5
…………. Medical Report of ……………… continued
ORTHOREPORT
Principals: St John's Court
Mr J P Hodgkinson MB.ChB, FRCS 76 Gartside Street
Mr P Kay MB.ChB, BA, FRCS Manchester
Mr I A Trail MD, FRCS M3 3EL
Associates:
Mr S Talwalkar MBBS, MS (Orth), MCH (Orth), FRCS (Tr&Orth)
Mr R Smith MB.ChB, FRCS.Eng (Tr&Orth)
Mr. Nikhil A Shah MBBS, MS, (Orth) MCh (Orth), FRCS (Tr&Orth)
Mr. Puneet Monga FRCS (Orth), Dip Sports Med, MSc, MS, DNB, MBBS
Mr. Stephen Bale, MB.ChB., BSc, FRCS (Ortho)
Contact Details: Anita Johnstone Tel: 07825 298969 Fax: 0161 839 1749
E-mail:
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MEDICAL REPORT TO THE COURT
Date:
Ref:
Prepared upon the instruction of:
Ref:
Re:
Address:
Date of Birth:
Present Occupation:
Occupation at time of accident:
Hand Dominance:
Date of Accident:
Date of Examination:
Date of Report:
Place of Examination: St. John’s Court, 76 Gartside Street, Manchester.
Records Reviewed: Photocopied GP records, hospital records, X-ray CD rom.
Date of Instructions:
Nature of Instructions: Claimant
……………. was examined at St. Johns Court, Gartside Street on …………… for the purpose of preparing this medical report for the Court.
HISTORY OF EVENTS ACCORDING TO CLAIMANT
History of Index Accident
………… tells me that on ……………., he stepped out of his house and was crossing the road to the shops. Due to the way the cars were parked, he was crossing in a slightly unusual place compared to his normal spot. He tells me he inadvertently stepped into a pothole just as he went off the kerb and went over on his right ankle.
Injuries Sustained
He immediately felt clicking and pain in the ankle and hopped home. The ankle was painful that night and due to the residual pain, he attended the accident and emergency department at the ………………... He had an x-ray which he tells me identified no fracture. Over the next few days, the ankle remained swollen and very bruised. The pain radiated up his leg during weight bearing. The pain in the ankle has improved over the subsequent three to four months and the bruising has diminished.
Progress and Subsequent Treatment
……….. has required no further investigations or treatment following this. He tells me he has done his own physiotherapy exercises as he has experience of ankle physiotherapy having broken his left ankle in the past.
PAST MEDICAL HISTORY
At 13 years old, …………. sustained a left ankle fracture. He is otherwise fit and well. He has had no previous injuries to his right ankle and no previous accidents or operations.
PRESENT SITUATION
………….. tells me the ankle feels a bit loose and wobbly at times. His foot feels numb at times. He finds that the ankle tips over easily and swells.
Functional Effects
……… was off work for one week following the accident. He is back on full duties and has had no changes to his employment as a result of the index accident.
Driving
……….. is currently learning to drive.
Hobbies
………. tells me he used to play football quite a lot but has to stop prior to the index accident due to looking after his children. He enjoyed swimming as a child and had done some rollerblading but doesn’t do anything now. This isn’t as a result of the index accident.
Domestic Activities
………. is involved with the cooking and shopping.
Gardening
……….. has never performed these activities and has not started to now.
DIY
…………. was limited for the first two months following the index accident but has now returned to most activities.
ON EXAMINATION
He walks with a normal gait in normal footwear. The left foot and ankle are of normal appearance and alignment. The right ankle dorsiflexes to 15 degrees symmetrical with the left. It plantiflexes to 40 degrees compared to 50 on the left. There is tenderness but no instability over the peroneal tendon. He has marked tenderness and a positive anterior impingement test over the lateral ligament complex. He is apprehensive on maximum ankle inversion suggestive of lateral ligament complex insufficiency. His anterior drawer test is negative (that is normal). Sub-talar joint and mid foot movement are normal.
