Right Ankle Injury

MOTORBIKE ACCIDENT MEDICAL REPORT

 

The motorbike accident claim was caused when he was hit by a car at a “T” Junction and dragged along the road.  Main injury related to the Claimant’s ankle.

 

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Civil Procedure Rules Part 35.6: –

We set out hereunder Part 35.6 of the Civil Procedure Rules concerning the parties right to pose questions to the expert;

“WRITTEN QUESTIONS TO EXPERTS

35.6 (1) A party may put to —

(a)          an expert instructed by another party; or

(b)          a single joint expert appointed under rule 35.7, written questions about his report.

(2) Written questions under paragraph (1) ‑

(a)          may be put once only;

(b)          must be put within 28 days of service of the expert’s report; and

(c)          must be for the purpose only of clarification of the report, unless in any case —

(i)           the court gives permission; or

(ii)          the other party agrees.

(3) An expert’s answers to questions put in accordance with paragraph (1) shall be treated as part of the expert’s report.

(4) Where —

(a)          a party has put a written question to an expert instructed by another party in accordance with this rule; and

(b)          the expert does not answer that question, the court may make one or both of the following orders in relation to the party who instructed the expert —

(i)           that the party may not rely on the evidence of that expert; or

(ii)          that the party may not recover the fees and expenses of that expert from any other party.”

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MEDICAL REPORT

This report is addressed to the Court

 

1. Motor Bike Accident

a)   Description of accident

Motorbike accident claims client was riding his motorcycle. He was wearing a crash helmet, motorcycle jacket and jeans. He was wearing gloves and trainers. Motorbike accident claims client explains that his motorbike was stationary at a T junction when it was hit by a car. He recalls that on impact he fell to the ground under his motorbike and he was dragged along the road for an estimated 3-4 metres.

b)   Injuries incurred.

1) Sprain injury to his right ankle.

2. Progress of symptoms/treatment.

a) Physical

Motorbike accident claims client was in shock at the scene of the accident. He was aware of some discomfort in his right ankle. He was able to stand and walk with a limp. The Police and Paramedics attended. He was taken home by the Paramedics and he then self referred to Hospital. He was examined by a Nurse in the accident department. No x-rays were taken. He was informed that he had suffered a soft tissue injury to his right ankle and he was advised to take Ibuprofen (anti-inflammatory analgesic tablets) as necessary.

The following morning Motorbike accident claims client woke with discomfort and swelling in his right ankle. There were some early signs of bruising visible and he walked with a limp. He took analgesic medication.

At five days post-accident Motorbike accident claims client consulted with his Doctor. The Doctor confirmed that he had suffered a soft tissue injury to his ankle and advised him to continue with the analgesic medication as necessary.

The pain symptoms in his ankle receded as the swelling and bruising faded and the ankle injury fully resolved at ten weeks post-accident.

Motorbike accident claims client has noticed that since the accident he has been a more cautious motorcyclist. He is more aware of the movements of other road users and he looks more often in his rear view mirror, however Motorbike accident claims client explains that he has not experienced any true phobic anxiety symptoms in relation to travel.

3. Effect on lifestyle.

1)      Work: Motorbike accident claims client was off work for one day.

2)      Hobbies: Motorbike accident claims client was unable to play cricket during the summer season because of the pain symptom in his ankle.

3)      Social activities: Generally his social activities have not been reduced by the pain symptoms.

4)      Daily domestic tasks have not been affected by the pain symptoms.

4. Present Condition.

Motorbike accident claims client is no longer aware of any swelling or discomfort in his right ankle.

5. Relevant Medical History.

Motorbike accident claims client has not previously had any right ankle injury and he has had no investigations for such symptoms.

6. Examination.

Height Weight  kg

Motorbike accident claims client is right handed.

He walked with a normal gait.

Examination of the right ankle revealed no swelling or bruising.

There was no tenderness to palpation of the medial or lateral malleoli

There was a full range of movement in the ankle joint without discomfort.

 

7. Opinion & Prognosis.

As a result of the accident on the [date] Motorbike accident claims client has suffered physical problems with disturbance to work and leisure activities as outlined earlier in this report. The motorbike injury is consistent with the accident. The claimant is a reliable historian and the actions taken by him are reasonable. The problems are attributable solely to the accident.

a) Physical.

Right Ankle Injury.

Motorbike accident claims client suffered a sprain injury to his right ankle causing soft tissue trauma. He had marked pain symptoms soon after the collision. Fortunately the symptoms settled and disappeared by approximately ten weeks after the accident.

At examination today there were no signs of ongoing injury. Recovery is therefore complete with no risk of post-traumatic arthritis or chronic pain symptoms.

The one day period of absence from his work as a [occupation] was in my opinion reasonable. There will be no interference with future work prospects or leisure activities as a result of this trauma.

This medical report is produced with access to photocopies of the GP medical records

Review of the Medical Records.

Review of the medical records reveals an entry dated the (date), Motorbike accident claims client consulted with his Doctor with symptoms of a painful heel syndrome. He was referred to a Physiotherapist. An x-ray of his heel showed a right sided calcaneal spur.There are no pre-accident entries specifically related to ankle symptoms.

Motorbike accident claims client attended the accident Hospital following the index accident. He presented with a painful right ankle. On examination there was a graze on the lateral aspect of the right ankle. A diagnosis of soft tissue injury to the right ankle was made and he was advised to take analgesic

 

medication as necessary.

Motorbike accident claims client consulted with his Doctor on the [date], his Doctor noted that he had suffered an inversion injury to his right ankle. There was some grazing over the lateral malleolus. He was advised to rest from sport.

Summary

In summary the medical records are consistent with the history given by Motorbike accident claims client and I have no reason to alter the opinion and prognosis.

I, [name of doctor] declare that the facts that I have stated in this report are true and that the opinions I have expressed are correct.

1. I understand my primary duty in written reports and giving evidence is to the Court, rather than the party who instructed me.

2. I have endeavoured in my report and in my opinions to be accurate and have covered all relevant issues concerning the matters stated which I have been asked to address.

3. I have endeavoured to include in my reports those matters, which I have knowledge of or of which I have been made aware, that might adversely affect the validity of my opinion.

4. I have indicated the sources of all information I have used

5. I have not without forming an independent view included or excluded anything, which has been suggested to me by others (in particular the instructing party).

6. I will notify those instructing me immediately and confirm it in writing, i ffor any reason my existing report requires any correction or qualification.

7. I understand that:

a)      My report, subject to any corrections before swearing as to its correctness, will form the evidence to be given under oath or affirmation.

b)      I may be crossed examined on my report by a cross examiner assisted by an expert.

c)      I am likely to be the subject of public adverse criticism by the judge if the Court concludes that I have not taken reasonable care in trying to meet the standards set out above.

8. I confirm that I have not entered into any agreement where the amount or
payment of my fee is in any way dependent on the outcome of the case.