Cases & News
Steven R. Graboff, M.D. Awarded Diplomate as Forensic Examiner
STEVEN R. GRABOFF, M.D. AWARDED DIPLOMATE STATUS BY THE AMERICAN BOARD OF FORENSIC EXAMINERS
SPRINGFIELD, MO (MMD Newswire) December 16, 2010 -- STEVEN R. GRABOFF, M.D. of HUNTINGTON BEACH, CA has earned the prestigious Diplomate designation from the American Board of Forensic Examiners (DABFE).
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Steven R. Graboff, M.D. Awarded Diplomate in Forensic Medicine
STEVEN R. GRABOFF, M.D. AWARDED DIPLOMATE STATUS BY THE AMERICAN BOARD OF FORENSIC MEDICINE
SPRINGFIELD, MO (MMD Newswire) January 17, 2011 -- STEVEN R. GRABOFF, M.D. of HUNTINGTON BEACH, CA has earned the prestigious Diplomate designation from the American Board of Forensic Medicine (DABFM).
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Steven R. Graboff, M.D. Earns ACFEI Certified Forensic Physician Designation
SPRINGFIELD, MO (MMD Newswire) March 31, 2009 -- STEVEN R. GRABOFF, M.D. of HUNTINGTON BEACH, CA has earned the prestigious Certified Forensic Physician (CFP) designation from the American College of Forensic Examiners Institute (ACFEI).
The Certified Forensic Physician is an advanced credential that recognizes additional training and expertise for forensic physicians. ACFEI has elevated standards through education, basic and advanced training. The CFP designation provides a mechanism for measuring scientific standards and procedures required to perform thorough forensic medical investigation and proper consultation.
The ACFEI is the world's largest forensic science association, and it covers a broad range of forensic specialties.
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Cases
Ask Orthopedic MedLegal Opinion Orthopedic Case review service - ask a question or submit your medical case for review by a medical expert.
Here are just some of the cases for which Dr. Graboff has provided Orthopedic Expert opinion and testimony. These are representative Personal Injury and Medical Malpractice cases for which Dr. Graboff was retained and qualified as the Orthopedic Expert Witness.
"Failure to Diagnose and Treat Acute Ruptured Achilles Tendon"
A 32 year old man while at work jumped off of the back of his work truck and thought that he sprained his right ankle. He felt a pop and had immediate pain and difficulty walking. His employer sent him to their designated industrial medical urgent care clinic where he was seen only by the physician assistant. After an examination and x-ray he was diagnosed as having an ankle sprain, placed into an “air-cast” and told to take Motrin for pain, weight bear as tolerated, and return for recheck in 3 weeks.
He was reevaluated 3 weeks later by the physician assistant who found that the sprain had improved and released him to work without limits. No clinical tests or exam was ever performed of the Achilles tendon. He tried to work but because of severe limp and posterior heel pain could not, and went to see an orthopedic surgeon 2 weeks later. The orthopedic surgeon on exam found a ruptured Achilles tendon, confirmed on MRI scan, and told the patient that he needed surgery to repair the torn tendon, but that because so much time had elapsed since the day of injury primary repair could not be done, and a tendon reconstruction surgery would be required, with a less than optimal result.
The issues in this case include: failure to be seen and examined by a medical doctor; evaluation and treatment only by a physician assistant; failure to diagnosis an acute ruptured Achilles tendon; failure to timely treat an acute rupture Achilles tendon; and delay in appropriate surgical treatment leading to inability to repair the tendon.
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"Failed Total Hip Arthroplasty with Instability from Malpositioned Acetabular Component"
A 62 year old otherwise healthy women with right hip pain was evaluated by her orthopedic surgeon, found to have severe osteoarthritis, and was scheduled for a right total hip replacement. She was admitted to the hospital, had an uneventful surgery, and was discharged home 4 days later to be seen and treated by home health nurse and physical therapist. She started to have hip popping and pain almost immediately upon beginning weight bearing and was told by her surgeon that this “was normal” and would eventually stop as she got stronger. Post hip replacement x-rays were obtained by her surgeon and she was told that everything “looked fine.”
She continued to have increasing hip popping and pain months after the surgery and her surgeon continue to tell her that everything looked good, but eventually the hip completely dislocated, requiring an emergency room visit and closed reduction of the dislocated prosthetic joint, after which she was put into a large hip brace by her surgeon, and told by him to be “more careful” and not dislocate the artificial joint again.
