EWJ June 61 2025 web - Flipbook - Page 42
due to their occupation or pre-injury level of activity,
while others may adapt remarkably well to more
significant objective deficits.
secondary surgery - typically results in increased
stiffness and diminished grip strength.
• Adherence to rehabilitation: Patient motivation,
access to physiotherapy, and early active range-of-motion exercises all influence final function.
Assessment tools such as the Disabilities of the Arm,
Shoulder and Hand (DASH) questionnaire, or the Patient-Rated Wrist Evaluation (PRWE), can help quantify functional limitation, though their interpretation
requires caution, particularly in cases involving
potential secondary gain.
The medicolegal expert should resist attributing poor
outcome to a single factor without considering the
broader clinical picture. This includes the often-underappreciated psychosocial determinants of recovery, such as patient expectations, anxiety, depression,
and secondary gain. For example, two patients with
identical radiographs may have markedly different
outcomes depending on pain thresholds, comorbidities, and psychosocial influences.
From a medicolegal standpoint, the expert must
address whether the level of disability is consistent with
the injury, whether recovery has plateaued, and if future treatment may offer any realistic improvement.
These are critical determinants in calculating general
damages and future loss claims.
Moreover, the presence of pre-existing conditions such as rheumatoid arthritis, diabetes, or prior wrist
injuries - can heavily influence prognosis and must be
accounted for when assessing causation and attributing levels of disability. It's crucial in medicolegal reports to comment explicitly on how these variables
interact with the index injury.
Prognostic Indicators and Predicting Outcomes
From a medicolegal perspective, predicting outcome
is both a science and an art. A clear understanding of
prognostic indicators allows for informed, balanced
expert opinion. Some of the most significant predictors of long-term outcome include:
• Fracture pattern and complexity: Intra-articular
fractures, comminution, and metaphyseal bone loss
can be associated with poorer outcomes.
Imaging and functional assessments can aid in supporting opinions about prognosis. Late-stage imaging
may show arthritis, hardware migration, or persistent
malunion, helping to explain ongoing symptoms.
Objective measures such as grip strength, range of
motion, and validated questionnaires (e.g. DASH
score) are valuable for quantifying functional limitation and guiding appropriate compensation estimates.
• Age and bone quality: Older patients or those with
osteoporotic bone often have more complicated
recoveries, with greater risk of displacement, stiffness,
or CRPS.
• Initial reduction quality: Anatomical or nearanatomical alignment correlates strongly with better
functional results.
In summary, outcome prediction is multifactorial and
requires a holistic approach that combines radiological, clinical, and psychosocial insights.
• Postoperative complications: Any event that delays
mobilisation - such as infection, hardware failure, or
Image 1: This is a PosteroAnterior (PA) radiograph of a
right wrist. It shows an extraarticular distal radius fracture
(marked A) with shortening
and loss of radial inclination/angulation (i.e. the hand
doesn’t align with the forearm).
There is also a fracture at the
base of the ulna styloid
(marked B) which is displaced.
Image 2: This is a Lateral
(Lat) radiograph of the same
wrist. It shows an extra-articular distal radius fracture
which is dorsally displaced toward the back of the forearm/hand i.e. away from the
arrow (marked C). There is
some dorsal comminution i.e.
fragmentation (marked D).
The shape of the wrist is the
classical Colles type wrist fracture and would have the appearance of a dinner fork.
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Image 3: This is a postoperative PA radiograph demonstrating that the patient has
undergone Open Reduction
Internal Fixation (ORIF). The
distal radius fracture has been
reduced well i.e. all cortices
(edges of the bone) are lined up
and the correct joint angles
have been restored.
Image 4: This is a postoperative Lateral radiograph
demonstrating a volar locking
plate (i.e. the plate is on the
thumb/palm side of the bone).
All the screws are the correct
length and don’t protrude excessively through the dorsal
cortex thus won’t irritate the
tendons precipitating a tendon
rupture.
JUNE 2025
