Peripheral nerves are responsible for conducting impulses to and from end organs. They can be purely sensory, purely motor or mixed. These injuries may occur as a result of external compression, stretching or complete transection. The usual period of recovery is about 6–8 weeks. However, some nerves may never recover due to permanent damage.

Classifications

Nerve injuries can be classified on the basis of the residual function, pathology and according to the severity of injury.

Complete or incomplete

A nerve injury is said to be complete when all neurones traversing the injured segments are disrupted, leading to complete loss of motor and sensory functions. On the other hand, in incomplete injuries, some neurones remain intact and retain their function resulting in a partial motor or sensory loss.

Pathological classification

Seddon classified nerve injuries into three types: neuropraxia, axonotmesis and neurotmesis.

Neuropraxia: This mild injury is often described as ‘nerve concussion’. It is characterized by a temporary conduction block due to segmental demyelination of the neurones following stretching or compression. Because there is no structural damage to the neurones, function is restored in days or weeks soon after remyelination of the injured segment. A common example of such an injury is ‘Saturday Night Palsy’ which occurs as a result of prolonged pressure on the medial side of the arm against a sharp edge such as the back of a chair.

Spinal injuries: general aspects

Road traffic accidents and falls from a height are the common causes of most spinal injuries. Standard precautions should be observed in all cases with a suspected spinal injury. The use of a ‘hard cervical collar’ and principles of ‘in-line immobilization’ and ‘log roll’ are mandatory in order to avoid any further injury.

Pain is the most common symptom in a conscious patient. Local bruising, tenderness and a palpable step suggest a significant spinal injury. A complete neurological assessment (Fig. 58(a)(i)(ii)) should be carried out at initial presentation; and repeated at regular intervals. This should include the assessment of the cranial nerves, motor and sensory functions and testing of reflexes (anal, bulbocavernosus, deep tendon reflexes, etc.). Rectal examination is mandatory in order to detect the loss of anal tone, diminution in perianal sensation and presence of blood in the anal canal.

About 10% of patients with a spinal injury at one level may have spinal involvement at a different level. Therefore, a complete clinical and radiological assessment of the entire spine is necessary in all cases.

Standard AP and lateral radiographs should be requested for all spinal injuries irrespective of the level of involvement. However, an open mouth (peg view) is also required to rule out injury to the odontoid process or body of the second cervical vertebrae (axis). Oblique and flexion–extension views are reserved for stable injuries and should be performed only under the supervision of an experienced clinician.

A fracture is a break in the continuity of the cortex of the bone. It represents failure of the bone to respond to a high impact, which can be direct or indirect. Associated injuries to the adjacent soft tissues (e.g. ligaments, tendons, etc.) are not uncommon.

Mechanism of injury

Although most fractures occur due to direct or indirect trauma, other mechanisms may be responsible in some special situations.

Direct injuries

In these injuries, the forces are concentrated at one site and, therefore, the bone fails at the point of impact. Fractures occurring due to direct mechanisms are often comminuted and may be associated with significant soft tissue injuries. A typical example is a comminuted tibial fracture sustained by a pedestrian due to direct impact from a speeding car.

Indirect mechanisms

The force causing the fracture is applied at a distance in indirect mechanisms and therefore, associated damage to soft tissues may not be much. An intracapsular fracture of the femoral neck is a typical example of an injury with indirect mechanism. An olecranon fracture caused due to a sudden contraction of the triceps during a fall is another example of an injury from indirect forces.

Pathological fractures

Such fractures occur with trivial trauma to the bones that are already weakened by a disease process such as malignancy or infection. Pathological fractures occurring due to secondary malignant deposits in the hip often involve the subtrochanteric region. The patient may give a history of local pain or discomfort prior to fracture.

A fracture communicating with the external environment through a break in the skin or other viscus is described as an open or compound fracture. The wound is either produced from a sharp spike of the fractured bone (compounding from within) or through external penetration of an object. The risk of infection rises exponentially when a fracture is exposed to the external environment. Open fractures should therefore, be regarded as an orthopaedic emergency.

