Misunderstanding the extent of shoulder injuries and failure to refer to specialist review are frequent episodes in the agenda of those who scrutinise medical conduct.
Their attention should be directed to the circumstances of Jeshua Chester – a twenty-something plasterer – who arrived at a country hospital at the end of a night of drinking during which he injured his left shoulder.He was seen just before midnight by a doctor who placed his arm in a broad arm sling before discharging him with Panadol, Nurofen and an icepack and directing him to return the following day – 1 August 2009 – for an X-ray.
The radiologist reported a ‘Dislocation of the left AC joint has occurred’, in reference to the acromioclavicular joint in his left shoulder.
The doctor who saw the patient at the Busselton Hospital following the X-ray, recorded he had an ‘A/C joint dislocation’. The same doctor prepared a Discharge Summary recording a diagnosis of ‘AC joint subluxed L shoulder’.
He was again given analgesia and advised to consult his GP in two weeks. Chester’s recollection was that he was told to keep his arm in the sling for four-six weeks and that – with steady improvement – would be back to work in six weeks.
Jeshua attended his GP on 2 August with the Discharge Summary when the GP noted ‘left AC JT subluxation … x-rays confirm this’ with some improvement in his pain level but shoulder mobility still reduced.
By September – with heightened pain whenever he took weight through his shoulder – GP Anthony Taylor referred him to Bunbury orthopedist John Openshaw who eventually performed reconstruction surgery in February 2010.
Notwithstanding the successful surgery, Chester continued to suffer pain in the left shoulder and restrictions in terms of his daily activities.
He filed injury compensation proceedings against the Busselton Regional Hospital for misdiagnosing the shoulder injury as subluxation and failing to promptly refer him – in August 2009 – for orthopaedic review.
Notably, the hospital had not classified the grade of AC joint injury Chester has sustained.
The WA District Court heard that AC joint injuries range from a partial rupture of the ligaments (grades 1 & 2 which are referred to as a subluxation); to a complete rupture (grade 3) and one also rupturing the coracoclavicular ligaments and displacing the clavicle (grade 5).
Grade 3 and 5 injuries are properly described as a dislocation, where the displacement is vertical and upwards. Grade 4 and 6 dislocations are rare and involve horizontal displacement of the clavicle in either a posterior or an anterior direction.
Judge Bruce Goetze found that Chester had suffered a grade 3 dislocation but concluded that notwithstanding “failures by the hospital medicos,” Chester had failed to establish that an earlier referral to an orthopaedic surgeon would have led to earlier reduction surgery and that such surgery would have left him with a better outcome.
Chester’s appeal required a consideration of the issues from a different perspective.
The appeal judges ruled that the primary judge’s finding that Chester had failed to prove the earlier surgery would have achieved a better outcome should be overruled because he had failed to provide adequate reasons for that finding.
The appeal court noted expert witness evidence regarding patients in manual occupations like Chester was to the effect that reduction surgery should be carried out within two to four weeks post-injury to return the clavicle back into position.
“It is well accepted that surgery performed soon after the injury is easier than later surgery,” the appellate judges observed.
If such surgery is not undertaken within that time frame, it will invariably be necessary to reconstruct the shoulder by excising the distal end of the clavicle which can be the cause of chronic pain.
The court also acknowledged though, that there are competing views among competent orthopaedic surgeons as to whether conservative or surgical treatment is optimal for this kind of injury.
Noting that the plasterer’s case was not simply a complaint about the delay but rather that the early reduction surgery would not have required excision of the distal end of the clavicle, they ordered a retrial.
Regrettably, there were many issues that the learned trial judge had not adequately addressed and “which this court cannot determine merely from the record”.
“An order for a retrial must always be an occasion for regret; perhaps more so in a case such as this, where the relevant events were many years ago,” they observed.
Categories: Medical Negligence