When she went for a second opinion to another orthopedic surgeon, as soon as he took an x-ray of her hip, he told her that the acetabular component was too vertical which caused the hip popping, pain, instability, and eventual dislocation, and advised her that she needed a revision surgery of the hip to place the acetabulum into the proper position.
The issues in this case include: placement of the acetabular component by the surgeon in an unacceptable vertical position during the initial total hip replacement surgery; failure to diagnose the cause of the hip popping, pain, and instability postoperatively from the vertical acetabular component; blaming the patient for the hip dislocation when it was caused by the instability from the mal-positioned components; falsifying the medical records postoperatively to indicate that the hip components were mechanically correct when in fact they were mal-aligned.
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"Supracondylar Humerus Fracture in an 8 Year Old with Neurovascular Injury"
An 8 year old healthy boy fell at the playground onto his outstretched left arm suffering a fracture above his left elbow with severe deformity. He was transported to the local emergency room where after examination and x-rays, he was diagnosed with a posterior displaced severe supracondylar humerus fracture. He was found on exam to have no radial or ulnar pulses at his left wrist, but the fingers, hand, and arm were pink and warm with minor diffuse tingling. The orthopedic surgeon saw him emergently in the ER and he was taken directly to surgery where he underwent a closed reduction and percutaneous pinning of the posterior supracondylar fracture. He was admitted for 24 hours observation.
The following day his pulses had not returned, his tingling and numbness were significantly worse, and his fingers, hand and arm were cool and no longer pink. He was emergently returned to surgery by the orthopedic surgeon where he underwent exploration of the fracture and was found to have an entrapped brachial artery, which upon release was found to be torn requiring emergency vascular repair. The fracture healed well but as a result of the vascular compromise his left arm suffered permanent muscle damage and functional loss.
The issues in this case are: should the orthopedic surgeon have explored the fracture and artery at the time of the first surgery since the child had no pulses; is it the standard of care to always explore this type of fracture when there are no pulses, even if the hand and arm are well perfused; is it reasonable to closely observe the injury after the initial closed reduction and percutaneous fixation and take action only if there are no return of pulses, or a worsening of the condition.
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"Death From a Fall and Fractured Hip in a Nursing Home Resident"
A 75 year old woman, who is the resident of a nursing home, has a number of general medical conditions, including senile dementia and confusion. The nursing home performs a fall risk evaluation and determines that she is high risk for fall. In spite of telling her many times that she is not to get out of bed without assistance and attaching a bed alarm, she manages to get out of bed confused one night and is found wandering the halls. After she is returned to bed she again gets out, this time falling on her left side. She is again assisted back to bed, the doctor is notified, and an x-ray is taken of the left wrist. She is diagnosed as having a wrist sprain and she is placed into a brace.
Over the course of the next few weeks the staff notice that she is more irritable, not eating, and having increasing difficulty moving about and walking, preferring to stay in bed. The nurse determines that her left hip area is painful and an x-ray is obtained showing a femoral neck fracture. She is transferred to acute care and taken to surgery where she receives a left hemiarthroplasty for the fracture. She is eventually returned to the nursing care facility where her condition deteriorates and she expires.
The issues in this case are: was the nursing home negligent in not taking steps to prevent this patient from getting out of bed without assistance; failing to perform a complete examination after she fell; failing to promptly diagnose and treat the hip fracture; was the acute hip fracture the cause of her death; was this situation unavoidable and just an accident.
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"Misdiagnosed and Untreated Knee Injury Leads to Premature Joint Destruction and Arthritis"
A 26 year old athletic man hyperextends his knee while playing basketball. He feels a pop and the knee is immediately painful. He hobbles off the court, unable to continue to play, and rests his knee for a few days thinking it will resolve. When it doesn’t 3 days later he is seen by his family doctor who takes an x-ray and tells him he has a sprained knee, that it is not serious, and gives him crutches to help him walk.
A week later it is no better so he is referred to an orthopedic surgeon who makes the tentative diagnosis of a torn anterior cruciate ligament (ACL) and sends him out for an MRI scan of the knee. The radiologist interprets the MRI as showing a torn ACL. Four days after the MRI is performed he returns to see the orthopedist, who tells him that it is probably a sprain and that the results of the MRI are not available, but will notify him if there is any abnormality on the MRI. The orthopedist sends him to physical therapy for a few weeks where he is encouraged to aggressively use his knee, play basketball, and return to his athletic lifestyle. He is never called by the orthopedist about the abnormal MRI.
