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A crucial x-ray overlooked

01 May 2004

Mr V injured his right wrist whilst playing with his son. The next morning he went to A&E, where his wrist was x-rayed. A fracture of the wrist was suspected and a plaster applied to the right wrist and forearm, with follow-up at the fracture clinic arranged for the following week.

The x-ray film was later reported by a consultant radiologist as showing no fracture. Seven days later, Mr V was seen at the fracture clinic by orthopaedic registrar Mr F. Suspecting that Mr V had a fractured scaphoid, he applied a scaphoid plaster and arranged a follow-up appointment for two weeks hence.

Mr F reviewed Mr V, removing his plaster and sending him for an x-ray. This x-ray clearly demonstrated a fracture of the waist of the scaphoid. Mr F claimed that he never saw the x-ray and it was never formally reported on. Mr V’s scaphoid cast was not replaced and he was sent home with strapping to the right wrist. Mr F saw Mr V again in fracture clinic three weeks later, but no further x-rays were taken.

About a year later, Mr V was suffering pain in his right wrist and he was referred back to the orthopaedic clinic where he saw Mr F again. Mr F noted limitation of Mr V’s wrist extension but didn’t request further x-rays.

He diagnosed tenosynovitis, gave a local steroid injection and referred Mr V for physiotherapy. This alleviated some of Mr V’s symptoms but his wrist was still stiff and sore. Mr V was discharged from the clinic about 18 months after his original injury.

Five years later Mr V injured his wrist again and had an x-ray at another hospital. This showed an un-united fracture of the scaphoid. Mr V required bone grafting to correct the condition, carried out by another orthopaedic surgeon.

Nine months after surgery the fracture had healed fully and Mr V was told that he could return to his job as a precision engineer. However, this was not wholly possible because Mr V continued to experience pain and dysfunction in his wrist, which limited the range of work he could undertake.

Mr V started legal proceedings against Mr F.

Expert opinion

We took advice from orthopaedic experts, who were critical of Mr F’s management from the point at which the second x-ray demonstrated the scaphoid fracture. Mr F’s failure to review the film and act accordingly was seen as indefensible. Mr V’s symptoms were almost certainly directly attributable to the suboptimal management of his fractured scaphoid.

The experts attached no blame to the radiology department as the first film had been reported correctly; scaphoid fractures may not be visible immediately following an injury. The second film was mislaid and was never sent for reporting.

We settled the case to compensate Mr V for his prolonged pain, suffering and the impact on his employment.

Learning points

  • If you have ordered review x-rays, make sure you see them. If they don’t materialise, chase them. A reliable system for logging and tracking requests is a fundamental risk management measure, as is good inter-departmental cooperation.
  • It is important to maintain a high index of suspicion of scaphoid fracture when treating wrist injuries. This suspicion should be maintained during follow up, as the clinical and radiological features of the injury can be equivocal and the consequences of incorrect management significantly damaging. Failure to diagnose scaphoid fractures often results in high claims due to the impact on the sufferer’s employability and earning capacity.
  • A guide to the assessment, diagnosis and management of scaphoid injuries can be viewed online here.