CASE VIGNETTE – MARCH 2020

Past History Is So Very Important

I recall seeing a patient who was injured in a road traffic accident whilst descending the Toowoomba Range on a very powerful Harley Davidson motor cycle.

It is likely that the accident was not her fault and she was seriously injured.

When assessing her three years later, and after she had reached that magical state of maximal medical improvement, I noted that she had very severe thigh muscle wasting. The right thigh was 4cm less than the left thigh in girth at a position 10cm above the superior pole of the patella. This was quite significant, given that she had a body mass index of only 22. She was relatively trim.

She had been categoric in her denials of previous problems referable to the thigh or any problem in the region of the lumbar spine, the hip joint or the knee joint for that matter which could have explained thigh muscle wasting. In the absence of any evidence to the contrary therefore, I attributed the muscle wasting to the subject accident. This gave her an impairment rating of 5% of whole person function for the wasting alone.

There was some delay in bringing her case to mediation and it was necessary to re-examine her for a contemporaneous report. In the interim, she had been examined by another Orthopaedic Surgeon who had been more successful than me in gleaning a totally accurate past medical history. It transpired that the muscle wasting in the thigh had predated the road traffic accident on the Toowoomba Range by several years. She had even been reviewed by a Neurologist and an EMG/nerve conduction study had suggested that there may have been some central cause in either the cauda equina or the spinal cord itself.

This failure to mention this important point at the time of my original examination was a very serious oversight on the part of the Plaintiff. It cast doubt upon her credibility, obviously compromised the accuracy of my original opinion and probably served her no good at all when the case did come to mediation.

I am uncertain about how the matter was finally settled. Suffice to say, it would have been better for all concerned had she been totally honest from the outset.

Case Vignette – March 2021

Implant Breakage

Total hip replacements have been performed in one form or another for about a century. By comparison with current standards, the early implants were quite naïve and often failed rather quickly.

Professor Sir John Charnley made pivotal advances with material sciences and techniques in the 1960’s. He is recognised as being the modern father of hip replacement surgery.

Joint replacements do fail. Loosening, infection and wear are three of the possible causes.

During the latter part of the twentieth century, implant breakage was also a phenomenon that was recognised. It was never common but unfortunately, it did occur.

Understandably, civil actions sometimes ensued and the surgeon was deemed to be liable. In Australia, hip replacement devices are scrutinised by the Therapeutic Goods Administration and if deemed to be safe and acceptable, are listed on the Australian Register of Therapeutic Goods. Provided the surgeon involved uses the device as it has been designed (and not in a so-called “off market” mode), then the surgeon is probably guilt-free should that device subsequently fail.

The problem lies with the Therapeutic Goods Administration. Its charter obliges the organisation to be competent in the assessment of both the safety and efficacy of these medical devices. It is a gargantuan task and one that is not easily accomplished.

“PIC/S Guide to Good Manufacturing Practice for Medicinal Products, PE009-14, 01 July 2018
23 July 2020
Section 36 of the Therapeutic Goods Act 1989(link is external) allows the Minister for Health to determine Manufacturing Principles that are to be applied in the manufacture of therapeutic goods”.

The Australian Orthopaedic Association has a National Joint Replacement Registry which chronicles the performance of joint replacements. Quite often, under-performance can be recognised early (albeit in the post-market surveillance arena) and early signs of premature failure may be witnessed.

The National Joint Replacement Registry has become a most valuable tool for Orthopaedic Surgeons in Australia.

Case Vignette – March 2022

I Sometimes Change My Mind

Prior to seeing a patient for a personal injury claim, I read the available documentation. This includes hospital and medical notes, recordings from the general practitioner and importantly, specialty notes and reports. Understandably, I form an opinion about the matter before I actually see the plaintiff. I almost always do it. I can’t seem to help myself.

Frequently, after taking a full history, performing a thorough physical examination and reviewing the ancillary investigations, my mind is changed, sometimes through 180°.

There will be many reasons for this seismic shift and they include the failure of some experts to have had access to all of the relevant data, misinterpretation of data, the failure to glean a proper history and the basing of opinions on falsehoods.

