Last month I completed a series of three articles that addressed certain common ankle injuries as well as some common foot injuries. This month I am beginning a series of articles that will address hand injuries.
Generally speaking, the appropriate expert witness in a hand injury case will be an orthopedic surgeon, preferably an orthopedic surgeon with fellowship training on the hand. The hand is a very specialized field and most orthopedic surgeons do not perform surgery on the hand unless they have hand-specific fellowship training. Of course, if a generalized orthopedic surgeon is on-call in a hospital setting and a traumatic hand injury arrives in the ER, the orthopedic surgeon should and does perform emergency hand surgery.
Before going into any specific injuries, I first wanted to begin with a basic understanding of a hand examination. A hand examination is a very complex process with somewhat unique terminology. Physicians will use the terms radial side of the hand and ulnar side of the hand. The radial side of the hand is the side of the hand where the first two fingers are located, commonly referred to as the index finger and the middle finger. The radial side of the hand includes the thumb. The ulnar side of the hand is the side of the hand where the third and fourth fingers are located, commonly referred to as the ring finger and pinky finger.
When examining the hand, the physician will perform a number of provocative maneuvers in order to isolate a particular abnormality. The most common provocative maneuvers are called the Tinel’s test, radial stress test, the ulnar stress test, the TFCC test, Phalen’s test and reverse Phalen’s test.
The Tinel’s test is designed to test for nerve entrapment for one of the three nerves that innervate the hand. Those three nerves are the ulnar nerve, the median nerve and the radial nerve. The test is performed by tapping (or percussing) directly onto the nerve in a particular spot. The test is abnormal when it produces a pain response.
If only one of the three nerves produces an abnormal response, it allows the physician to isolate the affected nerve and better define the injury. The radial stress test is designed to determine the integrity of the radial and collateral ligaments. This test is also referred to as a varus stress test. The test is abnormal when it produces pain or instability, also known as laxity. The ulnar stress test is designed to determine the integrity of the medial or ulnar collateral ligaments. The test is also referred to as a valgus stress test. The test is also abnormal when it produces pain or instability.
A TFCC (triangular fibrocartilage complex) test is performed by rotating the wrist in the area of the TFCC. The test is abnormal when the physician can appreciate an audible clicking in the wrist. The Phalen’s test and reverse Phalen’s test are both designed to test for carpal tunnel syndrome. The tests are not abnormal when producing pain; rather, the tests are abnormal when causing numbness or tingling in the thumb, index or middle fingers.
When cross-examining a defense medical expert, it is important that the plaintiffs attorney understand each of the different tests and terminologies so he or she can fully understand which abnormalities the plaintiff is demonstrating on exam.
An effective cross-examination can be crafted when the particular patient has consistent abnormalities on particular provocative maneuvers, yet is normal on other provocative maneuvers. In other words, the patient is presenting with consistent anatomical complaints that isolate a particular injury.
A very important test on the hand is the Jamar Dynamometer test. I highly recommend that all attorneys go on Youtube and watch an instructional video on how this testing is performed, because many defense medical examiners will use this test on exam to allege symptom magnification.
The test is too detailed to describe in one article, however, essentially the test is performed on both hands to test for grip strength and pinch. The test is performed at various forces and a series of results are recorded. The examiner tests both the injured hand and the non-affected hand. A so-called valid test will produce what we call a bell-shaped curve response.
All physicians accept that a patient cannot fabricate a bell-shaped response. The plaintiffs attorney needs to be aware of this for two reasons: First, all defense medical examiners will be forced to admit that a bell-shaped response is a valid response and indicative of a true injury, presuming the bell-shaped response demonstrated weakness in the affected hand.
Second, the plaintiffs attorney needs to be aware that a motivated defense medical examiner can use the exam to demonstrate symptom magnification when none really exists. If the defense medical examiner does not specifically explain to the patient the nature of the test and what he or she is hoping to accomplish, the results may be unfair due to the patient’s reluctance to perform any exam that may cause pain.
As this series continues, I will go into specific injuries and their known causes.
Brandon Swartz is a founding partner of Swartz Culleton. His practice focuses on all types of personal injury cases including wrongful death, medical malpractice, civil rights violations, motor vehicle, premises liability, products liability, trucking accidents and workers’ compensation.