined with the barrister engaged by the solicitor who had requested my attendance.  I remember the evening well.  We dined on mud crabs.

cooked mud crab (1)

The case was first on the list the following morning and we duly arrived just before 10:00am.  The barrister that was taking my evidence in chief was acting for the defendant.  The plaintiff had allegedly injured his back in a lifting incident whilst working at one of the local cane mills.  As we walked up the steps of the District Court in Victoria Street, the barrister informed me he had read somewhere in the past medical history that the plaintiff had sustained some form of back injury.  I made a mental note.

 

During the course of the examination in chief, the barrister with whom I had dined mentioned this past history of back problems and questioned whether or not that could have been responsible for his current circumstance rather than the accident in question.  I foolishly answered “yes”.

 

My response was foolish for several reasons.  The first was that I had not taken a history from the plaintiff about this particular event that had allegedly occurred prior to the subject accident, I had not read the notations to which the barrister referred and had no idea about the significance or otherwise of this antecedent problem.

 

The barrister undertaking the cross examination appeared to be about as naïve as me.  He did not bring it up either.

35630932 - dvd drive on laptop computer.

35630932 – dvd drive on laptop computer.

 

My come-uppance was brought about by the District Court judge himself.  At the conclusion of the cross examination, His Honour asked me for more detail about this past medical history and how it could have an effect upon the opinion that I had previously proffered.  He produced the documents in question and it was revealed that the patient had previously suffered with a mild episode of coccydynia.  This is a condition that affects the coccyx and not specifically the lower lumbar spine.  Apparently, the condition had arisen “out of the blue” and without any precipitating traumatic event.  There was no previous history of previous back problems and my unwise apportionment of blame was exposed for the worthlessness that it contained.  This was a most embarrassing moment.

 

It was one of many lessons that I have learned.  Whilst past medical history is of vital importance, it deserves to be carefully scrutinised.  Whilst it may be of some value in the final analysis, it may be totally unrelated.  I have not made that mistake again.

thumbnail_doctor showing x-ray plates to patient

Case Vignette – April 2019

CASE VIGNETTE – APRIL 2019

An Evening At The Broncos

Try to imagine a winter’s afternoon, a Friday, at about 5:30pm. I was sitting in my consulting rooms on Wickham Terrace with my back to the window. The window gave a splendid view of the city lights. Seated opposite the desk was a young couple, probably in their late thirties or early forties. They had two children, both boys, aged 11 and 8.

The wife was the patient. She gave a six weeks history of lower back pain which was almost constant, definitely disturbing her sleep and without any particular radiation into the lower limbs suggestive of a sciatica. She had been reviewed by her general practitioner on numerous occasions, had undergone a month of physiotherapy and had also attended a chiropractor.

Senior male doctor looking at worried couple. Man is consoling sick woman. They are sitting in hospital.

Clinical examination revealed some tenderness in the lower part of her lumbar spine and in particular, lateral to the sacroiliac joint. This joint is made up of the sacrum (which is part of the vertebral column) and the hemi-pelvic wing on that side.

I looked at the radiographs. Those of the lumbar spine were unremarkable. The CT scan examination that had been arranged was also within normal limits. There was no sign of any disc narrowing, disc bulging or neural compromise.

What I did see however caused considerable alarm. It was on the left side, medial to the SI joint, and involving the sacrum proper. The lesion was approximately 5cm across and it looked as though a small shark had taken a bite. This was her first presentation with breast cancer. This was a secondary deposit in the pelvis, destroying bone and heralding a premature end to her life.

thumbnail_Conventional-radiograph-of-the-pelvis-revealed-an-osteolytic-lesion-arrows-with-a

The cause for this problem was clearly outside my purview. I broke the news as gently as I could, I made several telephone calls while they sat in my office and I made arrangements for her to be seen by both a breast surgeon and an oncologist the following morning, the Saturday. It was obvious that they were grateful but more importantly, they were overwhelmed with grief.

The level of grief, its intensity and its sudden onset were all understandable. There was however a dimension that I had not expected.

The four of them (the husband and wife with the two boys) were en route to a home match of the Broncos. They were trickling down the hill towards Lang Park. They were going to stop for a bite to eat at a hamburger joint on the way. The family was very excited.

thumbnail_Broncos Rugby

Amongst the myriad of thoughts passing through the minds of this young couple was how they would go out into the waiting room and break the news to the boys. Would they hold the news until tomorrow so that the boys could enjoy the Broncos match, would they tell the boys but still go to the match anyhow and try to enjoy themselves, or would they tell the boys and simply abort the evening and go home?