Far from finding this circumstance distressing, I find it very refreshing. Whilst I am tempted to pre-judge, I genuinely endeavour to keep an open mind. This is one form of evidence that I might be successful.

CASE VIGNETTE – MAY 2018
Who Fractured My Femur?

My heart went out to this 78 year old lady. She had undergone a total hip replacement about six years previously. It was never much good from the start. She was hospitalised for seven days in the public sector in Queensland and on the day of her discharge from hospital, the wound was still weeping copiously. She was visited on a second daily basis by a community nurse and wound dressings were applied for almost four weeks.

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She awoke one morning just after 3:00am. The wound had burst open, her bed was filled with creamy pus and the pain was excruciating. She had suffered with a post-operative infection around the hip replacement and the abscess had burst.

Over the next 18 months, she was subjected to no fewer than seven operations. The first six of those operations were directed at debriding the infected tissue, lavaging the joint, using antibiotic-laden acrylic cement beads as spacers, and even having the joint continuously flushed with a detergent-containing solution.

The seventh operation was to remove the hip replacement implants themselves. It was during the course of this seventh operation that her thigh bone was fractured.

She thought that things couldn’t get much worse. Obviously, they did. Not only was she left without a hip joint and with a large gaping wound in her buttock, but now she had a thigh bone that was broken, unstable and painful. Whilst uncommon, unfortunately this sequence of events can occur. There has been no malicious intent, no true negligence and in all probability, no chance for a claim.

The consenting process to which she was subjected was generic in nature. It did not mention specifically the femoral fracture which occurred during that seventh operation. The real question however is “Even if it had been mentioned, would she have refused the seventh operation?”

In all reality, she probably would not have refused it. She had few other options. She relied upon her Orthopaedic Surgeon to be as careful as possible. Despite maximal care, these complications sometimes occur.

There is no real solution to this conundrum. The sequence however should have a sobering effect upon all of us. Any type of orthopaedic surgery is serious, risks exist and complications can occur.

I recall when I was much younger that one of my senior mentors gave me some advice. He said that “All orthopaedic conditions should be managed without an operation – unless a true indication for an operation exists”. Sage advice indeed!

CASE VIGNETTE – MAY 2019

The Issue Of Causation – Direct And Indirect

I recently saw a chap who sustained an exceedingly severe compound fracture dislocation of his ankle. In fact, his foot was almost ripped off. The photographs that he displayed showed the lower end of his tibia (the shin bone) protruding through a large wound in the skin with the foot dangling posteriorly, with the ability to swing in mid-air. It was an awful injury and despite the passage of two or three years, five expertly performed operations and extensive physiotherapy and rehabilitation, he was grossly impaired and disabled. It begs the question of whether he really should have undergone a primary below knee amputation at the time. That is a different issue.

The point is that he started to suffer with discomfort in the contralateral uninjured foot. He developed a so-called Morton’s neuroma. This is a swelling on a nerve in between two metatarsophalangeal joints. The metatarsophalangeal joints are where the toes join the forefoot. The nerve can be pinched between these two regions, giving rise to local swelling (a neuroma) and a burning sensation spreading down the inside of the adjacent toes.

There can be many causes for Morton’s neuromata. Suffice to say, many are “iatrogenic”. This is a term that we use when we simply do not know what the cause is.

It is tempting in this particular case to say that because he could not walk on his injured leg adequately for a prolonged period, he was placing additional stresses and strains on the contralateral foot, giving rise to this indirect causation of the Morton’s neuroma.

Temptation is insufficient. There is simply no orthopaedic evidence that such a scenario occurs or exists.

It is a belief that many plaintiffs and their lawyers hold. Disappointment is expressed when the concept is dismissed by the expert.

I remain sympathetic but unconvinced. In general terms, favouring one limb does not give rise to significant orthopaedic pathology in another limb.

