Outcomes following upper limb injuries and their medicolegal implications

Injuries to the upper limbs can arise as the result of both disease processes, often associated with repetitive movements and wear and tear, and traumatic accidents. While many conditions can be treated successfully, the loss of the use of an upper limb can be particularly devastating for the patient who may be left unable to perform everyday tasks or remain in employment. Over recent years, the number of claims relating to conditions of the upper limb received by the National Health Service Litigation Authority has nearly trebled, although the number being successfully defended has also increased. The majority of claims arise in connection with two common conditions, namely fractures of the upper limb and carpal tunnel syndrome. Interestingly, in the UK, complex hand surgery almost never results in allegations of medical negligence. 

Distal radius fractures account for around 15% of all fractures encountered in an emergency setting. Despite its relative frequency, there is not always a clear consensus on how best to manage this type of injury and the treatment offered can be very variable. As a result, a significant number of these fractures can result in a poor outcome for the patient. The most commonly cited reasons for a claim being launched are pain and impaired wrist function, such as lack of mobility or joint weakness. These arise mainly due to diagnostic errors, where either a primary displacement or the re-displacement of an adequately reduced fracture is missed; errors in treatment decisions or planning, such as when a fracture is identified but no intervention offered; and limitations in technical expertise, leading to poor casting techniques or a failure to adequately reduce fractures. The provision of follow-up visits can also be inadequate, particularly in the early post-treatment period, although complaints about follow-up treatment are much less common in patients who have received surgical intervention for their fracture than in those treated conservatively.

Fractures of the wrist and scaphoid bones are common injuries, particularly due to their association with falls during spells of bad weather, and their treatment is an ‘everyday’ procedure. As with distal radius fractures, most claims result from incorrect, missed or delayed diagnoses. Mismanagement, poor care and suboptimal surgery make up a smaller proportion of claims. While many upper limb fractures heal extremely well, delays in diagnosis and a failure to manage an injury or infection can have severe consequences for the patient and could ultimately lead to amputation of the affected limb. Even when healing is good, post-traumatic osteoarthritis remains a risk. The likelihood of its development is dependent on many factors, including the involvement of the surrounding joints and blood vessels, the degree of soft tissue damage, the type and severity of fracture and the resulting angular deformity. As the condition can take up to 10 years to develop, it is important that patients are aware of the possibility of potential future issues.

Carpal tunnel syndrome occurs when the median nerve is compressed as it passes through the carpal tunnel in the wrist. This leads to pain, numbness and altered sensation in the thumb and fingers of the affected hand. The patient may also experience weakness in the hand. The gold standard treatment for this condition is surgical release of the compression. While this procedure has a very high satisfaction rate, complications do occasionally occur, the most frequent of which is damage to the median nerve. Overall, though, it remains a rare occurrence, and has been reported in fewer than 1% of procedures. In proving a case of alleged negligence, the surgeon’s training and experience can be particularly influential and should also help to ensure that selection of both the procedure and the patient was appropriate from the outset. 

One feature common to many cases of alleged negligence involving upper limb conditions is a failure to obtain properly informed consent from the patient. Up to two-thirds of all complaints regarding upper limb fractures are in fact due to the normal pathway of this type of injury. This indicates that patients are not adequately informed about the likely course of their condition. Furthermore, research shows that the common risks associated with this condition, such as infection, vascular and nerve injuries and stiffness are not always properly documented on consent forms and that the use of abbreviations, which may not be understood by the patient, is also common. Such poor communication means that patients are not receiving appropriate information and that any consent given may not in fact be valid. Improvements in the information given to patients during the consent process could have a major impact on the likelihood of litigation occurring. 

Overall, the prognosis for most upper limb injuries is good and the likelihood of treatment resulting in a claim of alleged negligence remains rare. However, as many of the claims that do arise relate to commonly occurring conditions, this suggests that better training is required for so-called ‘routine’ surgical procedures. Strict adherence to treatment recommendations given in current care guidelines and obtaining detailed informed consent would also help to reduce the possibility of future claims being made. 

Further reading:

Ganesh Kumar, N., Hricz, N., & Drolet, B. C. (2019). Litigation Following Carpal Tunnel Release. Hand (New York, N.Y.), 14(4), 466–470. https://doi.org/10.1177/1558944718760032

Sandelin, H., Waris, E., Hirvensalo, E., Vasenius, J., Huhtala, H., Raatikainen, T., & Helkamaa, T. (2018). Patient injury claims involving fractures of the distal radius. Acta orthopaedica, 89(2), 240–245. https://doi.org/10.1080/17453674.2018.1427966