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No knuckling under

01 May 2004

Gary, a 12-year-old schoolboy, received a blow to the back of his right hand whilst playing. He attended a rural A&E department where an x-ray showed a comminuted fracture of the head of the third metacarpal.

Dr S, A&E SHO, diagnosed a chip fracture of the head of the third metacarpal. He gave tetanus toxoid, arranged for the wound to be dressed, and booked a surgical outpatient appointment for four days hence. Dr S noted that Gary was left-handed.

At the outpatients’ clinic, Gary saw Mr Q, surgical registrar, who diagnosed a displaced fracture of the dorsum of the third metacarpal head, involving its articular surface and epiphyseal plate. Mr Q referred Gary to the fracture clinic.

Three days later, Gary saw Mr P, consultant orthopaedic surgeon. Mr P admitted Gary for day-case surgery in which he reduced and fixed the fracture with K-wires. Gary was sent home the same day, returning ten days later to have his sutures removed. The wound was very swollen and a back-slab plaster was applied.

At Gary’s next review, four days later, the swelling had resolved and the wound was re-dressed. Gary was seen twice over the next few weeks. His hand remained stiff and he had difficulty moving his fingers. Mr P arranged his admission for removal of the K-wires.

A subsequent x-ray showed evidence of avascular necrosis of the fracture fragment and Gary was referred to a physiotherapist. Several months later, there was major loss of flexion at the affected joint. Gary was discharged from treatment four months after the original injury.

A claim for negligence was brought against Dr S and Mr Q, alleging that their failure to provide immediate surgical intervention had led to Gary’s impaired hand function.

Expert opinion

We obtained orthopaedic and A&E expert advice. According to the orthopaedic opinion, the severity and site of the original fracture meant that long-term complications were likely, regardless of the speed of surgical intervention. He felt that there may have been some postoperative infection, which contributed to Gary’s difficulties.

However, the impaired hand function and pain were thought to be largely due to avascular necrosis and the expert could not state with certainty that this complication would have been avoided if Gary had received earlier treatment.

An expert in A&E judged that Dr S had not been negligent in his initial treatment of Gary. Referral to the next available surgical clinic would be accepted as responsible by a reasonable body of doctors. He also took the view that earlier intervention would not have materially affected the outcome.

Given the experts’ reports, we defended the claim, which was struck out by the court before it came to trial.

Learning points

Management of metacarpal head fractures is not straightforward. Where the metacarpal head is involved, and where there is significant displacement/angulation, open reduction and internal fixation is normally advised.

This is the treatment given in this case, but the complainant alleged that the delay had significantly affected the outcome.

See emedicine.medscape.com/article/1239721-overview for an online tutorial on metacarpal fractures. It provides useful information for those working in A&E or training in orthopaedics.

This case occurred in the Republic of Ireland in the early nineties. At that time, many rural hospitals had access only to visiting orthopaedic surgeons.