Over the course of the next two years he has repeated episodes where the knee “goes out” feels unstable, and causes repeated “sprains” that require him to return to his family doctor for treatment. He is reassured that it is just a sprain and nothing serious. He eventually goes for a second opinion to another orthopedic surgeon who promptly diagnoses a torn ACL with chronic knee instability. During the arthroscopic surgery to reconstruct the ACL the surgeon finds complete destruction and loss of the cartilage in the knee from the chronic ACL instability and repeated episodes of the knee giving out.
The issues in this case are: failure to diagnose the torn ACL; failure to follow-up and read the MRI scan; failure to notify the patient with the results of the abnormal MRI scan; failure to protect the unstable knee; failure to advise the patient of the danger of not protecting his torn ACL unstable knee and the permanent damage it could cause to the knee joint cartilage; failing to surgically treat or brace the unstable knee; misdiagnosing as a recurrent sprained knee.
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"Slip and Fall Accident Causes Injury to Spine and Aggravation of Preexisting Condition"
A 42 year old man has chronic back pain and symptoms of spinal stenosis, including numbness, tingling, and pain down his left leg as a result of severe scoliosis and degenerative disease of the spine. He has been seeing a doctor for many years dealing with these symptoms and even had surgery recommended to him to fuse his spine as a last resort.
He slips and falls on a wet floor while entering a grocery store and suffers injury to his back and right ankle. He is transported by ambulance to the emergency room where he is diagnosed with a lumbar sprain and an ankle sprain. Almost immediately he develops severe radiating pain and tingling down his right leg. He continues to treat with the same doctor, but a new MRI shows a herniated and extruded disc in his lower back that was not present on an MRI done the year before he fell.
He undergoes lumbar surgery for the herniated and extruded disc but continues to have worsening symptoms of low back pain and spinal stenosis, with increasing numbness in both legs, pain, and occasional bladder incontinence. The following year he receives additional surgical treatment including anterior lumbar interbody fusion, correction of the scoliosis, and posterior spinal fusion with instrumentation and bone graft.
The issues in this case are: even though he had extensive preexisting disease and treatment, the herniated and extruded disc was a new injury that required surgical treatment; since the force transmitted through his spine was of such magnitude that it herniated and extruded the disc, it also aggravated the preexisting scoliosis and degenerative disease warranting additional and extensive surgical treatment; would he have required the same surgical treatment for the scoliosis and degenerative disease had the fall not occurred based solely on his preexisting condition; are there apportionable issues of causation and need for medical care.
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"Total Hip Replacement Causes Limb Length Discrepancy and Drop Foot"
A 68 year old otherwise healthy and active business executive is taken to surgery for degenerative arthritis of the hip and undergoes a non-cemented primary total hip replacement. The surgery is uneventful but when he wakes up in the recovery room he has a right drop foot and loss of sensation. He is told by his surgeon that this should get better over time and he is placed into a brace (ankle foot orthosis AFO) and is discharged home.
Over the course of the next few months the drop foot does not improve. A neurologist is consulted who performs electrodiagnositc tests including EMG and nerve conduction velocity, and he finds permanent damage to the sciatic nerve at the level of the hip. A second opinion is obtained from another orthopedic surgeon who on examination and measurement of the legs finds that the operated leg with the drop foot is 1 inch longer than the non-operated leg, and that the total hip components appear oversized and too large for the dimension of the hip.
The issues in this case are: implanting total hip components that were too big for the patient’s anatomy; causing a leg length discrepancy that stretched and damaged the sciatic nerve; causing a drop foot and permanent sciatic neuropathy by over lengthening the operated leg, failing to diagnosis the leg length discrepancy immediate post-op with acute sciatic palsy (drop foot); failing to take steps surgically immediately post-op to relax the acute stretch to the sciatic nerve and correct the limb length discrepancy; was the excessive length to the leg required to provide stability to the total hip components.
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"Total Shoulder Replacement with Post Operative Brachial Plexus Palsy"
A 54 year old executive chef is diagnosed with osteoarthritis of his dominant right shoulder and is taken to surgery where he undergoes a total shoulder replacement. The operation is performed in the standard manner but when he wakes up in the recovery room he has no feeling in his right arm and the arm is also paralyzed. A neurologic consultation including electrodiagnositc studies confirms a dense brachial plexus traction stretch injury and significant damage.
After many months of physical therapy there is only minor improvement in sensation and motor function. A comprehensive neurosurgical workup is performed, including contrast MRI of the brachial plexus and cervical spine, as well as repeat electrodiagnostic testing, and it is determined that the traction injury to the brachial plexus occurred at the level of the cervical spine during the total shoulder replacement surgery. Various complex tendon and muscle transfer surgeries were performed to try and improve the function of the right arm and shoulder.