To this day, I cannot quite remember what decision they made. I do remember though feeling the grief for them. I suppose there is half a dozen memories I have like this after 40 years in practice. You will understand that these memories just never fade.

Case Vignette – August 2018

CASE VIGNETTE – AUGUST 2018

A Simple Stumble – A Lifetime Of Misery

I recently saw a 45 year old male who sustained a knee injury whilst leaving work one afternoon.  The injury occurred in winter of 2015.  It was only 5:45pm but it was already dark.  He was leaving a donga on a work site in central Queensland.  There was only one step from the donga down to the uneven ground below but somehow, he tripped and fell.  He did not actually roll onto the ground but instead, took all of his weight on his right foot with his knee joint partially bent and his torso twisting to one side.  He experienced immediate pain.

Sep 18 CV - man about to trip on yellow metal beams

He was helped by friends, taken to a local hospital, spent the night in bed with analgesics and elevation, and was then referred to a regional centre for further assessment.  He had sustained fractures involving the upper end of his shin bone (the tibia) and both sides of the tibia that contributed to the knee joint (the tibial plateaux).  The fractures were displaced and the joint surface was no longer pristine and smooth.  The treating surgeons opened the fractures, reduced the fragments as best they could and used metal plates and screws with some biosynthetic bone graft in an effort to reconstruct the upper end of the shin bone.

As valiant as the efforts were, a so-called anatomical reconstruction could not be achieved.  Over the next 20 months he was subjected to braces, physiotherapy, crutch ambulation, analgesic ingestion and several programmes of rehabilitation.

Aug 2018 CV (a) and (b) LL films

As nature would have it, the fractures did heal but the joint surface was no longer smooth or congruous.  In addition, the soft tissues had been damaged quite severely and whilst the ligaments remained intact, the surrounding capsule became adherent to the lower thigh bone and upper shin bone.  The knee joint became stiff, painful and swollen.

 

Now it’s early days but clinical and radiographic examinations confirm that this knee joint is not retrievable.  He is likely to require a total knee replacement within the next couple of years.  That puts him in his late forties, and this is very early for this type of operative intervention.

 

When total knee replacements are performed in patients in their sixties, the arthroplasty or artificial joint has a survivorship of approximately 90% at 20 years.  That is to say, only 0.5% of these joints fail annually.  Failure is defined as the joint requiring revision or a second replacement.

 

The results of knee replacements in younger men are not quite as good.  His failure rate could actually be twice that.  By the time he is 70 therefore, he has a 40% chance of that joint requiring revision.  The primary replacement would have cost in the order of $50,000.  The revision will involve costs in the order of $60,000.

 

Apart from the knee, this poor fellow was otherwise in excellent health.  There is no reason to believe that he may not live until his mid-eighties or even longer.  In fact, his father lived to 101 and his mother, whilst dying in her early seventies, was fatally injured in a road traffic accident.  In other respects, it is probable that she would also have lived until her late nineties or even beyond.  This chap’s genetics therefore are such that he could also live at least that long.

 

That therefore raises the spectre of him requiring a re-revision.  Costs in the order of $70,000 may be involved.  He may have a 15%-20% chance of requiring this re-revision.

 

Aug 2018 CV - 4 knee films

Added to the complexities of these surgeries is the risk of complications.  Arteries or nerves may be damaged, he may suffer with deep venous thromboses or emboli travelling to the lungs, he may suffer a stroke or even a debilitating cardiac event.  The infection rate for the primary arthroplasty is only about 0.6% but with the revision and the re-revision, the infection rate may double, treble or even quadruple.

 

This simple fall therefore has the ability to open up a very unpleasant further 40, 50 or even 60 years.  Unless your reporting expert is aware of these scenarios, your client is at risk of being severely under-done at the time of settlement.  Choose your expert wisely.

 

Case Vignette – August 2019

CASE VIGNETTE – AUGUST 2019

Lovers’ Heels
How many of you have heard of this injury – Lover’s Heels?

