An unlucky break

Mr P was playing football with his sons when the ball struck his right hand, resulting in a hyperextension injury of the right wrist. He decided to deal with the resulting pain by applying an ice-pack and taking some analgesics.

Two days later the pain in his wrist had still not improved and he attended A&E at his local hospital. On arrival he was triaged to the walk-in centre adjacent to the unit where he was seen by an emergency nurse practitioner. On examination, a diagnosis of a wrist sprain was made, bandaging applied and Mr P discharged with instructions to mobilise the wrist.

The following week Mr P was still experiencing persistent pain and returned to the walk-in centre where he was seen by another emergency nurse practitioner. A possible scaphoid fracture was suspected and the nurse ordered a plain x-ray of the wrist. She made no mention of a suspected scaphoid fracture on the x-ray request form. The radiologist who reviewed the film saw no bony injury and Mr P was sent home with strapping to the right wrist.

Six months after the initial injury Mr P consulted his GP as the persistent pain and reduced range of movement in the wrist was interfering with his job as a draughtsman. The GP suspected a prior scaphoid fracture and ordered scaphoid x-rays of the wrist, which showed an un-united fracture. Mr P was referred to an orthopaedic surgeon and eventually underwent bone grafting to correct the condition.

Eight months after the surgery the fracture had healed fully and Mr P was advised that he could fully return to his job. However, this was not wholly possible because he continued to experience pain and dysfunction in his wrist, which limited the amount of work he could undertake.

Two years after the initial presentation Mr P started legal proceedings against the unscheduled care organisation responsible for running the walk-in centre. Expert review concluded that Mr P’s symptoms were almost certainly directly attributable to the suboptimal management of his fractured scaphoid. No blame was attached to the radiology department at the hospital as the film had been reported correctly – scaphoid fractures may not be seen on a plain wrist x-ray.

The case was settled to compensate Mr P for his prolonged pain, suffering and the impact on his employment.

Clinical and radiological features of wrist injuries can be equivocal and the consequences of incorrect management significantly damaging. If a scaphoid fracture is suspected then appropriate x-rays must be requested and the provisional diagnosis mentioned on the request. Failure to diagnose scaphoid fractures can result in high value claims due to the impact on the sufferer’s employability and earning capacity.