Fifteen-year-old Dana had a short history of pain in her right hand and wrist. Following X-ray and diagnosis of either an aneurysmal bone cyst (ABC), osteomyelitis or giant cell tumour, she was referred to the Royal National Orthopaedic Hospital.
Following further X-ray, the radiologist reported that a diagnosis of hyperparathyroidism, possibly primary with an associated distal radial Brown’s tumour should be considered.
An MRI showed that the lesion most likely represented an ABC but could not absolutely exclude other pathology and Dana underwent a GA CT guided needle biopsy. A multi-disciplinary team meeting was then held to review the radiology and it was decided that the features were not typical of giant cell tumour and the team could not exclude hyperparathyroidism and Brown's tumour, meaning Dana would need blood tests to investigate further. It was also said that Dana should be considered for doxycycline injection - where albumin foam is injected to treat aneurysmal bone cyst. This was not standard procedure and the RNOH was the only centre in the UK to carry out such treatment.
In May 2017, just after Dana turned 16, she underwent the doxycycline injection under general anaesthetic by a musculoskeletal radiologist, even though she had only been consented for a local anaesthetic and blood tests had not yet excluded a hyperparathyroidism.
The procedure appeared uneventful but Dana did not wake up in recovery and there was poor blood profusion to her right hand. She was transferred to St George's hospital and an MRI showed extensive infarcts (areas of dead tissue). Dana was in a coma for several months and on 22 September 2016, her right hand was amputated due to gangrene and necrosis.
Following months of rehabilitation at The Children's Trust, Tadworth, she was discharged home on 8 December 2016.
The Royal National Orthopaedic Hospital Trust completed its own investigation. When the blood tests were done postoperatively, hyperparathyroidism and Vitamin D insufficiency were identified raising the possibility of a diagnosis of right distal radial Brown's tumour secondary to hyperparathyroidism rather than ABC.
The investigating team concluded that had this result been known pre-operatively, it is unlikely Dana would have received the doxycycline injection at that time and the procedure would probably have been delayed pending treatment with Vitamin D and calcium.
The Trust declined to make an immediate admission of liability, so we were forced to conduct our own investigations including histopathology analysis of Dana's amputated hand. Our expert musculoskeletal radiologist was highly critical of the technique used by the Royal National Orthopaedic Hospital which he considered was inevitably going to result in leakage of the injected fluid into the overlying soft tissues.
In a Letter of Claim, we said that the Vitamin D deficiency was the cause of the cyst and treatment would have addressed this without the need for surgical/radiological intervention. Treatment would have consisted of oral high-dose Vitamin D and calcium therapy for six to eight weeks followed by repeat blood tests to gauge return to normality. It would have taken three months for a complete normalisation of bloods. The short time interval between the injection procedure and the development of the symptoms would be consistent with Dana suffering an inter-operative event. There was early evidence of both hypofusion and neurological problems.
The Trust has now made a full admission of liability and judgement is being entered with damages to be assessed.
Remarkably, Dana has been able to return to school with one-to-one support, although she missed sitting her GCSEs. She is now studying a BTEC course rather than A Levels.
Having been highly organised and independent and a high-achieving student, Dana now has significant problems with her memory, slow processing speeds and difficulties with visuospatial skills, meaning she needs significant support to access learning. Dana also has difficulties with executive functioning skills and she suffers with cognitive fatigue which affects her ability to learn.
Dana now wears a cosmetic prosthesis on her arm. She is learning to use her left hand to write but it takes effort and is slow. She suffers with increased sensitivity around the stump of her right arm and phantom pain limb sensation. She also has balance problems and is at risk of falls, particularly when using stairs.
Dana requires assistance with many basic daily self-care tasks such as, showering, dressing and undressing, tying up her hair or shoe laces, cutting her food. She can no longer cook for herself.
The Trust offered an interim damages payment to fund a case manager, neurology and neuropsychology assessment, OT and prosthetics. Dana has already been assessed at the London Prosthetic Centre and is a good candidate for an electric prosthesis. Dana's final award will be assessed after a period of rehabilitation.
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