top of page

Inadvertent scaphoidectomy

A junior surgeon gets a horrible surprise during a routine Trapeziectomy

Before I start let me state the facts: why did this mistake happen? It happened because I didn't even contemplate that it could happen.


All going smoothly


“…this is a procedure I have performed 14 times before (both supervised and unsupervised) and assisted a further 7 times. The consultant stood to my right, passing me instruments and the scrub nurse was sat opposite me stabilising the arm...”


One false move


The anatomy on the back of the wrist can get a little busy. You have to identify the interval between APL and EPB while watching out for the SBRN in order to identify and protect the radial artery.


The next step is often to place a McDonald's dissector (or similar) between the base of the 1st Metacarpal and the Trapezium to confirm the location of the 1st CMC joint.

"It happened because I didn't even contemplate that it could happen"

Warning signs


In retrospect everyone agreed that there were warning signs from the beginning. A Trainee too eager to make a good impression? A highly experienced Consultant who was willing to trust them? An incision a few millimetres out of place? Not just taking a few extra seconds to double check the position.... and then triple check....


Holy f******* ****


When the 'Trapezium' came out it was more or less whole, which is unusual. It was also massive and some very big alarm bells started to ring.


The patient was awake under Regional Anaesthetic, so that needed careful management. The wait for Xray was one of the longest of everyone's lives, and when it arrived it told the whole sorry tale.


OK so it's not just me, then?


As dreadful as this mistake was it turns out it is not as rare as one might think / hope. As one study showed:


"...We distributed the survey to 777 hand surgeons via email... Ninety-nine surgeons responded to our survey. Twenty-three respondents had participated in an excision of the incorrect bone in the wrist. The most common error was partial or complete excision of the scaphoid during a planned excision of the trapezium...."


- Caggiano 2017


Managing


Full duty of candour was undertaken verbally and in writing. The patient was transferred to to the care of another Surgeon in the region. They underwent an arthroscopy but have not at time of writing (4 years later) required any further surgery. They even elected to have a Trapeziectomy on the other side...

コメント


bottom of page