In simplest terms, it refers to fractures of one or both of the calcanei or heel bones. It is classically sustained by a male who has been unexpectedly found in a bedroom with another man’s wife. As the husband of the household ascends the steps to the bedroom, the lover jumps from the bed, runs to the verandah and leaps over the railing. Landing on the concrete driveway three metres below gives rise to this awful injury.

man jumping off balcony

Heel fractures are particularly troublesome in orthopaedic surgery. They give rise to extreme pain and extraordinary swelling. Bed rest, elevation, ice and analgesia are the hallmarks of early treatment, especially if the fracture is extensive and comminuted (many fragments).

The calcaneus or heel bone forms a very important joint with the ankle bone or talus. This so-called “subtalar joint” allows the heel to move inwards and outwards when walking over uneven terrain. If this movement is restricted as a result of post-traumatic arthritis, walking becomes particularly arduous and almost impossible on soft sand, construction sites or through the bush.

calcaneal-fractures

Whilst these fractures can be opened surgically, pieced back together a little like Humpty Dumpty and held in position with plates, screws, wires and other devices, the joint between the talus and the calcaneus is often left irreparable.

heel fracture

The salvage operation is in the form of a subtalar fusion or arthrodesis. Arthrodeses are very important in that they convert a stiffish, painful joint into a stiff, painless joint. The afflicted individual loses the 10° or so of inversion and eversion of the heel, but also loses the pain. It is a most attractive trade-off.

My advice to men in this situation is initially to avoid it altogether but if the attraction is so great, stay in bed and just face the music. It’s likely to be less painful than the calcaneal fracture!

violins

Case Vignette – December 2018

CASE VIGNETTE – DECEMBER 2018

ASSESSING SPINAL INJURIES USING THE AMA 5 GUIDES

Chapter 15 of the AMA 5 Guides explains specifically that whenever possible, the Diagnosis Related Estimate method should be employed. For example, if there is a fracture of L3 that has given rise to a loss of 30% of normal anterior body height, the assessor would refer to Table 15-3 on page 384. Fractures that give rise to a loss of 25%-50% of normal anterior body height quality for DRE Lumbar Category 3 with a range of 10%-13% of whole person function. That range allows the assessor to make some allowance for associated pain and discomfort. A patient who has sustained such a fracture but is otherwise relatively unscathed, would be assessed at the lower limit of the range and given a 10% whole person impairment rating. Conversely, another patient with that same fracture but who has near constant pain and considerable difficulties with a broad spectrum of activities of daily living may rate at the upper limit of that range and qualify for a 13% impairment assessment.

L3 fracture xray

Consider however the patient who has more than one fracture within the lumbar spine. Let’s say that there is a loss of 10% of anterior body height at L1 as a result of a compression fracture with another loss of 30% of anterior body height at L3. In this circumstance, the AMA 5 Guides instruct the assessor to use the “Range of Motion” method. This is best outlined in Table 15-7. It appears on page 404. The fracture at L1 (a loss of 10% of anterior body height) would qualify for a loss of 5% of whole person function. The fracture at L3 with a loss of 30% of anterior body height would qualify for a loss of 7% of whole person function. Those two losses would be combined to yield a loss of 12% of whole person function. In addition, the assessor must also make allowances for any restrictions in range of motion. Tables 15-8 ad 15-9 make allowances for losses of flexion, extension and lateral flexion to the right or left. This is a more complex analysis but is demanded by the AMA 5 Guides because there is more than one segment within that same region of the spine which has been injured.

lumbar fractures xray

To make it even clearer, if there was a fracture in the cervical spine, a fracture in the thoracic and a fracture in the lumbar spine, the assessor would still use the Diagnosis Related Estimate Category method and refer to Tables 15-5, 15-4 and 15-3 respectively. It is only when there is more than one fracture in the same region (cervical, thoracic or lumbar) that Table 15-7 is used.

Case Vignette – December 2019

CASE VIGNETTE – DECEMBER 2019

Even Santa Claus is Vulnerable

Folklore has it that Santa became stuck in the chimney of an old house in East Brisbane in December 2017.

There was no particular obstruction in the chimney flue itself but he was obese, his sack was heavily laden and the bells on his waist became caught on the roughened interior.

Fortunately, Santa could breathe but his cries for help were muffled and the terrified children who found him soon after dawn were understandably shocked.

The Emergency Services were able to retrieve Santa and took him to the Princess Alexandra Hospital. Whilst radiographic examinations excluded any fractures, his left lower limb had been caught in a fully flexed position and the blood supply to the muscles below his knee had been seriously curtailed for more than four hours.

