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Can you handle it?

01 September 2008

Mr M, a 30-year-old professional percussionist, played in a prestigious regional orchestra. He had been troubled by a soft, protruberant lump at the base of his right thumb. It snagged on the mallets he used to play his instruments, becoming painful and inflamed after practice or performance. He was examined by Mr O, a newly appointed orthopaedic  consultant working at a nearby district general hospital.

Mr O diagnosed a large volar ganglion of the right wrist and recommended open surgical excision. Mr M agreed and Mr O undertook the procedure Unfortunately, the procedure left Mr M with numbness and paraesthesia affecting most of the right thumb, such that he was unable to work or enjoy playing music for a period of nine months. An orthopaedic handsurgery specialist subsequently examined Mr M’s wrist under anaesthesia and found damage to a branch of the right superficial radial nerve, with an associated neuroma. The neuroma was excised and Mr M recovered sufficiently to return to work.

However, he never regained full, normal sensation in his right thumb. This hampered his technical musical prowess and orchestral career. Mr M started a legal claim against Mr O alleging negligence in his performance of the surgery. He alleged negligence for a failure to warn Mr M of the possibility of damage to the radial nerve and its branches, which, given his career, would have greatly influenced his decision on whether or not to proceed with the surgery.

Expert opinion

An orthopaedic specialist agreed that Mr O had been negligent for not warning of possible radial nerve trauma (an accepted complication of surgery in this area). The expert was surprised that the patient’s occupation had not been elucidated or recorded in the clinical record. Mr O appeared not to have taken this into account in deciding whether open surgery was the best option in this context, or whether he was the best person to perform it. Mr O’s subspecialty training had largely been in the region of the lower limb. It became clear that Mr O’s knowledge of the anatomy and operating techniques in this region were insufficient and probably contributed to the poor outcome. The case was settled for a moderate sum.

Learning points

  • The GMC stipulates in Good Medical Practice that you must provide a good standard of practice and care by keeping your professional knowledge and skills up to date and recognising and working within the limits of your competence.
  • Know your limits. It is better to admit you do not have relevant expertise than to plough on as if you had. The start of a career as a consultant can be a challenging time. While there are many responsibilities that correctly become your own, you should also be wary of exceeding your skills and experience. If in doubt discuss the case with a senior consultant colleague. MPS has recently published a book, Taking Care: Making the Most of your Consultant Post, which provides plenty of useful guidance. It is free to members – visit the consultants’ section of the UK MPS website for more details. 
  • A patient’s occupation and handedness are vital parts of the medical history. This case shows that these factors and others, such as the timing of the operation, can be very pertinent in considering the best treatment options and the most suitable practitioner to carry out an intervention.
  • Patients must be warned of the known complications of a given procedure during the consenting process. Preprinted consent forms are a good way of recording the information discussed during the consent process. However, they do not replace a proper discussion, tailored to the needs of the specific patient sitting in front of you. More information can be found in the MPS Guide to Consent, available at www.medicalprotection.org.