Tokyo, 1994, starting with medical training

Chapter 68 The Elephant in the Room

Kazusuke Kiryu, who possesses the skill of "perfect fracture reduction," has an almost intuitive sensitivity to the spatial relationships between bones.

The distal dorsal displacement mentioned in the emergency room report is only the most basic symptom.

The real devil is in the shadows.

His gaze was fixed on the lateral radiograph, on the small, crescent-shaped bone in the center of his wrist.

lunate.

A normal lunate bone, on a lateral radiograph, should resemble an inverted cup, supporting the capitate bone above and resting in the lunate fossa of the radius below.

However, the crescent bone in this film is not directly facing the skull; instead, it is tilted slightly towards the palm side at a few degrees.

Takikawa Takuhei and Tanaka Kenji didn't notice, probably thinking it was just a problem with the angle of the photo or a change in posture caused by a fracture.

But Kiryu Kazusuke immediately recognized the problem.

The palmar incision segment is unstable.

This means that the ligament connecting the lunate and triquetrum bones has ruptured.

If left untreated, even if the radius fracture heals, the patient's wrist joint will rapidly degenerate due to this minor instability, eventually leading to severe traumatic arthritis.

At that time, let alone attending a tea party, even holding chopsticks will hurt.

More importantly, this instability cannot be treated with simple plaster cast immobilization.

In fact, if the plaster cast is not positioned correctly, it can worsen the dislocation.

For someone like Mrs. Ando who values ​​quality of life, having her cast removed would be an absolutely unacceptable disability.

What will she do then?

A wealthy and leisurely woman who is extremely particular about her quality of life would definitely take her medical diagnosis to a law firm.

Medical malpractice lawsuits are inevitable.

The media loves news stories like "Misdiagnosis at a university hospital leads to disability for a wealthy woman".

At that point, Kenji Tanaka, who conducted the initial diagnosis, will be caught, Takuhei Takikawa, who oversaw the process, will be caught, and Ori Imagawa, who signed the consent form, will certainly not be able to escape.

Mrs. Ando became a little impatient.

His gaze swept among the doctors before finally settling on Kiryu Kazusuke, who was staring at the film reading light.

It's just a simple fracture, isn't it?

Can't you just give me a straight answer: either put a cast on me or have surgery?

"Doctor, are you done?"

She covered her nose, even though there was no strange smell in the room, it was just a gesture.

Kenji Tanaka was about to agree, thinking he could arrange it immediately.

"Please wait a moment."

Kazusuke Kiryu's voice rang out, speaking rapidly and directly interrupting Kenji Tanaka before he could finish speaking.

Why?

Imagawa Ori turned around, looking at him with her phoenix eyes, waiting for him to continue.

As a specialist, she realized something was wrong with the scan and made a preliminary judgment.

But it's hard to say for sure.

Kiryu Kazusuke pulled a ballpoint pen from his white lab coat pocket and asked, "Ando-san, does the tea ceremony require a high level of skill in hand movements?"

"That's right, that's right." Mrs. Ando nodded repeatedly.

The tea ceremony demands a high level of wrist deflection and palm flexion, especially when preparing tea and turning the teacup, where wrist flexibility is crucial.

"Okay, thank you, Ando-san."

Kiryu Kazusuke turned to the light box, held the pen in his hand above the side panel, and then drew a circle on it.

"So, I'm a little worried about the location of this crescent bone."

"The radius reduction looks fine, but isn't the projection angle here slightly tilted towards the palmar side?"

"What if VISI (palmar incisional instability) is caused by ligament laxity?"

"In that case, directly using a plaster cast for fixation may not provide enough support to counteract this tilt."

"It would be such a shame if the healing process affected Mrs. Ando's ability to serve tea."

He said these words after carefully considering the wording.

First of all, in front of patients, I am just a resident physician.

Secondly, this isn't a critical moment on the operating table, so we should give everyone a way out, since this isn't one of his patients.

Upon hearing the word "VISI," Takikawa Takuhei and Tanaka Kenji's expressions changed instantly.

This is a relatively obscure diagnosis in the field of hand surgery, and it is generally only noticed by doctors who specialize in hand surgery.

But they were aware of the consequences.

If a cast is applied for a common fracture and the wrist is immobilized in a ulnar deviation position, the patient will experience persistent wrist pain and weakness several months later.

Missing the diagnosis of VISI, which led to the loss of wrist joint function in the patient, is an absolute medical accident.

The starting compensation is ten million yen.

The two leaned closer to the film review light, carefully staring at the area circled by Kiryu and Kazusuke.

The angle of tilt is indeed small enough.

But once it's pointed out, it's like the elephant in the room—it's hard to miss.

Imagawa Ori stared at the film for a few seconds, and her doubts finally subsided.

really.

The reason for the awkward feeling is the tilt of the crescent bone.

I didn't notice it earlier because it was an extremely subtle accompanying injury. If you don't deliberately suspect it, it's easy to be distracted by the obvious fracture line.

But now we have a hint from Kiryu Kazusuke.

It's like finding a crucial clue in a puzzle game; the previously chaotic image instantly becomes clear.

In a normal wrist bone arrangement, the Girules tri-curve should be continuous and smooth.

However, the patient's lunate bone is palmar flexed, and the capitate bone is dorsiflexed.

A typical VISI malformation.

The likelihood of a ruptured lunar deltoid ligament is extremely high.

She turned her head and gave Kiryu Kazusuke a deep look.

Last time, a hidden ligament tear was discovered during surgery; this time, wrist instability was discovered during preoperative X-ray review.

This can no longer be explained by good luck.

Although Mrs. Ando didn't understand what VISI or the moon bone meant, she understood the two key words: "affecting the tea serving" and "regret".

"Doctor, is what he said true?"

She put down the fashion magazine in her hand, her expression turning somewhat unpleasant.

"Very likely."

Imagawa Ori turned to the side and gently tapped the film on the light.

"But this is only an inference based on the location of the bones."

"X-rays can only show bones; they can't show soft tissue."

"To be absolutely sure, we also need to arrange an MRI scan for you to get a clear view of the ligaments."

"This is also so that your hands can be restored to their most perfect condition."

When dealing with a VIP prospect like Mrs. Ando, ​​who is both suspicious and difficult, relying solely on the doctor's subjective judgment is insufficient.

There must be irrefutable evidence.

Without supporting imaging evidence, if the intraoperative situation differs from the prediction, it could very likely turn into a medical dispute.

"If that's the case, then... what should we do? Will we need surgery?"

Mrs. Ando's breathing quickened slightly, and her expression visibly tensed up.

"We need to see the specific condition of the soft tissue to confirm whether the ligament is torn or not, and whether the tear is complete."

Imagawa Ori paused here, her tone becoming more serious.

"If an MRI confirms a ligament tear, surgery is necessary."

"Because without surgery, a cast alone cannot repair a torn ligament."

"We must use internal fixation to reconstruct the linkage mechanism between the lunate and triquetrum while treating the distal radius fracture."

"Only in this way can your wrists lift the teacup again."

An extra chapter has been added. Thank you all for your support.

(End of this chapter)