One of the types of claim regularly encountered by clinical negligence lawyers is where patients have fallen on their hand, attended hospital and have been diagnosed with a sprain which later transpires to be what is known as a ‘scaphoid fracture’. A delay in diagnosis of such a fracture can have significant consequences and any competent primary care or emergency care practitioner should be alert to the possibility of such an injury.
The scaphoid bone is a small bone in the wrist and is usually damaged by direct impact – the classic mechanism being falling onto an outstretched hand. The bone has a poor blood supply and there can be significant issues with healing if it is not managed properly from the outset.
In any patient reporting a history of a fall or impact on an outstretched hand, and pain in the hand or wrist, the assessing practitioner should carry about a careful examination and look for signs of tenderness around the scaphoid area – particularly at the base of the thumb. The situation and option for diagnosis is complicated because fractures of the scaphoid bone often do not show up on X-rays carried out soon after injury – but will do on X-rays taken a couple of weeks later. Practitioners therefore cannot be reassured by a ‘clean’ X-ray of the wrist and if the history and area of tenderness is consistent with a scaphoid fracture, the patient should be managed as having a suspected fracture.
In these cases the wrist should be immobilised and repeat X-rays arranged if the fracture has not shown on the first X-ray. Once a diagnosis is made, if the fracture is undisplaced (ie the bones are not out of alignment), then often immobilisation in a plaster cast is the only management needed, although sometimes screw fixation is used. A fracture that has displaced usually requires open surgery and fixation and one of the risks of failing to identify a potential scaphoid fracture and immobilise the wrist is that the fracture displaces, meaning the patient has to have such surgery. The general consensus is that fractures which are not immobilised or fixed within the first few weeks post injury have a much lower chance of successful healing / union. Delays in diagnosis and correct management can therefore have a significant impact.
The other feature of delayed diagnosis is the risk of osteoarthritis. All scaphoid fractures carry a risk of osteoarthritis in the future but in a promptly and successfully managed fracture, this is only about 5%. In a fracture that does not heal properly, the risk escalates significantly and the patient is highly likely to suffer problems in the future, with a consequent impact on all day to day activities.
Philippa Luscombe, partner in the specialist clinical negligence team at Penningtons Manches, comments: “Most of the cases we have dealt with relating to a delay in diagnosis of a scaphoid fracture involve a classic history of injury consistent with this type of fracture. The reasons behind the failure to diagnose at first - and sometimes even second - attendance include inadequate history taking and / or examination, immediate diagnosis of a sprain without considering other possibilities and being reassured by normal X-rays when it is known that this type of fracture is not always visible early on. In some cases the delay is relatively short and the impact on the patient is limited. However, in others the delay has resulted in a need for major surgery and / or incomplete healing with long term pain and limitations in function. Some of these claims have settled for substantial sums, particularly where the injury is to the dominant hand.”
For further details on Penningtons Manches’ experience of claims involving emergency care and fracture management, visit the accident and emergency and orthopaedic claims pages. If you would like to discuss any concerns about management of a fracture, please email the team at firstname.lastname@example.org or call freephone 0800 328 9545. Initial advice is provided without charge and with no obligation.