A 57-year-old woman fell down stairs, causing injury to her left shoulder. She presented to a New Jersey hospital emergency department, where the emergency physician ordered films and a radiologist interpreted the injury as a simple fracture.

The patient contended she had actually dislocated her shoulder and that because of a delay in treatment, her condition worsened, leaving her unable to use her left hand.

The plaintiff claimed that the radiologist had misread the x-rays and that the emergency physician failed to realize her pain was out of proportion to the diagnosis. The plaintiff claimed that the emergency physician should have ordered more tests and sought a radiological consult. Two nurses were also named as defendants, with the plaintiff maintaining that they had failed to notify the emergency physician when her condition deteriorated.

Outcome
According to a published account, a $2.75 million settlement was reached. The hospital, the emergency physician, and the nurses will pay a total of $1.5 million, and the radiologist, $1.25 million.

Comment
Complex regional pain syndrome(CRPS, formerly known as reflex sympathetic dystrophy) is frequently a source of litigation. Though CRPS is not specifically mentioned in this case synopsis, given the $2.75 million settlement, it seems highly likely that CRPS was claimed as the resulting injury. A relatively minor trauma can lead to CRPS, and why only certain patients subsequently develop the syndrome is a mystery. Yet it is no mystery that CPRS is recognized as one of the most painful conditions known to humankind. Once it develops, the syndrome can result in constant, debilitating pain, the loss of a limb, and near-total decay of a patient’s quality of life.

Plaintiffs’ attorneys are quick to claim negligence and substantial damages for these patients, with their sad, compelling stories. Because the underlying pathophysiology of CPRS is unclear, liability is often hotly debated, with cases difficult to defend.

Malpractice cases generally involve two elements: liability (the presence and magnitude of the error) and damages (the severity of the injury and impact on life). CRPS cases are often considered “damages” cases, because liability may be uncertain, but the patient’s damages are very clear. An understandingly sympathetic jury panel sees the unfortunate patient’s red, swollen, misshapen limb, hears the story of the patient’s ever-present, exquisite pain, and (based largely on human emotion) infers negligence based on the magnitude of the patient’s suffering.

Here, presumptively, the 57-year-old patient sustained a shoulder injury in a fall that was initially treated as a fracture (presumptively proximal) but later determined to be a dislocation. Management of the injury was not described, but we can assume that if a fracture was diagnosed, the shoulder joint was immobilized. The plaintiff did not claim that there were any diminished neurovascular findings at the time of injury. We are not told whether follow-up was arranged for the patient, what the final, full diagnosis was (eg, fracture/anterior dislocation of the proximal humerus), or when/if the shoulder was actively reduced.

Under these circumstances, what could a bedside clinician have done differently? The most prominent element is the report of “pain out of proportion to the diagnosis.” When confronted with pain that seems out of proportion to a limb injury, stop and review the case. Be sure to consider occult or evolving neurovascular injury (eg, compartment syndrome, brachial plexus injury). Seek consultation and a second opinion in cases involving pain that seems intractable and out of proportion.

One quick word about pain and drug-seeking behavior. Many of us are all too familiar with patients who overstate their symptoms to obtain narcotic pain medications. Will you encounter drug seekers who embellish their level of pain to obtain narcotics? You know the answer to that question.

But it is necessary to take an injured patient’s claim of pain as stated. Don’t view yourself as “wrong” or “fooled” if patients misstate their level of pain and you respond accordingly. In many cases, there is no way to differentiate between genuine manifestations of pain and gamesmanship. To attempt to do so is dangerous because it may lead you to dismiss a patient with genuine pain for fear of being “fooled.” Don’t. Few situations will irritate a jury more than a patient with genuine pathology who is wrongly considered a “drug seeker.” Take patients at face value and act appropriately if substance misuse is later discovered.

In this case, recognition of out-of-control pain may have resulted in an orthopedic consultation. At minimum, that would demonstrate that the patient’s pain was taken seriously and the clinicians acted with due concern for her. —DML

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 2998-6288.

Pain Out of Proportion to a Fracture