REVIEW OF RECORDS
Hospital Records
. Accident and emergency records. Inversion injury to right ankle whilst walking. Swelling over the lateral malleolus with painful weight bearing, no other associated injury. On examination right ankle, swollen over lateral malleolus, tenderness +. Plan x-ray right ankle. X-ray no fracture seen. Advice and home.
GP Records
Correspondence
Accident and emergency attendance with injury to left foot.
Attended fracture clinic with injury to left foot, possible fifth metatarsal fracture.
A & E discharge letter. ? fracture right ankle. Diagnosed as sprain or strain, discharged home.
X-rays
Right ankle, AP and lateral. No bony injury, a small amount of soft tissue swelling over the lateral malleolus.
Handwritten entries
No relevant entries.
Computer generated entries printed 20 September 2013
No further relevant entries.
OPINION AND PROGNOSIS
………. sustained an inversion injury to his right ankle on …………. The mechanism of injury described, that is twisting his ankle in an inversion manner stepping in a pothole is that which in my opinion is consistent with sustaining a soft tissue injury to the lateral ligament complex of the ankle. …….’s symptoms were significant enough for him to attend A & E where he had an x-ray that has demonstrated no fracture. In my opinion the treatment provided to ………. thus far has been appropriate. In my opinion the fact that ……….. has made a good recovery over the ten month period of time subsequent to the index accident is consistent with the nature of the injury sustained.
……… does complain of some persistent problems with pain and swelling but more so over the ankle feeling loose and wobbly and that it gives over easily. One of the possible sequelae of an ankle lateral ligament tear that does not improve is that in fact the ankle can remain unstable and require further investigation and treatment. In my opinion at this stage, ………. would be best assessed by having an MR scan of the ankle to look at the integrity of the lateral ligament complex and also to look at the talar dome.
Should he have persistent problems with lateral ligament instability, I would suggest that assessment by an foot and ankle orthopaedic surgeon with a view to performing stress views to see if the ankle gives way and if it does, to perform lateral ligament reconstruction surgery maybe what is to be required in the short to medium term. I would suggest further assessment of ………… subsequent to investigation and necessary treatment in order to provide a final prognosis.
Declaration
1. I understand that my overriding duty is to the court, both in preparing reports and in giving oral evidence. I have complied and will continue with that duty.
2. I have set out in my report what I understand from those instructing me to be the questions in respect of which my opinion as an expert is required.
3. I have done my best, in preparing this report, to be accurate and complete. I have mentioned all matters which I regard as relevant to the opinions I have expressed. All of the matters on which I have expressed an opinion lie within my field of expertise.
4. I have drawn to the attention of the court all matters of which I am aware, which might adversely affect my opinion.
5. Wherever I have no personal knowledge, I have indicated the source of factual information.
6. I have not included anything in this report which has been suggested to me by anyone, including the lawyers instructing me, without forming my own independent view of the matter.
7. Where, in my view, there is a range of reasonable opinion, I have indicated the extent of that range in the report.
8. At the time of signing the report, I consider it to be complete and accurate. I will notify those instructing me if, for any reason, I subsequently consider that the report requires any correction or qualification.
9. I understand that this report will be the evidence that I will give under oath, subject to any correction or qualification I may make before swearing to its veracity.
10. I have attached to this report a statement setting out the substance of all facts and instructions given to me which are material to the opinions expressed in this report or upon which those opinions are based.
11. That I know of no conflict of interest of any kind other than any which I have disclosed in my report.
12. That I do not consider that any interest which I have disclosed affects my suitability as an expert witness on any issue on which I have given evidence.
13. That I will advise the party by whom I am instructed if, between the date of my report and the trial, there is any change in circumstances which affect my answers to either of the above two points.
Statement of Truth
I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.
I confirm that I am aware of the requirements of CPR Part 35 and PD 35, the protocol for the instruction of experts to give evidence in civil claims (supplementing PD 35, para 13.5) and the PD on pre-action conduct and confirm that I have complied with them.
Mr. Robert Smith, MBChB, FRCS (Eng) (Tr&Orth)
Consultant Trauma and Orthopaedic Surgeon