The issues in this case are: was excessive traction force applied during the total shoulder replacement; was excessive positioning used during the total shoulder replacement; does the level of the injury to the brachial plexus automatically make this a case of negligence; is this a consentable complication that can occur during total shoulder replacement surgery.
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"Trimalleolar Ankle Fracture Leads to Rapid Post-Traumatic Ankle Arthritis and the need for Ankle Arthrodesis (Fusion)"
A 36 year old waitress twists her left ankle while getting off the bus. Her ankle pops, is deformed, and is severely painful. She cannot walk and is taken to the hospital by ambulance. In the emergency room x-rays are taken and she is diagnosed with a trimalleolar fracture with dislocation of the ankle. The orthopedic surgeon arrives and performs a closed reduction of the ankle in the ER and puts the patient into a well padded posterior splint. Three days later she is taken to surgery where he performs open reduction internal fixation (ORIF) of the bimalleolar ankle fracture but does not fix the posterior malleolar fragment.
Postoperatively she is treated in a cast and eventually attends physical therapy. She has persistent ankle stiffness and inability to regain functional motion. Her pain initially during rehab was minimal but over the course of 18 months it steadily worsened to the point that she could no longer put any weight on that foot. X-ray and MRI studies of the ankle revealed severe loss of articular cartilage, post traumatic ankle arthritis, and malunion of the posterior maleollar fracture. As a last resort she underwent ankle arthrodesis (fusion).
The issues in this case are: did the posterior malleolar fracture require ORIF at the time of the initial ankle fixation surgery; was the size of the posterior malleolar fracture fragment small enough to allow the surgeon to treat it without internal fixation; was the lack of fixation and anatomic restoration of the posterior malleolar fracture the cause of the accelerated post-traumatic ankle arthritis and need for ankle fusion; was the need for the ankle fusion caused by the initial injury itself and would have occurred regardless of the treatment to the posterior malleolar fracture.
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"Fractured Arm While Being Arrested and Handcuffed by the Police"
A petite 38 year old woman is stopped by the police for erratic driving. After she pulls to the side of the road and the officer approaches her car, he suspects that she may be intoxicated and she is asked to get out of the vehicle. The officer calls for backup and another officer arrives. After further evaluation they tell her that she is going to be arrested for driving under the influence and ask her to place her hands behind her back to be handcuffed. She becomes excited and agitated and begins to resist the arresting officer. The second officer steps in to assist and they attempt to grab and gain control so she can be handcuffed. Each of the officers is at least 6 feet tall and over 200 pounds.
She continues to struggle and is pinned up against the back of the patrol car. One officer holds her left arm while the other applies a control hold to her right arm to force her to submit and be handcuffed. The control hold places the right arm behind her back while the officer forcibly internally rotates and elevates the bent arm away from her back. During this maneuver there is a palpable and audible pop in the arm, she stops resisting, and the handcuffs are applied. She complains of severe arm pain and after x-rays are taken at the local emergency room, she is found to have a spiral fracture of the distal part of the right upper arm, just above the elbow.
The issues is this case are: was excessive force used by the arresting officer applying the control hold; did the fracture occur as a result of the control hold or as a result of the woman resisting arrest; in a situation like this is it possible for a person to exert enough force on their own to fracture their own arm; but for the force applied by the arresting officer would the arm have fractured on its own due to her own muscle contractions; how could the arresting officer know that the arm was about to fracture; can a person’s state of mind be so altered that they don’t know that their arm is on the verge of breaking; did the fracture occur as the result of the combined forces of the control hold and the resistance to the arrest.
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"Wrongful Death from Deep Vein Thrombosis/Pulmonary Embolism"
A 42-year-old morbidly obese policeman slips and falls on the ice while descending stairs, causing a severe hyperflexion injury to his knee. He suffers immediate severe pain in the right knee, and could hear as well as feel a loud popping. He tried to walk and had significant difficulty ambulating prompting an urgent visit to the local emergency department. After emergency evaluation, it was felt that he suffered a severe sprain to the right knee and he was placed into a knee immobilizer and crutches and advised to follow up with an orthopaedic surgeon.
