Dupuytren's and Complex Pain
- David Tollafield
- Jun 9
- 11 min read
This is a case subject presenting with the after effects of Dupuytren's contracture and the unusual complication of complex pain syndrome.
The following article is based on correspondence from a concerned client who approached ConsultingFootPain (CFP) for answers. Having written about the condition for some years, an ultimate solution, treatment and prevention for this unpleasant condition still eludes the medical profession. The communication you are about to read had been edited.
Dupuytren's and Complex Pain in Male M
'I was not warned of the risk of Complex regional pain syndrome prior to my surgery, and I am faced with the situation that I need to prove that a reasonable body of people (surgeons) would say that I should have been, a medico-legal expert if you will.
I was wondering, given your extensive knowledge and experience of the condition, whether you had a view, whether indeed you provide medico-legal services of this nature or whether you knew of anyone that does? I would be most grateful to hear your advice. Kind Regards. M.'
Reply DRT
I am sorry to hear about your struggles with Complex Regional Pain Syndrome.
Routine operations leading to distress arise because we expect to recover, improve, and, ideally, be cured.
Many clinicians disagree on the diagnosis of CRPS. I believe there are distinctive stages, and the early stages are often missed due to ignorance. This means that the benefits and opportunities are missed.
While early treatment does not guarantee a cure, it can limit the later, more unpleasant effects.
CASE M replies
My issue is with CRPS in my dominant hand following the correction of a Dupuytren’s Contracture (DC) in May 2023.
I saw a registrar in October 2022 where my DC was not even at a 30% curvature (30% being the minimum required for surgery). The Reg explained surgery would be the best route if mine progressed. A “nicked” the nerve could lose sensation down the side of my hand (the part that would be the saw in a sawing action), and also could become permanently straight instead. The Consultant agreed with the diagnosis and plan of treatment and said “and you’ve had the risks explained to you”.
Six months later, my finger had gotten worse, it was bothersome in so far as I caught it on things and it gave me some pain, but nothing that the odd paracetamol couldn’t handle. This time I was seen by an Extended Health Practitioner (EHP), who said my curvature was now 30% or there abouts, said they could qualify me for surgery and waited for the Consultant to come in to see me. The Consultant agreed that I qualifed for surgery. Risks explained as per before. My surgery was planned for Monday 15th May.
The hospital then sent some documentation through for signing and some general literature, amongst which was a leaflet about what to expect from the surgery, which included a number of risk warnings, including CRPS. However, it was the very last warning listed, described it as a painful condition, did not give any instances of occurrence, and said it could be prevented by taking Vitamin C for 6 weeks post-surgery.
On the day of the surgery the Consultant consented me for redness, stiffness, swelling, bleeding and re-occurrence. He then, as an after thought said he should also warn me that if things go wrong he may have to amputate the finger, but that I shouldn’t worry as that never happens but procedurally he has to warn me. The last thing he said to me was, don’t worry you’ll be back in the gym by Thursday [3 days later].
Three days post surgery I has my splint/cast removed and within days of that I knew there was something wrong. On the 9th June at my follow up the Consultant told me that I had CRPS, and that he had never heard of it happening as a result of a DP contracture. I said, given the pain I was in, that I wished he had of amputated the finger and he replied, oh no, if I had you may have still got CRPS as it does happen as a result of amputation.
I have subsequently had the diagnosis confirmed by three separate pain consultants, and 2 years on, I have a disabled right hand and I am on 20 pain killers a day, just to keep the edge off of the pain. I can increase the dose, but to do so would render me incapable of work.
Actions taken as a consequence of this event
I have since lodged a complaint, and the hospital committed to re-writing their leaflet, as they, and the Consultant agreed that there is no medical or scientific proof connecting the prevention or cure of CRPS and Vitamin C.