CASE VIGNETTE – MAY 2020

Growth Plate Injuries and Their Importance

The long bones in our skeleton grow longitudinally. There are so-called growth plates at either end of the bone separating that part of the bone that forms a joint from that bone of the bone which forms the shank. The part that forms the joint is called an epiphysis and the part that forms the shank is called the metaphysis/diaphysis. The growth plate in between these structures is called the physis. The physis or growth plate is made up of cartilage in columns which grow incrementally with time. They continue growing until a person reaches so-called skeletal maturity. Longitudinal growth ceases, the cartilage ossifies (turns to bone) and the epiphysis is firmly united to the metaphysis/diaphysis. Further growth is impossible.

We refer to patients prior to closure of the physis as having an immature skeleton. This is in contrast to adults, who have a mature skeleton after the physes (physis plural) have closed.

Fractures in long bones can occur not only through the bone (the epiphysis, the metaphysis or the diaphysis), but can also occur through the growth plate or physis. These physeal or growth plate injuries can be exceedingly sinister. There are five or six types described and the classification most commonly used was one described by Drs Salter and Harris from the Sick Children’s Hospital in Toronto.

The importance of these fractures lies in the risk of the cartilage plate healing partly or wholly with a bony or osseous bridge.

If the entire physis heals with bone, longitudinal growth is lost at that particular level. This can result in limb length inequality with shortening at that site. There are several measures at the disposal of an Orthopaedic Surgeon to manage this potential for limb length discrepancy before skeletal maturity occurs.

The other risk (and probably of greater importance) is when only part of the physis heals with the bony bridge whereas the remaining part continues to grow longitudinally. This circumstance will give rise to an angular deformity, which can be much more deleterious to the functioning of the neighbouring joint.

2 color figures showing the correction of a femoral deformity of the knee in a child. Figure 1 shows a tension band plate in the medial distal femur with a 19° deformity. Figure 2 shows the deformity corrected w guided growth.

It is imperative that physeal injuries are recognised early and managed properly by an appropriate specialist. If your client is a minor, and has sustained an injury of this nature, ensure that your expert is on top of the case. What might appear to be benign and of no great significance now, can assume much greater significance in the future as longitudinal growth proceeds.

Case Vignette – May 2021

How Hard Do You Look?

I am referring specifically to past medical history.

I recently saw a plaintiff who was thought to have sustained a knee joint injury “over a period of time” as a result of the arduous work practices required of him.

These “over a period of time” injuries are difficult at the best of times. Without a precise description of a specific event, it is always difficult to link a clinical circumstance to something that is vague and almost ethereal.

Despite recognising these difficulties, in this particular case, two other experts had attributed his current condition wholly and solely to the work practices. Unfortunately, they did not delve deeply into the past medical history. The plaintiff had been a particularly active soccer player for a number of years playing at a high level, was a triathlete of some standing, a rock climber and an avid gym attender doing weights and circuits seven days per week. He had been doing all of these things for many years.

It is hardly surprising therefore that he did have some radiographic and MRI scan examination findings of degeneration within his joint. Whilst I have sympathy for his condition, it was just unrealistic to believe that six or weight weeks of work were totally responsible for his condition.

The question then is “how hard to you look at the past medical history”? I believe it requires careful scrutiny.

Case Vignette – May 2022

Do X-rays Lie?

With traumatic lesions, there is an old saying that the situation can “never be better than the worst x-ray”. There is much truth in this axiom. It means that if you can see a displaced fracture, then a displaced fracture exists.

What might be hidden however is an additional fracture (or even multiple fractures with comminution) and even more displacement. It cannot be better than what you are witnessing, but it could possibly be worse. That is the reason we engage in more sophisticated scans or multiple views of an afflicted region.

At a degenerative level, x-ray or radiographic changes take place over an extended period. Spurs, disc space narrowing, end plate sclerosis and facet joint narrowing in the lumbar spine take many years, possibly decades, to develop. Some patients will categorically deny any form of symptoms despite quite remarkably severe changes on their films. Whilst the correlation between these degenerative features and recognised symptomatology is not necessarily a direct line, or watertight, a relationship still does exist.