Approximately three weeks later, he was seen by an orthopaedic surgeon who on clinical examination immediately diagnosed a complete rupture of the quadriceps tendon at the insertion to the patella of the knee and expressed concern as to why this had not been treated sooner. Within four days, he took the patient to surgery and repaired the acutely ruptured quadriceps tendon, placing him in a long leg cast with the leg in extension, nonweightbearing and continued him on crutches. After discharge from the hospital, he was seen in followup three days later where the cast was not removed. However, it was felt that the patient was doing well.
Three days after that, however, this individual was found unconscious and down on the floor in his bathroom in full cardiac arrest. He was pronounced dead at the local emergency room and the medical examiner/coroner report identifies the cause of death as acute deep vein thrombosis with resultant massive pulmonary embolism and blunt knee trauma.
The issues in this case include: the misdiagnosis in the first emergency department visit where he was diagnosed as having a knee sprain only, the lack of urgent orthopaedic consultation at the time of the first emergency department visit, the failure to recognize the high risk of this individual developing deep vein thrombosis and pulmonary embolism due to his lack of weightbearing, immobilization, blunt knee trauma, lack of knee movement, delay in definitive surgical treatment, morbid obesity, and failure to provide deep vein thrombosis prophylaxis.
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"Motor Vehicle Accident with Preexisting Degenerative Spine Disease"
A 62-year-old hospital food service worker that has been permanently disabled for 10 years due to chronic low back pain syndrome as a result of advanced multilevel degenerative disk and joint disease/spondylosis, and who has been participating actively in chronic pain management treatment, is the seat belted driver involved in a motor vehicle accident.
At the scene of the accident, the patient is able to exit the vehicle freely and ambulate and no emergency medical care or treatment is required. After driving the same vehicle home, this patient does not seek out any medical care or treatment for the next five days but then sees the same treating chiropractor who has been treating the chronic condition for many years and identifies new complaints of back pain as a result of the motor vehicle accident.
The patient then embarks on an acute course of diagnostic evaluation including MRI, CT scans, electrodiagnostic studies, neurologic consultations and extensive chiropractic treatment based on this motor vehicle accident.
The issues in this case are: what if any injuries were truly sustained as a result of the accident as compared to the preexistent disease process and the ongoing need for medical care and treatment in the absence of this motor vehicle accident; were there any new true structural or anatomical injuries that required care and treatment; in comparing the subjective complaints and objective findings prior to and subsequent to this motor vehicle accident, was there any justifiable increase or change that warranted acute medical care and treatment?
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"Failed Total Hip Replacement with Post-op Nerve Injury"
A 58-year-old male heavy equipment operator underwent a primary total hip replacement for the diagnosis of advanced degenerative joint disease and arthritis. Rather immediately postop, the patient began developing a sense of instability of the right hip and lower extremity with a feeling of popping and clicking and persistent pain that began within days postoperatively and persisted in the postoperative rehabilitation.
On repeated evaluations by his physician, he was told that this was normal and to be expected. However, after months of pain and dysfunction, he sought a second opinion. The second opinion orthopaedic surgeon found that the primary hip replacement was placed in a negligent fashion and was the direct cause of the instability, chronic pain, and dysfunction. This prompted a rather premature revision hip replacement.
In the recovery room, immediately after the revision hip replacement, the patient was noted to have a complete dense ipsilateral peroneal nerve palsy and drop foot. Electrodiagnostically, this ultimately was found to be due to extrinsic pressure of the peroneal nerve at the level of the fibula head that occurred during the surgery.
The issues in this case are: technical negligence in the primary hip replacement surgery causing premature failure and need for revision hip surgery, and the permanent peroneal nerve damage caused by extrinsic pressure on the knee during the revision hip replacement surgery.
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"Blunt Knee Trauma and Meniscal Tear"
A 38-year-old railroad worker, while descending a boxcar ladder, fell from the bottom rung onto the ballast bluntly striking the anterior portion of his knee in a nonweightbearing position and with no twisting forces. He was able to stand up by himself and continue working the rest of his shift. The next day, he filed an injury report and sought medical treatment for his knee injury. He was evaluated and diagnosed as having a knee contusion and treated appropriately for that injury.
Four months later, after his claim became litigated, he was seen by an orthopaedic surgeon and diagnosed as having a torn meniscal cartilage in the knee necessitating arthroscopic meniscal surgery and extensive rehabilitation. He was ultimately deemed unable to return to his usual and customary job and permanently disabled.
The issues in this case are: was the torn meniscal cartilage caused by the fall from the railcar or was this an unrelated condition? If the meniscal tear was caused by this incident, was the treatment he received reasonable and necessary, and ultimately was he truly permanently disabled?
