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Care of woman with hand injury (14HDC01205)

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(14HDC01205, 16 December 2016)

Doctor ~ Medical centre ~ Musculoskeletal medicine ~ Finger ~ Fracture ~ X-ray ~ CT scan ~ Referral ~ Right 4(1)

A 39-year-old woman injured her left index finger and thumb. She presented to an accident and medical centre (medical centre) where she was assessed by a general practitioner (GP) who noted that the woman had "obvious bruising and swelling" and limited movement of her left index finger. The GP ordered an X-ray and  reviewed it with an orthopaedic surgeon who worked at the medical centre. The X-ray showed that the woman's finger was fractured. A plan was made to splint the woman's finger and for her to be reviewed  in a week's time at the medical centre's orthopaedic clinic.

The woman saw a doctor [1] (the doctor) at the medical centre's orthopaedic clinic on five occasions and was referred for physiotherapy. Despite a further X-ray showing a significant intra-articular fracture involving 50% of a joint surface with 4mm of displacement, the doctor continued to treat the woman with joint mobilisation and corticosteroid injection rather than referring her to an orthopaedic specialist. After seeing the woman four times the physiotherapist wrote to the doctor recommending that the woman have a specialist review. The woman then saw her regular GP and was referred to a specialist who operated on the woman's finger. Despite the fact that surgery went well the woman has been left with arthritis and limited function in her finger.

It was found that while the doctor at the orthopaedic clinic had experience in musculoskeletal medicine, which included managing fractures, he should have recognised the limitations of his expertise. The doctor failed to recognise the severity of the injury to the woman's finger and treat it appropriately, including when he administered a corticosteroid injection and recommended joint mobilisation. The doctor also failed to interpret relevant X-rays and radiology reports adequately, order repeat X-rays or organise CT scans at appropriate times, and refer the woman to a specialist.  Accordingly it was found that the doctor did not provide services with reasonable care and so breached Right 4(1).

Adverse comment was made in respect of the medical centre regarding the level of specialist support provided to the doctor.

The doctor no longer practises medicine. It was recommended that, in the event the doctor returned to practice, he undertake an audit of his clinical records within six months from the date of his return to practice to demonstrate that he has considered appropriate investigations and critically reflected on his treatment plans, and that he arrange for further training regarding the assessment of radiology reports, the use of corticosteroid injections, and when to make specialist referrals. It was also recommended that the doctor apologise to the woman for his breach of the Code.

It was recommended that the medical centre review the professional support available to medical staff that operate its orthopaedic clinic but who do not hold an orthopaedic qualification.

 


[1] The doctor was registered with the Medical Council of New Zealand under a general scope of practice, and had a special interest in musculoskeletal medicine.

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