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20LEGAL MEDICOMAGAZINESponsored by:1. The precise determination of the presence of injuries.The medicolegal implications of whether a fracture is actually present or not, are self evident when its comes to personal injury claims or following assault. However fine ‘cracks’ in the facial bones (which are technically fractures) can not always be proven (or disproven) with absolute certainty, based on clinical examination, or even following 'X-Rays'. There will always be an element of clinical judgement required in making such a diagnosis. X-Rays themselves are limited in their ability to visualise fine fractures. If the presence of a fracture is uncertain, clinicians are trained to err on the side of caution and will manage patients as though they do have a fracture. This is to minimise the likelihood of complications developing. However, such caution may then become misrepresented as ‘proof’ that a fracture is present.Furthermore, not all facial injuries require X-rays. The over-riding reason for taking these is if they will alter the management of the patient. As such, suspected ‘cracks’ and most isolated fractures of the nose do not require imaging. The days of x-raying purely for medico-legal reasons have long past. Aside from the unnecessary expense to the NHS, GMC and GDC guidance is clear on this and we must resist requests to take an X-Ray if they do not alter the care of our patients. Clinicians may be put under pressure from patients (and relatives) to ‘get a scan’. Refusal to do so can often be misconstrued as incompetence, inexperience, or not taking the patient seriously. Not surprisingly, some patients may feel aggrieved by this apparent lack of thoroughness. Nevertheless, unnecessary imaging is regarded as a major ‘sin’ within our regulating bodies and as such carries the risk of disciplinary action if guidance is ignored. 2. Missing treatable injuries.Not all injuries are obvious and, despite our best efforts, there will unfortunately be occasions when treatable injuries are overlooked. Whilst these are seldom life-threatening, some can result in disfigurement and troublesome symptoms. Some may require expensive treatment, for example the eventual loss or discolouration of a tooth. One particularly difficult group of patients to assess are those that are unconscious, for example following a head injury. In this group it is not possible to assess whether the patient has sustained any significant visual impairment. Examination of the eyes and face is at best relatively crude. In children, certain fractures of the eye socket may present with an irritable, vomiting child – signs more often associated with head injuries. Significant delay in diagnosis because of this ‘misdirection’ can result in permanent double vision (diplopia). 3. Pre-existing problemsWhilst the impact of missing such injuries may be difficult to defend, this may not always be the case. Pre-existing dental neglect and dental disease (notably decay and periodontal [gum] disease) will predispose teeth to injury and loss (including damage during anaesthesia). Any new injury may simply be the ‘straw that broke the camels back’ in a tooth that was already destined to be lost in the near future. Therefore, when determining ‘blame’ such considerations need to be balanced against the likelihood that the tooth in question did indeed have a good prognosis before the injury occurred. This may be difficult to prove, especially in patients who rarely see a dentist. 4. Interpreting injuries.In most cases, it is not possible to say with certainty the manner in which a particular injury occurred. Unfortunately, the likes of 'CSI' and other similar TV programmes tend to suggest otherwise. Police reports often ask clinicians to state whether a fracture occurred as a result of an assault, fall or some other mechanism. However, such information falls under the remit of forensics rather than medicine, particularly when it is required as part of the prosecution’s evidence. Whilst the ‘balance of probabilities’ test eases this pressure, as clinicians our expertise is in establishing the presence of an injury and treating it, not in establishing how it occurred. Police and medical reports can therefore be a slippery slope to the court. Interestingly, it could even be argued that our entire experiences are in fact flawed. In my experience (of over 20 years) only 2 patients have ever admitted they actually ‘started the fight’. This could lead to one of two conclusions – i) either attack really is the best form of defence, or ii) perhaps (more likely) we are never given the entire story. If this is indeed the case, then