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Unrealistic expectations

01 May 2010

Twenty-year-old Miss D was referred to orthopaedic consultant Mr A for assessment of an old clavicle fracture. Two years previously, Miss D had sustained a clavicle fracture after falling off her bike. This injury was treated in a different hospital in a conservative way, using a collar and cuff sling. In the early follow-up period, she moved to her current address and she was lost to further review.

At the time of the referral to Mr A, Miss D was complaining of a painful swelling at the level of the original injury. Although the pain was tolerable, she had discomfort in lifting weights with her hand. After carrying out the appropriate imaging studies, Mr A confirmed an old un-united middle third fracture of the clavicle, with a fibrous union that seemed to provide some stability. The patient was greatly concerned about the cosmetic appearance of the lump over her clavicle, which she considered an unsightly deformity.

Mr A had a long conversation with Miss D regarding the advantages, disadvantages and possible complications of the surgical treatment. Miss D remained adamant that she wanted to proceed with the treatment. She underwent an open reduction and internal fixation of her clavicle as an elective procedure. Mr A performed the surgery through a small incision, avoiding skin tension lines, placing the plate away from the subcutaneous tissues and closing the wound with subcuticular suture – therefore minimising the aesthetic consequences of the operation.

A year later, Miss D remained unhappy because she could feel the plate used to fix the old fracture. At that time, Mr A confirmed that there was osseous union at the fracture site and the plate was removed through the same incision. Miss D, however, continued to be dissatisfied with the result of the operation and with the appearance of the surgical scar. However, Mr A’s description in the surgical notes mentioned that “it has healed beautifully”.

Eventually, Miss D made a claim against Mr A.

The expert opinion of the two orthopaedic consultants was obtained. Both agreed that the management of the case was appropriate. They considered that the decision to operate was taken after explaining the implications of the operation to the patient. It also seemed clear that Mr A ensured that the patient understood the possible side effects and the potential complications of operating on a non-union of clavicle. The patient gave her informed consent to such an operation. The clinical notes were comprehensive and they included the explanations given to Miss D at the time of the informed consent and a description of the steps taken to reduce scarring.

The case was robustly defended and, after three years, the claim was discontinued.

Learning points

  • Most doctors will receive at least one complaint against them during their professional lives. The fact that a patient is unhappy or that a claim is made against him/her does not necessarily mean that the doctor has made a mistake. The majority of doctors who are sued have not been negligent. If you are sued it is unlikely that you’ve been negligent and if you have been negligent it is unlikely you’ll be sued.
  • Good and comprehensive recorded consent and record-keeping are the basis of a good defence.
  • Identifying and addressing unrealistic expectations is very important, especially in those cases where one of the main reasons for such surgery is cosmetic.
  • The management of clavicle fractures exceeds the scope of this article, particularly considering that it is often confusing. Traditionally, clavicle fractures have been treated conservatively, and the consensus used to be that eventually they all heal; however, evidence is mounting in support of operative treatment for displaced mid-shaft clavicle fractures.1

References

1. Canadian Orthopaedic Trauma Society, Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A Multicenter, Randomized Clinical Trial, J Bone Joint Surg Am 89 (1):1-10 (Jan 2007)