Mechanism of injury

The kinetic energy imparted to the tissues produces varying degrees of damage depending upon the amount of force applied. Severe forces may cause gross comminution of a fracture along with contusion, crushing or complete disruption of the surrounding muscles and other soft tissues.

Open fractures are usually caused by the following mechanisms:

Road traffic accidents: Direct impact on a body part causes shearing and disruption of tissues underlying the skin. A common example is an open tibial fracture sustained by a pedestrian after being hit on the shin by a fast moving vehicle.

Falls: Even simple falls may result in significant soft tissue disruption, and this is usually caused by the sharp end of the fractured bone.

Gunshot wounds: High or low velocity firearms cause tissue damage through two different mechanisms. The missile causes varying degrees of direct damage to the tissues, depending upon its distance from the body and also the amount of force imparted to it. The missile also produces destruction of the surrounding soft tissues through ‘shock waves’ generated around it.

Bone is a highly specialized connective tissue that normally heals with the formation of a similar tissue after injury. The healing commences soon after injury and the fractured segment undergoes a series of changes before normal strength and anatomy are restored. Fracture healing can be discussed under four headings:

• Haematoma formation

• Inflammation

• Callus formation

• Remodelling

Haematoma formation: A disruption of the endosteal and periosteal blood supply following an injury causes haematoma formation in the vicinity of the fracture. This haematoma may occur as a localized collection of blood bounded by a periosteal envelope. It may also appear in the neighbouring soft tissues, especially if the periosteum is completely torn. A fusiform swelling develops at the fracture site due to the combined effects of haematoma and oedema. The fracture ends start showing signs of ischaemia and necrosis as early as 24–48 hours of injury.

Inflammation: An aseptic inflammatory response develops soon after the injury and inflammatory cells such as polymorphonuclear leucocytes, lymphocytes, endothelial cells, etc. invade the fracture haematoma. The swelling produced by the haematoma at the fracture site causes periosteal loosening from the underlying bone. The mesenchymal cells beneath the periosteum proliferate and may differentiate into osteoblasts. The endothelial cells form capillary buds, which continue to grow at the fracture site with the development of bone tissue.

Callus formation: The osteoprogenitor cells beneath the periosteum and endosteum, undergo rapid multiplication which causes the growth of granulation tissue on either side of the fracture.

The community stands in awe of cardiac surgeons, who daily stop and restart the beating heart, symbolic of life itself. The community also has a high regard for neurosurgeons who, somewhat less dramatically, not only save lives, but may in addition be able to prevent a life of paralysis or dementia. Other surgeons occupy lesser positions on the pedestal, depending on their work. So avid is the public for surgical stories, it could be argued, that the term ‘the wonders of modern surgery’ has become hackneyed; wearied by a string of TV shows from Ben Casey to ER, House and Grey's Anatomy, not to mention countless numbers of newspaper articles, magazine features and books on the subject.

But all surgeons stand on the shoulders of their predecessors. The current state is the product of a process, gradual at first, which has followed an exponential path over about a 150 years since the discovery of anaesthesia let the ethereal genie out of the bottle. Many more than three wishes have been granted, and perhaps surgical success has become so trite that some fundamental truths are overlooked.

• The progress from which we now benefit can only have been achieved by a process of trial and error involving human subjects. It seems singularly unlikely that the necessary experimentation was always conducted in a way that would satisfy modern ethical standards, yet we incorporate the knowledge in our current practice anyway.

• The individual cardiac, neuro- and other surgeons that we so admire have not arrived at the height of their powers by some form of transmutation, but rather by means of a very human process of learning, involving, as it always does, trial and error. For surgeons, the trial and error involves – and adversely affects – human subjects.

