This is the third in a series of articles addressing hand injuries. Another often-encountered injury in a personal injury setting is the partial amputation of a finger. For the most part, we encounter partial amputations in a production line setting, so that is a workers’ compensation matter with a products liability aspect or strictly a products liability claim as a result of a product used at home that is defective, such as an unguarded mechanical saw or a food processor.
In almost every instance, the defendant in the action will downplay the significance of a partial amputation; however, the plaintiff’s attorney needs to understand that a partial amputation can be a devastating injury and could result in a large case.
By way of background, the four fingers and thumb have a total of 14 bones called phalanges, commonly known as finger bones. There are three phalanges in each finger and two phalanges in the thumb. There are also 14 knuckles in the hand. Each finger has three knuckles and the thumb has two knuckles. The knuckles are the joints of the fingers and thumb. Each knuckle connects the phalanges to each other. The first knuckle is the closest to the base of the hand or the palm, the second knuckle is at the midfinger and the third knuckle is the closest to the tip of the finger.
This is important to understand, because the medical reports will typically indicate that the amputation was to the third knuckle or second knuckle or first knuckle. Defense medical examiners will sometimes refer to the third knuckle as a minor knuckle. Plaintiffs attorneys cannot fall into this trap. Obviously, the more knuckles involved, the more cosmetic damage and more potential for functional damage. However, it does not necessarily mean the injury is worse just because it involves more knuckles. Stated another way, an amputation isolated to the third knuckle is many times a serious injury. The key is whether the injury is such that it leaves residual pain or dysfunction that compromises the utility of the entire hand.
It is necessarily true that when there is an amputation, there is resultant scar tissue. The nature of this scar tissue is such that it can become a neuroma. According to the National Institutes of Health website, a neuroma is a tumor made up of nerve cells and nerve fibers. This tumor can entrap the radial digital nerve and the ulnar digital nerve in the hand, causing intractable pain. All of the medical literature suggests that a painful neuroma in the amputation stump of a finger can be psychologically and physically disabling.
In fact, many hand surgeons have dedicated their academic careers to studying combating neuromas. Numerous surgical procedures been developed to prevent and treat amputation neuromas of the finger, but the results are universally considered inconsistent.
When cross-examining a defense medical expert, it is important that the plaintiff’s attorney understands how a neuroma is typically diagnosed and treated. The neuroma itself is a mass that develops at the area of the amputation. It is visible on examination and palpation. Even more importantly, assuming the plaintiff has undergone a procedure to address the neuroma, the surgical report should contain a wealth of information. For instance, the surgeon should be able to visualize the neuroma during the surgery. The surgical report should indicate whether the neuroma was impinging upon the radial digital nerve or the ulnar digital nerve or both. The surgical report should also indicate the size of the neuroma and whether or not it required resection. Any of these findings are objective indicia of pain and support any complaints of pain reported by the plaintiff.
During the surgical procedure, the surgeon will typically try to control the nerve damage by essentially capping the nerve endings to limit the amount of pain and sensitivity. There is a commercial product called a NeuraGen tube, which many surgeons will implant to cap the nerve endings. Information about the NeuraGen tube can be found on the website of the company that manufacturers the tube, Integra.
The plaintiff’s attorney should not allow the defense medical expert to testify that the plaintiff should not be experiencing pain merely because he or she has already undergone the implantation of a NeuraGen tube. The defense medical examiner should readily concede that the tube is not a guarantee of success and that many times the initial nerve injury and/or pain is, in fact, irreversible.
The plaintiff’s attorney should also be ready to respond with a variety of activities and circumstances known to aggravate the symptoms of a neuroma, such as a cold environment or any activity where the hand experiences vibration through using machinery.
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.