Management of the fracture during the appointment on 13 June
13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
14. We thank Mrs N for taking the time to bring her complaint to us. We recognise that she had difficult and painful experiences under the care of the Trust. Reassuringly, after considering all the evidence we have not found any indications that something has gone wrong.
15. Mrs N attended A&E at the Trust on 8 June 2023 after falling at home and injuring her wrist. Mrs N was diagnosed with a fracture and referred for an appointment at the fracture clinic the week following. During her A&E visit Mrs N’s wrist was manipulated into a stable position.
16. Mrs N attended an appointment at the fracture clinic on 13 June 2023. During this appointment she explained that her wrist was manipulated into position again as it was identified that it had moved. The Trust deny that this manipulation was carried out.
17. Mrs N described that this manipulation was carried out without any pain relief and was extremely painful.
18. In its complaint response the Trust explained that Mrs N did not have a second manipulation. It explained that the plaster technician will have adjusted Mrs N’s wrist slightly before they put the cast on as they had identified it had moved slightly since her visit to A&E.
19. The Trust acknowledged that this may have been painful for Mrs N however explained that there is a difference between a minor manipulation, as the plaster technician will have done when they put the cast on, and a full manual manipulation.
20. We asked our clinical adviser if there was evidence that Mrs N had a manipulation when she had her appointment at the fracture clinic on 13 June 2023.
21. Our adviser explained that there were three X-rays taken of Mrs N’s wrist at this appointment. They said that in the latter two of the X-rays, her wrist showed a slight improvement in position.
22. The adviser agreed that this was evidence of a slight adjustment of the position of Mrs N’s fracture. They explained that this is likely evidence of moulding of the plaster to ensure that Mrs N’s fracture was in the correct position. They explained that moulding will cause movement of the position of a fracture.
23. The BOAST guidelines say ‘when using a plaster cast to treat a distal radius fracture, the wrist should be in neutral flexion with 3point moulding used to hold the fracture’. This means that the plaster should be moulded to apply pressure at three points - the site of the fracture, and at two different points close to the fracture.
24. We asked our adviser if the Trust were correct to carry out moulding on Mrs N’s fracture at this appointment given that it had already been manipulated previously. They explained that the X-rays showed a clinical need for some level of moulding to ensure that the fracture was in the correct position for the cast to be applied.
25. Therefore, we consider that the Trust acted in line with the BOAST guidelines, which outline that moulding may need to be carried out when applying a plaster cast on a distal radial fracture such as Mrs N’s.
26. We recognise that Mrs N had a difficult experience during her appointment on 13 June 2023. We recognise that Mrs N did have some moulding of her cast to ensure that her fracture was in the correct position. This was the correct management of her fracture during this appointment.
Failure to act on the concerns Mrs N was raising after treatment
27. Mrs N explained that following her treatment on 13 June 2023 she began to experience pins and needles, swelling and numbness in her wrist. She says that she raised these concerns to the Trust on multiple occasions, and they did not act on these concerns quickly enough.
28. In its response the Trust explain that Mrs N was referred to the Hand Therapy Team for support with her symptoms. It explains that it provided treatment, and it was satisfied that this was the appropriate treatment for the concerns that Mrs N was raising.
29. The records show that it was noted during the fracture clinic appointment on 13 June 2023 that Mrs N was in excessive pain and was having difficulty moving her fingers. The consultant felt that this may be due to acute inflammation causing her to have a loss of sensation and pain in her fingers.
30. Mrs N had follow-up appointments on 30 June 2023 and 24 July 2023. It was noted at these appointments that Mrs N was experiencing continuing pain and stiffness. Therefore, a referral to the Hand Therapy Team was made.
31. We asked our adviser if the treatment that the Trust provided when Mrs N raised concerns to them about the pain and numbness she was experiencing in her hand on 13 June 2023, 30 June 2023 and 24 July 2023 was correct.
32. Our adviser explained that the Trust correctly referred Mrs N to the Hand Therapy Team for further investigations when she raised her concerns about ongoing pain and numbness.
33. The referral to the Hand Therapy Team was only made after Mrs N had her cast removed and splint applied on 24 July 2024. Our adviser explained that a referral to the Hand Therapy Team for physiotherapy could not be done earlier as the wrist would need to be immobilised whilst in the cast. Our adviser said the referral was timely and was an appropriate course of treatment for Mrs N as she was experiencing post treatment pain and stiffness.
34. The GMP explains that medical professionals ‘must refer patients to another suitably qualified practitioner where this serves a patient’s needs’. The Trust followed this by referring Mrs N to the Hand Therapy Team for investigations into, and treatment for, the symptoms she was experiencing.
35. On 12 September 2023 Mrs N had an appointment with a physiotherapist in the Hand Therapy Team who raised concerns that she had complex regional pain syndrome (CRPS) as a result of the fracture, which was being contributed to by her existing diagnosis of psoriatic arthritis.
36. The CRPS guidance outlines the diagnosis process and the treatment guidelines for CRPS. It explains that the diagnostic criteria for CRPS includes symptoms such as ‘sensory’ and ‘motor’ symptoms including pain, sensitivity, weakness, and motor dysfunction. It also explains that CRPS is common after fractures.
37. Our adviser said the symptoms Mrs N was presenting with reflect the diagnostic criteria outlined in the CRPS guidance. We therefore conclude that the referral to the Hand Therapy Team, and subsequent diagnosis of Mrs N with CRPS was appropriate and in line with the GMP and the CRPS guidance.
38. The CRPS guidance also outlines the treatment options for CRPS. It explains that pain relieving medicine, physiotherapy and neuropathic medication are all appropriate treatment options for CRPS. The records indicate that Mrs N was appropriately provided with these as part of her treatment plan in line with the CRPS guidance.
39. We also discussed with our adviser Mrs N’s view that she has nerve damage caused by the Trust’s treatment of her fracture.
40. Mrs N had a neurophysiological assessment of her wrist following her referral to the Hand Therapy Team that showed that she did not have any injury to the median and ulnar nerves.
41. Our adviser explained that although the assessment showed that Mrs N did not have any injury to these nerves, it did indicate that she may have a mild compression of her posterior interosseous nerve (PIN) which is a nerve in the forearm.
42. We asked our adviser if the nerve compression could have resulted from the treatment provided to Mrs N by the Trust. They explained that PIN compression generally results from injury or agitation near the elbow. Mrs N fractured her wrist, and the treatment provided did not relate to her elbow.
43. The PIN guidance explains that PIN compression may cause patients to report pain in the forearm or elbow which is aggravated by activity. It also explains that the PIN is a branch of the radial nerve, which runs along the elbow.
44. Although we recognise that Mrs N did have some pain and numbness following the treatment for her fracture, we feel that the referrals, the diagnosis of CRPS, and treatment the Trust provided her with was appropriate.
45. We acknowledge that Mrs N did have a slight nerve compression of her PIN but conclude that this was not as a result of the treatment the Trust provided to her and likely resulting from another injury or agitation of her elbow rather than her wrist fracture.
46. We conclude that the Trust acted correctly and in line with the relevant guidance in its management of Mrs N’s ongoing symptoms.
47. We are sorry that Mrs N has experienced pain and discomfort during the treatment for her wrist fracture. We understand that it will have been difficult for Mrs N to feel that the Trust caused her nerve pain. We thank her for taking the time to bring her complaint to us and wish her the best with her ongoing treatment.