Introduction

Obtaining informed consent from patients and research subjects is often seen as an impossible goal. Practical difficulties abound in the disclosure of information, the processing of information and with patient understanding of information. Some people view these practical difficulties as limitations of informed consent. These difficulties and perceived limitations are some of the objections appealed to when it is suggested that patients offered surgery should have access to information about individual clinicians' performance (Clarke, this volume; Clarke and Oakley, 2004). In this chapter I outline the requirements for informed consent and comment on the moral authority of informed consent. I then outline recent influential criticisms of informed consent by Onora O'Neill and Carl Schneider and assess the main practical limitations these authors identify. Based on this assessment, I argue that the practical difficulties can be dealt with – they do not rule out the possibility of informed consent. Instead of practical difficulties, major impediments to achieving informed consent are the result of a failure to adequately value patient autonomy (the value underlying informed consent) and relying on an impoverished or underdeveloped view of autonomy. I argue that a proper understanding of informed consent and patient autonomy clarifies the ethical obligations of health care professionals. A proper understanding of informed consent and patient autonomy also shows us that there is an ethical obligation to provide information about individual clinicians' ability to perform an intervention. I conclude by considering the effect on the doctor–patient relationship of providing information about clinician performance.

Reporting performance information

Surgeon performance information has been collected, tabulated and publicly reported since the early 1990s, first in New York State and then in other American States, and now in the United Kingdom. Performance information on surgical units and on hospitals has been collected for some time before this, but the public release of such information is a relatively recent phenomenon, as are report cards on the performance of individual surgeons and certain other clinicians. In this final section of the collection we turn our attention to the ‘report cards movement’ itself, with chapters examining a variety of issues that have emerged in studies of the impact of report cards on the performance of hospitals, units and individual surgeons.

Our first chapter in the section, by Silvana Marasco and Joseph Ibrahim, examines the impact of public reporting of surgeons' performance on patient care. The authors consider, in some detail, the impact of cardiac surgeon report cards on the quality of cardiac surgery, on cardiac patients and on cardiac surgeons and other stakeholders, particularly in light of the US experience with report cards on individual cardiac surgeons. Rachel Werner and David Asch also examine evidence of the impact of public reporting on the quality of health care services. They argue that existing US public reporting initiatives have not been conclusively shown to improve healthcare quality, and indeed, that there is some evidence that public reporting has various unintended negative consequences for patient care.

Every few years a rogue doctor comes to prominence in the international media. Some, like James Wisheart, the senior paediatric cardiac surgeon at the centre of the Bristol Royal Infirmary Scandal are deemed to be plainly incompetent to perform the operations that they have been undertaking. Others, like Jayant Patel, the surgeon at the centre of the recent scandal at the Bundaberg Base Hospital in Queensland, Australia, appear from the evidence to combine incompetence to perform operations undertaken with a willingness to place their patients in situations of unnecessary risk. The focus of the media on such sensational cases can obscure the fact that there are many less newsworthy, but nevertheless incompetent, physicians practising. According to Atul Gawande, science and technology writer for the New Yorker:

When people are faced with the prospect of having to undergo surgery, they invariably like to be reassured that they will receive a high standard of care. There are many variables that contribute to the determination of the standards of care in a surgical operation. One of them is surgeons' performance ability. Surgeons vary considerably in their ability to conduct particular operations. Some are outstanding performers, some are adequate performers and some are inadequate.

Should report cards on surgeon performance be publicly available? Yes, but only if the information is presented in ways that can be easily understood by consumers and patients. The merits of public reports or provider profiles have been constantly debated since their first appearance in the public domain in the early 1990s. Some of the arguments against reporting include the potential to misinterpret data, the lack of clarity about what is counted and the potential the information may have in lowering staff morale. Better consumer choice, greater clinical accountability and improved quality are arguments in support of public reporting. But missing in this debate is the need to prepare and enable patients to make real choices about their doctors or hospitals.

system not designed for patient choice

Many patients lack genuine choices in healthcare either because of the nature of their disease or because the health system is yet to recognize the scope of the informational needs of patients and their obligations to provide it. A redesigned health system is required if patients are to have genuine choice in their healthcare. The way the health system is currently structured and organized relies on patients being passive receivers of their healthcare.

