This hypothetical scenario considers the legal issues for a physiotherapist who relocates a sportsperson’s finger joint, in the absence of formal training.
Athletes, both amateurs and professionals, commonly receive proximal interphalangeal (PIP) joint injuries. Your netball captain dislocates the fourth PIP joint of her hand during a defensive training drill two nights before your semi-final. In obvious pain and distress, the player pleads with you to relocate her finger and help to relieve her pain.
You inform her that there is the possibility that she may have a fracture and you have no formal training to relocate her joint and best practice is to go to the emergency room of the local hospital for an x-ray and to have a medical practitioner relocate it and advise how best to manage her injury. She states that she has a full day at work tomorrow and cannot afford to spend 6 hours in an emergency room and is in quite a lot of discomfort and again asks for your help.
You closely assess her finger and note it is a closed dorsal dislocation, there is no loss of circulation to her fingertip and she reports no pins and needles or numbness. You decide to try and reduce her joint by applying gentle distraction as you hyperextend her middle phalanx and then provide dorsal pressure to her proximal phalanx as you flex it. The joint relocates easily and she immediately feels relief of her pain.
You then check her joint stability with active range of motion and passive stability tests in both flexion and extension, with no signs of instability evident. You then advise her that it is in her best interests to now go to the emergency room for an x-ray to rule out a fracture and have it formally assessed by a doctor. She insists she is now fine and refuses to go tonight so you do the next best thing and write an x-ray referral for her to go first thing tomorrow morning and advise her of symptoms that would be indicative of neurovascular compromise.
Upon contacting her the next day she states her joint is swollen and movement is limited but not too sore as long as she doesn’t move it. She has no time to go for her x-ray, does not feel it is too bad and still wants to play in the semi-final tomorrow night. Prior to the game you reassess her finger which is swollen and moderately bruised, but structurally stable. She plays with taping without complication, but is quite sore after the game. The following week she finally has an x-ray and it is noted that she does have a small fracture in the dorsum of her proximal phalanx but her joint has been successfully reduced.
Legal issue: Scope of practice
A key issue is whether the physiotherapist is acting within their scope of practice when relocating her joint, in the absence of formal training.
The Physiotherapy Board of Australia does not have a definitive statement on what treatments do and do not fall within a physiotherapist’s scope of practice.
The Physiotherapy Board of Australia’s Code of Conduct states that the practitioners themselves have a responsibility to recognise and work within the limits of their competence and scope of practice. The Code reminds practitioners that scope of practice varies with different roles, and that a practitioner must question themselves whether they have the appropriate qualifications and experience.
The Australia Physiotherapy Association’s Position Statement defines physiotherapy broadly to involve a holistic approach to the prevention, diagnosis and therapeutic management of disorders of movement or optimisation of function to enhance the health and welfare of the community from an individual or population prospective.
In this context the critical question in this case is whether, judged objectively by a peer, the physiotherapist has the appropriate qualifications, skill and experience to perform the relocation.
If the physiotherapist does not have the skill, training and expertise to perform a relocation, then notwithstanding what the patient’s stated wish is, he or she should not proceed with the requested treatment. If you proceed with the treatment, the physiotherapist runs the risk of disciplinary action, and possible civil action if the patient has suffered injury, loss or damage.
Legal issue: Legal liability
But what happens if, after the relocation, the phalanx becomes unstable and deformed, such that the patient requires surgery? The critical facts in this case scenario are:
- the patient herself is demanding that the physiotherapist relocate the joint;
- the physiotherapist recommends an x-ray before any attempted relocation;
- the patient refuses to go for an x-ray.
If an x-ray is fundamental to the decision whether relocation is or is not an appropriate treatment option, or whether the relocation is within the treating physiotherapist’s scope of practice, then a prudent physiotherapist would refuse to perform the relocation absent x-rays, and notwithstanding the patient’s demand.
A physiotherapist should not proceed with the requested treatment if he/she cannot confidently state it was appropriate treatment without an x-ray, or if obtaining an x-ray is fundamental to determining whether the treatment is within their scope of practice. However if, through clinical examination and testing, the practitioner, even absent x-rays, is confident that the relocation was an appropriate treatment option and within their scope of practice, then it would be appropriate to proceed with that treatment provided that the patient has given her informed consent to the treatment.
For the player to be able to give informed consent, the practitioner must at least explain the risks of the treatment and specifically, the risks of performing the relocation without first establishing there are no fractures.
If the patient has been given a clear explanation of the risks of proceeding, and the patient elects to proceed and if one of the warned risks eventuates, then at law the patient does not have a claim for negligence and for failing to warn, provided that the relocation procedure was performed appropriately.
Principal Kellie Dell’Oro can discuss the legal issues with you if you have a question or concern.