The Case of the Missed Fracture

Scaphoid fractures are relatively common after a fall on the outstretched arm and present with pain around the wrist, particularly at the base of the thumb, known in medical circles as the anatomical snuff box. These fractures require special x-ray views of the wrist and may not be obvious in the immediate aftermath of the fall with radiological signs developing over the next week. This is why it is common practice to place patients into a scaphoid fracture cast from just below the elbow to the hand, including encasement of the proximal phalanx of the thumb. If a fracture has been shown initially, the plaster may be in place for up to eight weeks, and longer under certain circumstances. However, most claims in negligence arise when a plaster or splintage has not been applied to the wrist, and the fracture picked up perhaps one to two weeks later following a re-referral to an Emergency Department, either by the patient or their general practitioner. Certainly, there may be a breach of the duty of care if the diagnosis was not entertained on the first visit and appropriate x-rays taken or, if x-rays were taken, and no fracture was seen or it was missed. However, if the fracture is picked up within one to two weeks and stabilised in plaster, or even after a month or so if x-rays showed that the scaphoid had healed, then, apart from some pain and suffering over the first few weeks, there is no significant consequential damage.

Scaphoid fractures may cause ongoing weakness of the wrist over a year or more after the incident with frequent complaints of an inability to lift weights such as shopping, a heavy pot or kettle. However, this is due to the fact a fracture occurred and not because of any delay in diagnosis and splintage. On the other hand, if the scaphoid bone does not heal and goes on to what is termed “non-union” leaving pain in the wrist, this may be evidence of consequential damage as there is a higher incidence of non-union in fractures which are not immobilised and stabilised at an early stage. Under such circumstances, a case in medical negligence may be entertained.

MDU figures for 2016 show that less than one in six actions in medical negligence actually succeed with the vast majority failing on the grounds of causation. It must be remembered that subsequence is not the same as consequence.

Initial screening is therefore essential to manage client expectations at an early stage. This avoids unnecessary effort and costs for all concerned. Too many cases are taken to Court with no chance of success. This is stressful for both the client and their legal advisor and indeed for the medical personnel involved.