Report cards about surgeons' performance have been available to patients for more than a decade, yet the evidence is that patients rarely use them to choose their surgeons or hospitals (Marshall, 2001; Schneider and Lieberman, 2001).

Informed consent

One of the main lines of argument for publishing surgeon performance information appeals directly to the doctrine of informed consent. It is a commonplace in medical ethics that a significant medical procedure cannot ordinarily be conducted on a patient without that patient's consent. It is also widely accepted that consent cannot be effectively provided unless it is grounded on a proper basis of relevant information. Hence the phrase ‘informed consent’. It has become standard in medical practice, and indeed in medical law, to hold that medical professionals have a responsibility to ensure that patients have given their effective informed consent, before a significant medical procedure can be conducted.

The first chapter in this section, by Steve Clarke and Justin Oakley, argues that standard treatments of the doctrine of informed consent, such as that due to Faden and Beauchamp (1986), have implicitly been committed to the provision of surgeons' performance information to prospective patients before a surgical operation can take place. Standard treatments of the doctrine of informed consent concur on the requirement that all significant risks involved in undergoing an operation must be disclosed to a patient before that operation can take place. The significant risks of an operation will vary, inter alia, according to the performance abilities of the surgeon undertaking the operation. Clarke and Oakley argue that, because standard treatments of the doctrine of informed consent require that the actual risks of an operation be disclosed, this doctrine implicitly requires that the performance abilities of prospective surgeons who may be conducting the operation in question be disclosed.

Introduction

The performance records of cardiac surgeons have been disclosed publicly in several states in the USA, for example New York and Pennsylvania, since the early 1990s. In response to the growing interest in the quality of healthcare, such records have also begun to be disclosed in the UK, starting in 2004. Various studies seem to show that disclosure has, indeed, contributed to the improvement of the quality of healthcare. However, at the same time, disclosure does have its critics.

In this paper, I discuss what I call the ‘defensive medicine objection’ to the disclosure of performance data; that disclosure is not justified because it could cause surgeons to experience high levels of anxiety, which might eventually lead to the practice of defensive medicine. Although this objection is often mentioned by ethicists and medical professionals, it has never been carefully analysed or evaluated. The aim of this chapter is to consider it in detail. I argue in favour of the objection; disclosure could, indeed, lead to the practice of defensive medicine if it is not conducted properly.

Surgeons' anxiety

There are two main arguments for justifying the disclosure of performance data. According to the first, which might be called the ‘rights-based argument’, patients have the right to know the skill of their surgeons. This argument seems to be underpinned by the doctrine of informed consent, which aims mainly at protecting patients' right to autonomy.

Introduction

The concept of report cards for doctors is one aspect of accountability for medical practitioners' conduct, success rates, efficiency and effectiveness in communication. Report cards for doctors and for health institutions at this stage have no formal legal status, although, like a variety of other documents, they have the potential to be utilized in an evidentiary sense as a yardstick for delineating acceptable from actionable conduct. In the past, ethical codes of conduct and practice, guidelines and protocols have all been used by both the civil courts and disciplinary tribunals as indicia of whether medical practitioners who have not complied fully with them have breached their duty of care to patients. An important question for the future is whether doctors' report cards can, or should, fulfil a similar function. If so, a secondary question is how they can be framed so as to minimize the potential for misuse.

The impetus toward enhanced professional accountability has been generated and facilitated by the law for two decades. It has become a core characteristic of latter-day tort law and disciplinary law, in particular, as the informed consent revolution continues to redefine what is required of medical practitioners' interactions with their patients.

This chapter contextualizes the phenomenon of doctors' report cards within the impetus toward greater accountability by health service providers. It contends that doctors' report cards are an inevitable development, against which doctors' performance to some extent will be measured, but that care needs to be taken in developing such report cards so that expectations are reasonable, so that the contents of report cards achieve their objectives and so that they do not have counter-productive consequences.