I don’t that think I have ever seen a patient with a severely diseased spine who does not have some discomfort, some stiffness and some disability.

CASE VIGNETTE – NOVEMBER 2018

Farm Accidents

II have harboured a long-held passion for all affairs of an agricultural nature. My interests extend to cattle, sand mining, sandstone quarrying and also viticulture.

When I was a lad, I had a motor bike accident and my ambulatory capacity has always been compromised.

Over the last few years, I have been galloping around the farm on a Segway. I expect all of you have seen a Segway and many of you have probably hired them when you have toured any of the major cities around the world. London, Paris, Rome, New York and San Francisco to name just a few all offer splendid inner central business district tours on these fantastic two-wheel devices.

My Segway is an X2. It has large, heavily treaded tyres and I can negotiate terrain of near impossible difficulty. It travels at approximately 20km/hour if I lean forward and breathe in and has a range of approximately 30km without a recharge of the battery.

Unfortunately, and like many aged farmers, I came a gutser. I was travelling near top speed along a gravel road when I lost control in a small dust storm. I was pitched forwards and sustained a significant gravel rash on my forehead. More importantly, my chest came in contact with the handlebars on the ground and I sustained a haemopneumothorax. My lasting memory of the event is my black labrador Nero snuggling into my armpit and patiently waiting until help arrived.

I raise the matter in this forum because agricultural accidents are becoming more common and more serious. Whereas in controlled factory environments or large construction sites in the city, safety regulations and practices are observed closely, that is definitely not the case on the average farm. A casual visit to a farm workshop will display a myriad of unsafe practices, materials and environments.

Regulation is designed to mitigate risk. I do not personally wish for greater interference in my agricultural activities. I already find the regulators to be a pest. This is one area however where greater regulation would probably help to save lives, reduce the frequency and severity of injuries and help preserve the funding corpus required for the health care of our nation.

I will be a reluctant supporter.

CASE VIGNETTE – NOVEMBER 2019

Military Service and Tribunal Claims

When attempting to link orthopaedic pathological conditions with previous military service, the issue of causation can be particularly vexing.

All too often, the nexus is quite nebulous. For example, a 70 year old male with exceedingly severe degeneration or spondylosis throughout the cervical spine, the thoracic spine and the lumbar spine would have great difficulty in convincing a Tribunal that his widespread disease is due to a heavy landing in a helicopter during a training exercise 45 years previously. Despite the obvious difficulty, I do see litigants attempting to bridge the gap!

In securing belief in causation, there are several features which can be very helpful. They can be summarised as follows:

1. A Specific Event

This refers to an injury or accident that occurs at a defined moment, resulting in an obvious outcome of an adverse nature and leading to a recognised condition.

2. A Temporal Link

As the time from injury to the onset of symptoms increases, so does the presence of a causal link become more tenuous. If the fellow in the helicopter accident 45 years ago had immediately complained of pain, had it recorded and had an unbroken link between the event and his current claim, causation could be more certain.

3. Adequate Investigation and the Making of a Diagnosis

Rather than some vacuous (over time) injury that had never been investigated and with a diagnosis never having been made, an individual presenting with clear investigation results performed in a timely manner and resulting in a secure diagnosis, again points to a causative link appearing more obvious.

4. Operative Intervention

If the injury or insult is of such severity that operative intervention is required immediately or soon thereafter (or at least with a traceable link into the future), acceptance of causation is also more likely.

5. Adequate Notations

Our 70 year old with the trans-vertebral column degeneration had not been consulting with a General Practitioner, had not undergone any other investigations as an interim measure, had not received any form of treatment and could not reasonably link the event from 45 years ago with his current presentation. Conversely, if excellent notes had been made at the time, if he had been a regular attender with a practitioner who had also kept good records, and if he had been subjected to reasonable and diagnostic investigations and followed an expected natural history, then his claim may have been more palatable.

In essence therefore, none of us have a crystal ball which guarantees accuracy. All we can do is estimate, interpolate and extrapolate. The more secure the evidence, the more likely it is that causation can be confirmed.