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The kinds of questions that are commonly asked of treating orthopedic surgeons in the medicolegal context are often outside of the scope of ordinary clinical practice. Although questions regarding diagnosis and treatment are easily answered, questions regarding causal attribution, functional impairment and disability, prognosis, and future need for care are more difficult to address. The primary reason for this difficulty is the degree to which probabilistic reasoning and inference is relied on as a basis for the opinion, rather than observation and interpretation, the latter being the most common mode of medical practice.
A Systematic Approach to Medicolegal Causation
The nature of the types of injuries encountered in an orthopedic practice makes causation assessment a straightforward process in many instances. This is not the case with orthopedic injuries that do not require a high degree of energy, that can be present without producing symptoms, and that can have an insidious symptom onset. Spinal disk and joint degeneration, hip labral tears, and rotator cuff injuries are examples of conditions that commonly result from the wear and tear of the physiologic forces of daily life and that exist, to some degree, in a large portion of the asymptomatic adult population. They are also conditions that make individuals more prone to injury following a relatively minor trauma, such as a minor traffic crash or a ground-level fall. The methodology described here is directed at assessing the causation of such conditions when they have become symptomatic after minor trauma.
The scientific bases for general (population) and specific (individual) determinations of cause and effect were first formally described in the inductive canons of John Stuart Mill in 1862 and the rules proposed by the philosopher David Hume in 1739.1 In the modern era, rules for assessing potential causal relationships have been formalized in the form of the “Hill criteria,” a set of 9 viewpoints set forth by Sir Austin Bradford Hill in 1965.2 Although Hill did not personally endorse the term “criteria” because he did not want the viewpoints to be seen as a causation checklist, this description is commonly used.
The Hill criteria can be distilled to 3 basic elements or steps for practical application in clinical assessments of causation3–5:
1. Plausibility. This first step addresses whether it is...