Mr P, a right-handed project manager, developed a stiff right elbow following a previous injury, and had reached the limit of his progress with physiotherapy. X-rays showed degenerative changes and he was referred to an orthopaedic consultant, Mr A, who diagnosed osteoarthritis of his elbow. He advised Mr P that as he had significant anterior and posterior osteophytes he may need multiple arthroscopic debridements to achieve a good outcome.

After an arthroscopic anterior debridement, there was only minimal improvement and further surgery was planned. There were another two debridements, the third one being more than six months after the initial procedure, before Mr A was happy with the result.

Two months later Mr P returned with a reduced range of movement in his elbow. X-rays confirmed the presence of massive heterotopic ossification (new bone growth), which was confirmed on CT. Mr A planned a fourth arthroscopic debridement two months later. No discussion relating to the possible risks and complications of surgery was documented. The limited operation note for this complex arthroscopic debridement described significant bone removal and a full range of movement at the end of the procedure.

In clinic two days later Mr P was noted to have a radial nerve palsy, but Mr A felt that some nerve conduction was present and that this was a neuropraxic nerve injury, which should recover completely. He commented that the procedure had been lengthy at over an hour and ten minutes. Mr P returned ten days later as there was no change in his symptoms, but Mr A was reassured by the presence of a positive Tinel’s test and felt the nerve palsy would recover. He planned M for review in six weeks, which was three months post-surgery, but again there was little improvement. Mr A commented that the positive Tinel’s could now be felt up to the fingertips. An appointment for three months later was made, but still there was no improvement.

Six months post-surgery, Mr A now requested nerve conduction studies, which were performed within days, and reported the presence of a severe radial nerve injury. Plans were then made for surgical exploration of the nerve with possible repair, grafting or neurolysis as necessary.

Mr P made a claim against Mr A, stating that his nerve injury had left him with a permanent disability including reduced grip and manual dexterity, plus an inability to extend his fingers. He believed that the surgery should have been an open procedure rather than arthroscopic, and that had his injury been diagnosed sooner, and not presumed to be a neuropraxia, then he would have had a better outcome.

On review of the case, an expert felt that as long as Mr A had the necessary experience it was not negligent to carry out the surgery arthroscopically. There is still a risk of radial nerve injury when carrying out this surgery with an open technique. However, Mr A was found to be negligent in causing the nerve injury, keeping poor documentation, and delaying arranging nerve conduction studies. The lack of any documented discussions about the risks of the surgery was also a factor in the outcome of the case.

The case was settled for a substantial sum.

Learning points

• With a CT scan showing extensive heterotopic ossification, the fact that there is no documentation of any discussion regarding risks of surgery, including possible nerve injury is unacceptable.
• Mr A’s operation note was not of an acceptable standard, with only minimal procedural details of the debridement and no comment on the integrity of the capsule at the end of the procedure.