It became apparent during Christmas Day that Santa had a compartment syndrome. Despite immediate decompressive fasciotomies, multiple operative procedures thereafter with skin grafting and expert care, his limb was deemed to be non-salvageable. Santa was subjected to a below knee amputation in the third week of January.

Even though this case is rare enough to be worthy of a report, the scenario is quite well recognised. Inebriated revellers can fall asleep on a toilet, fall in remote locations without assistance, or be otherwise denied prompt therapeutic intervention, resulting in significant functional losses.

Whilst Santa was eventually successful with his personal injury claim, I suspect that these events will eventually disappear from our radar. I further assume that Amazon will take over Santa’s delivery role in the future and with proper workplace health and safety initiatives, we may no longer see this type of injury.

Case Vignette – February 2019

CASE VIGNETTES – FEBRUARY 2019

Who Would You Get To Do Your Hip Replacement?

Lawyers typically know which fellow practitioners are good and those who are not. Whether the need is for a commercial litigator, a mediator, a criminal lawyer or a family law advocate, all of you will know just who to go to and when.

Orthopaedic Surgeons should be the same. Unfortunately, some surgeons will themselves require surgical intervention from time to time. The key question then is, who do you trust?

doc queries

question marks

This can be more difficult than you might imagine. Personality obviously has a role to play but ultimately, most of us want an expert technician with a low complication rate and with a reputation for producing results that yield a long-term survivorship or outcome.

Not many Orthopaedic Surgeons visualise other surgeons operating. Trainees are usually well-positioned because they have an opportunity to assist many Consultants in a variety of settings. Consultants themselves however are often busy at the coalface and do not spend much time in the presence of their colleagues in the operating theatre environment.

The Australian Orthopaedic Association National Joint Replacement Registry collates outcome data following hip replacements, knee replacements, shoulder replacements and knee joint anterior cruciate ligament reconstructions on an annual basis. Contribution rates by surgeons in Australia are close to 100%. Longitudinal analyses are possible and observers are therefore able to determine which surgeons are performing better than the average.

graph 2

 

graph

Next time you contemplate undergoing orthopaedic surgery in the form of a joint replacement, ask your surgeon how he or she fares at a national level.

Case Vignette – February 2020

CASE VIGNETTE – FEBRUARY 2020

Indolent Infection  Following Serious Orthopaedic Injuries

Bacterial infections continue to give rise to significant difficulties with orthopaedic surgery, whether it be in the emergency setting or at the time of elective operations. The pivotal work of Fleming and Florey bringing penicillin to market in the first two or three decades of the last century made a significant change to the outcome of surgical endeavours. Research and development by the major drug marketing companies has brought a plethora of new and different types of antibiotics into the market.

Unfortunately, our bacterial adversaries are extremely clever in the way they mutate and learn to overcome the obstacles presented by the antibiotics, and thereby thrive in the post-surgical setting. Some of the difficulty is of our own doing. There are practitioners who will use antibiotics unwisely, patients who do not always take a full course, and bacterial whose virulence sets them apart in their ability to develop resistance.

So serious is this problem that as we enter the next decade, it is likely that we will witness infections even in our own community with bacteria expressing resistance to every chemotherapeutic agent at our disposal.

Most infections are obvious. They are accompanied by pain, redness, swelling, an increase in temperature and often a discharge (whether it be serous or pus). Other infections however are vastly more subtle and can remain indolent for weeks, months and even years.

For example, it is possible to have an osteomyelitic bacterium that has lay quiescent in sequestrum in a bone for some decades. It is only when that sequestrum or local deposit is disturbed (say at the time of an injury with a fracture or at the time of undergoing a hip or knee replacement) that the bacterium is again released, prodded into action and a spectacular infectious result is witnessed.

Whilst non-operative modalities such as the use of antibiotics are of great importance in fighting infections, it is the scalpel which is the most effective of all tools. Abscesses should be drained, dead and devitalised tissue debrided or removed and vascularisation of the local region maximised.

This has very special medicolegal implications. There is a risk that a patient may be deemed to have achieved the state of Maximal Medical Improvement. The condition could be thought to be both stable and stationary. A claim could therefore be closed prematurely. The recurrence of an indolent infection after claim closure could result in significant morbidity, great financial imposts and even mortality. It is worthwhile ensuring that your medicolegal expert always considers this possibility when formulating a report.