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Could it make me worse?

01 August 2004

Mr W had suffered with left-sided ulnar nerve pain for some years. He saw Dr H, an orthopaedic surgeon. Fifteen years previously he’d had surgery on his left ulnar nerve to treat his pain, but had recently suffered increasingly severe pain.

Dr H arranged nerve conduction studies on Mr W, which he described as ‘borderline’; he listed Mr W for exploration of the left ulnar nerve in an attempt to alleviate his symptoms. The operation note reads, ‘Old incision opened – nerve identified – lying on medial condyle of humerus – neurolysis – nerve transferred into a gutter fashioned in the common flexor origin. Closed 2/0 dexon, 3/0 nylon.’

Mr W didn’t fare well after the operation. His pain returned and he gradually developed features of an almost complete ulnar nerve palsy. This caused left-sided clawing and severe wasting of the relevant intrinsic muscles of the hand.

Mr W sued Dr H, alleging that his treatment had made his hand much worse and that he had not been warned of this possibility.

Expert opinion

Expert orthopaedic opinion was that Dr H’s surgery had worsened the situation, probably by compromising the blood supply when the nerve was dissected off underlying scar tissue and transferred to a muscle gutter. The expert felt that magnification should have been used during the procedure. It was felt that it was probably best if the surgery had not been done at all, but if it was done, then the patient should have been warned of the risk of significant worsening of his condition.

The expert felt that there was no prospect of a recovery of function for Mr W.

Dr H accepted that his consenting process, although clearly outlining the risk of no significant improvement, had failed to explain the possibility of worsening the situation. We settled the claim.

Learning points

Where a surgical procedure has an appreciable risk of profound and disabling complications, such risks must be discussed in detail with the patient so that they can give informed consent for the procedure. Such discussions should be clearly documented in the clinical record.

Before carrying out a procedure, make sure you have the relevant expertise and experience to carry it out satisfactorily, and refer for advice if this is not the case.

The GMC states that the duties of a doctor include ‘Recognising the limits of your professional competence, keeping your professional knowledge and skills up to date and working with colleagues in the ways that best serve patients’ interests.’ See