Causation and complications

Abstract

hese are the facts that the authors presented: 1. The patient developed his infection eight weeks after his injections. 2. Despite having an infection that required drainage, the patient had normal range of motion in his metacarpophalangeal joints. 3. The patient refused to be admitted to hospital for “surgical drainage under general anesthesia”, hence, “less thorough surgical debridement under Bier’s block, in the emergency room, was performed.” 4. The extensor tendons were found to be intact at that time. 5. Two days later the patient was revaluated and claimed a one-day history of loss of full extension. On examination his active metacarpophalangeal joint motion was only -30˚ / 90˚.6. Additional surgery was performed that confirmed the rupture of the extensors to the index, long, and ring digits. 7. One week later tendon grafting was performed. 8. One year later the patient’s metacarpophalangeal joint motion was -25˚ / 90˚.The authors claim that this is a “case of rapidly progressive suppurative extensor tenosynovitis, with tendon rupture, following improper administration of local steroids”. By the authors’ own admission, the infection occurred eight weeks after the steroid injections. Eight weeks is a rather long time from alleged bacterial inoculation to clinical infection. Furthermore, when the patient was first examined by the authors he had no tendon ruptures and had normal extension. Using a Bier block for anesthesia, they operated under substandard conditions. The patient lost extension within a day. One week later they attempted to reconstruct his extensors, but the final measurements of digital motion were practically the same as immediately after the rupture. Is the authors’ claim valid? Were the tendon ruptures caused by “improper administration of local steroids” or were they caused by something else? More importantly, is there any sound scientific evidence that the steroid injections resulted in the patient’s final result? Stating that a treatment is ‘improper’ implies that the authors are giving a legal opinion that a malpractice has occurred. Hence, it is worthwhile to consider legal approaches to the causation. The concept of ‘proximate cause’ is used in the United States and is similar to causation under English Law.