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"Failure to Diagnosis and Treat Acute Post-Op Cervical Spine Infection"
The patient is a 36-year-old professional country Western singer who insidiously developed neck pain with burning paresthesia into the shoulder and upper extremity with some associated numbness and tingling. She saw her orthopaedic surgeon who after MRI scan found that she had neuroforaminal stenosis and degenerative disease and took her to surgery performing a cervical decompression including foraminotomy.
While admitted in the hospital, she had excellent relief of her symptoms with resolution of the burning paresthesia and symptoms into the upper extremity immediately postoperatively. However, within three days, she not only had a return of the same symptoms but they were even worse, spreading to the opposite side and causing a systemic response including low grade fever and nausea. Without any definitive workup, her treating physician placed her on an oral antibiotic and discharged her home from the hospital.
The following morning, however, she returned to the emergency room even worse with symptoms now into the ipsilateral lower extremity. The emergency department physician ordered an urgent cervical MRI scan, intravenous antibiotics and she was admitted to the care of her treating orthopaedic surgeon. The following day, however, the surgeon canceled the MRI scan and discontinued the intravenous antibiotics. He did not call for an infectious disease consult and asked the physician assistant to attempt to aspirate the cervical surgical wound area. After being advised by the physician assistant that no liquid could be aspirated, the patient was discharged home again in spite of her complaints of nausea, vomiting, fever, and increasing pain and burning, numbness and tingling into the upper and lower extremities.
The patient did not go home and instead went directly to another emergency room where she was admitted to the care of another surgeon who promptly took her to surgery and drained a large postoperative cervical epidural abscess. She developed osteomyelitis necessitating vertebrectomy and multiple additional cervical surgeries. Ultimately, she was left with a partial right hemiparesis.
The issues in this case include: misdiagnosis, the failure to treat a significant postoperative spinal infection, and disregard for the welfare of the patient.
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"Apparent Minor Traffic Accident with Neck and Back Injuries"
The patient is a 21-year-old right front seat passenger involved in a rear-end motor vehicle accident. There is no visible damage to the vehicle except a scratch to the bumper and the patient did not develop any symptoms of neck or back pain until five days later. After retaining an attorney, she embarked on a course of medical and chiropractic treatment for over two years with treatments to the neck, middle back, lower back, hips, upper and lower extremities.
The patient underwent multiple x-ray, MRI and CT analyses, all found to be normal. She was examined by neurologists, chiropractors and orthopaedic surgeons, all identifying her complaints of pain but finding nothing objectively abnormal on the physical exam. Upon discharge from treatment, she was deemed as suffering from a chronic pain syndrome that would forever permanently alter her lifestyle and need treatment.
The issues in this case include: the orthopaedic biomechanics of the claimed injuries, and what, if any, injuries were sustained at all; what treatment may have been indicated and reasonable, and what reasonable costs would have been associated with that treatment; do the medical findings truly support the diagnosis, impairment, and future medical needs?
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"Acute Carpal Tunnel Syndrome versus Chronic Continuous Repetitive Trauma Carpal Tunnel Syndrome"
The patient is a 38-year-old legal secretary who, for over 12 years, has been extensively performing data entry and keyboard work as a usual and customary part of her eight-hour job duties. On the way home from work, she was involved in a front-end motor collision. The collision was not severe enough to activate her airbags. However, she states that she was holding onto the steering wheel and suffered injuries to both wrists, neck and back.
She required no emergency treatment. However, one week later, she began physical therapy for her neck and back complaints. Six weeks after the date of incident, she began complaining of numbness and tingling in both hands and all of her fingers. Her treating physician thought she may have had a neck injury with radiculopathy and sent her for electrodiagnostic studies. Those studies, however, found the neck was not the source of her symptoms but that she was suffering from carpal tunnel syndrome bilaterally, worse on the right than the left.
With this finding, she was referred to an orthopaedic hand surgeon who promptly performed bilateral carpal tunnel release surgery and in the ultimate legal report stated that the carpal tunnel surgery was directly caused by the motor vehicle accident and blunt trauma.
The issue in this case is: the cause of the carpal tunnel syndrome and its relationship to the motor vehicle accident. Blunt force trauma to the wrists and hands is a known cause of acute carpal tunnel syndrome. However, a more common cause is continuous repetitive trauma such as keyboard data entry, typing and computer work. Did this patient fit the clinical pattern with supporting objective findings of an acute carpal tunnel syndrome or rather was this an incidental finding and representative only of continuous trauma due to her over 12 years of typing activity?
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