The Consultant also commented that he has changed his private practice to ensure that he gives a full CRPS warning to all of his patients, and he would make changes to his NHS/Private clinics to ensure that those switching from one to the other always had a consult with him in-between so he could go through the risks with them (as this didn’t happen to me due to the lack of the practice requiring it, and the time frame between the surgery being booked and proceeding (Thursday at 1pm to Monday at 0900).
Effects of the condition
At nearly 2 years on — I used to go to the gym 5 days a week, I used to play tennis 3 times a week and I used to run once a week. I can now do none of these things, I cannot even prepare or cook food properly or safely, as I only have the use of 1 hand. Due to the lack of exercise and the tablets I have to take, my weight has gained and I am now extremely negative and depressed about my body shape and size.
I was told by a lawyer and the hospital and Consultant that even if they had warned me of CRPS, I would likely still have gone ahead with the surgery (which I would not) as so consequently my brain has interpreted this as my condition being my fault. As a consequence I have developed the protective mechanism of severe OCD which I am being treated for and I have also developed depression and anxiety.
The mental anguish and torture that this has caused me is unmeasurable. I now doubt every decision I make, even down to standing in the supermarket unsure of what bread to buy, scared to make a mistake.
My life has been turned upside down. Just 5 weeks prior to the surgery I set up my own business, which I have since had to close as I could not manage it, so I have had to return to being an employee of a company. I work in financial services, my job is to prevent money laundering, terrorist financing, fraud, bribery, tax evasion etc, so I am very risk averse. Why would someone who is risk averse, just set up their own business, went to the gym, ran and played tennis, take such a risk of swapping a slightly bent little finger for CRPS?
A lawyer indicated 'there was a duty of care to consent you adequately and that duty was breached. The Consultant should have warned you that, at the very least your condition might get worse and that duty was breached too.'
However, the lawyers say you would have to prove that you would have acted differently if you had been warned of CRPS, and they believe a judge would conclude that I am using hindsight to make that decision.
They also say the risk of CRPS is so small that it is not unreasonable that the Consultant would not tell me of the risk (Bolam), and I would have to prove the risk of CRPS was significant (Montgomery).
M's further arguments
It is my absolute view that I would not have proceeded with the surgery had I known of this potentially disastrous outcome. Why would I have swapped all that I had for now, what I have got and being so naturally risk averse.
If he had heard of it happening post amputation, as he consented me for amputation, why did he then not further consent me for the known complication of CRPS?
Would I like compensation for being left disabled, with a pain crippling condition for the rest of my life that I was never even warned could happen to me? YES.
Do I think every planned hand surgery patient should be warned of the possible complication of CRPS? YES
CRPS is not necessarily the worsening of the existing condition, it is a brand new condition that patients should be warned about. (Untrue: CRPS has been known since the 1860s)
Would I like to see more public awareness of the hidden risks of surgery that we as patients rely on our surgeons and hospitals to warn us about, absolutely.
How can anyone be making an informed choice and decision about elective surgery if we are not told the facts. If we are told the facts and the risk materialises, then there is no come back on anyone.
I know surgeons cannot be expected to tell their patients about every risk, especially those that have a small risk of occurrence, and given CRPS is quoted through various pieces of literature to occur in anything from 1% to 10% of patients, surgeons cling to the lower end of the scale and so don’t warn patients of it. If CRPS is known to happen as a result of trauma, and surgery (to the hand or foot) is classified as a trauma, then 100% of the people having hand (or foot) surgery is at risk of getting CRPS and so should be consented for it, regardless of how small the population of patients that go on to actually get it.
Evidence of Risk
Clinicians do mention and support the fact that pain can arise, but dampen the complications should this occur in terms of CRPS specifically. Consequently, patients see the chances of complications as low.
CRPS is associated with a risk of less than 1%, although this risk is higher in patients undergoing nerve surgery. The problem here is that 1% is not a good indicator because the impact of something like CRPS is very high. On a scale of 1-5, CRPS sits at 4/5.
FIVE is the worst impact factor - loss of job, constant turmoil, disability, and effects on the family. I wrote about impact factors for my professional body in 2010, but this only relates to the feet. PASCOM USER GUIDE.
An infection, in contrast, which is always stated on a consent form, may have a risk of 5% and has an impact factor of 1, maybe 2, as it is easily managed.
The patient (complainant) must prove that the clinician was negligent, but the standard is set very high for the judge. Settlements outside of court are more common and are designed to resolve the issue with a financial settlement. Money never removes the fact of impact; although, given time, CRPS can ease and be tolerated with understanding and management. You may have been warned, but not in the way you might have imagined.
Dupuytren’s contracture is a minor surgery, of course, but like all extremities, it is more prone than other parts of the body to CRPS.
Legal Issues & Consent
Hands and feet are the body’s radar and are a long way from the spinal cord, so they are more exposed to these injuries. The two points below are crucial for legal interpretation.
o Consent method and content
o Bolam & Montgomery
As you stated:-
The hospital then sent some documentation through for signing and some general literature, amongst which was a leaflet about what to expect from the surgery, which included a number of risk warnings, including CRPS. However, it was the very last warning listed, described it as a painful condition, did not give any instances of occurrence and said it could be prevented by taking Vitamin C for 6 weeks post surgery.
This paragraph alone is critical, as your lawyer would have said. Vitamin C plays no value to CRPS. In today's consent process, the fact that CRPS was mentioned is not enough to support consent if the words CRPS were not spelt out and the meaning understood. Consent has to be understood to be valid.
The breach of duty of care is murky
Tested on the basis of Montgomery, ideally, all hand and foot surgeons should change how consent is taken. You have to prove beyond doubt that had you known more, or at least had considered the inference of complications, you would not have proceeded.
The problem here is that we all want to be better and believe that we could not be made worse, given the fact that the surgery proposed seemed so minor. Bolam has been weakened over the years because of other considerations.
Montgommery
In a 2017; GMC citation “The Montgomery ruling has not radically changed the process of consent; it has simply given appropriate recognition to patients as decision makers.” There are newer papers, as consent is a significant aspect of clinical litigation, driving most cases toward some form of legal settlement.
I have always been very pro-patient, offering as much information as possible. I believe in everything I have written and try to offer patients and the public more than curated information, diluted and not just simplified so that a 13-year-old could understand the content.
The clarity of what is important to the patient, as opposed to what is important to the clinician, is vital.
The problems with too much detail
When I told a patient the impact factor of 4/5, which included CRPS, for a nerve excision was possible but the chances were low, the patient declined to proceed. Using such language as the impact factor has more meaning than the risk factor. If I operate, you will only have a 2% of CRPS occurring. However, if I said that this has an impact factor of 4-5, which means disabled, in pain, slow to treat and heal with the prospect of no improvement, then would you proceed?
As far as feet are concerned, impact factors have not been tested in trials or followed by my own professional body, and yet, as clinicians, we fail to embrace the new world of consent, by focusing on risk and not impact.
On the clinicians' side, if we gave impact out alone, without balancing the explanation of low risk, fewer operations would be carried out; however, some conditions would remain that could cause problems. There is no easy solution.
Should you have compensation?
Yes, of course, through no fault of your own. Your life has been indelibly affected. Clinicians also suffer terribly from litigation, but not in the way of pain, of course. Still, litigation can sometimes change our attitudes in ways that are not helpful, through overprotectionism, which is exactly what Montgomery tried to prevent. Few set out to deceive or harm patients, but I understand only too well the anxiety, bitterness, and destruction left behind when treatment has not gone to plan.
My words are unable to help you with your current condition. As mentioned, using a help network and seeking assistance from Bristol or Liverpool pain centres would be my only take-home. The links are underlined.
It is both important and kind that you have shared your story, as it will provide helpful assistance to patients and clinicians in reflecting on minor procedures that can lead to major, life-changing conditions.
Thanks for reading about Dupuytren's and Complex Pain
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