The subject is a 29 yo female with multiple traumatic injuries following a motor vehicle accident Of her various injuries, the issue in question is the treatment by the orthopedic surgeon
of comminuted, segmented, mildly displaced fractures to the right and left femurs. .
The orthopedic surgeon performed an open reduction, internal fixation with intramedullary rods on both the right and left femurs.
Thirty days later, a limb length discrepancy was noted.
∙ Per CT lower extremities,; the right leg length was 79.0 centimeters. The left leg was 81.4 cm..
∙ On the right, there was a a comminuted fracture of the proximal femoral diaphysis with a displaced fragment noted, greater than 9 mm and angulated medially.
∙ On the left, there was a comminuted fracture at the mid femoral shaft with adjacent heteroptic ossification. A mildly displaced butterfly fragment was noted.
Five days after that, the surgeon operated again, this time on the right femur, performing an open reduction, internal fixation of the segmental fracture of the right femur. A rod was removed and another rod was reinserted, with the placement of cerclage wires.
A CT scan after this second surgery showed the right lower extremity measured 78.6 cm and the left lower extremity measured 82.4 cm. The right femur from the most superior aspect of the femoral head to medial femoral condyle measured 40 cm. The left femur from its most superior aspect of the femoral head to the distal aspect of the femoral condyle measured 44 cm.
The second surgery was not successful.
∙ The patient has leg lengths differences currently estimated at 1 cm, with the right leg longer than the left.
∙ There are significant asymetric, rotational abnormalities of both lower extremities. The malrotation is significant enough to seriously impede her ability to walk, according to her new orthopedist, who is planning a third surgery. The new treating orthopedist privately states that the first surgeon may have used poor technique.
The client believes that the orthopedic surgeon used the wrong size rod, and that having failed to get it right after two attempts, he must have done something wrong.
Query: Was there malpractice, i.e. a deviation from the standard of care by the surgeon who performed the first two ORIFs resulting leg length differences and bilateral malrotation of the two lower extremities, necessitating a third surgery with uncertain results?
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Do you believe there might have been medical error?
The basic principles in the treatment of fractures of the femur include restoration of position and alignment, maintenance of length, immobilization until bony union occurs, and restoration of normal function after union. The incidence of malunion (rotational deformity, angulation, and LLD) ranges from about 5-25%. It is difficult to achieve the exact length of the bone in severely comminuted fractures. Failure to appropriately statically interlock unstable injuries can lead to malunion from postoperative shortening and malratotation. Inappropriate nail diameter can also iatrogenically needlessly propagate underlying likelihood to further shorten and angulate, or rotate after initial surgery. If both femurs are fractured, length is best judged by using the less comminuted side, and two nails of the same size and length are used. If the length of the fracture is unstable and shortens even with the nail seated, both distal locking screws should be placed first. The nail can then be driven in completely and proximally locked. In this particular case, the rotation and length discrepancy should have been appropriately managed during the initial surgery, but certainly more accurately addressed at the second surgery, when more appropriate preoperative planning, consultation with a trauma specialist, and requisition of optimal hardware (sizes and lengths) would be expected.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The substandard care of the bilateral femur fractures resulted in multiple surgeries and left the patient with dysfunctional limbs with rotational abnormalities and a residual LLD.
What makes you a good expert for this case?
As a board certified orthopaedic surgeon in practice for 25 years and with 2 decades of military service (ortho), I have managed a high volume of long bone fractures in isolated and multi trauma patients. I understand the expectations of handling these major orthopaedic injuries, and often the need to work as a team or coalition of specialists and partners to best treat these complex injuries knowing we have the the best opportunity for success during the first surgery when done appropriately up to the accepted standard of care.
How often do you encounter cases similar to this one in your practice?
I routinely see long bone tibia and femur fractures in my practice.
Do you believe there might have been medical error?
It is difficult to match limb lengths after bilateral comminuted shaft fractures. In fact there is a possibility that the limbs were different lengths prior to the injuries.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I would need more information including imaging and observing the patient’s gait to determine the malrotation. Based on the provided information, And the fact that femoral implants have a bow, it is difficult to see how malrotatiom would have occurred.
What makes you a good expert for this case?
I have performed many femoral IM nails
How often do you encounter cases similar to this one in your practice?
At least a few a month on trauma call
Do you believe there might have been medical error?
From this information it is apparent that this is a very rare and complicated case bilateral comminuted femur fractures are difficult as there is no normal lengths when you are fixing 1 and then the other. Having a leg length discrepancy within 1 cm after such a surgery would actually be pretty decent result. However in this case there seems to be an issue of healing and also rotational deformity. Definitely challenging cases to get the correct rotation with a comminuted femur fracture but there are ways to get it closed. I would have to see the x-rays and the operative notes to understand exactly what happened to determine if a medical error was a part of this treatment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If at the time of surgery rotation was not paid attention to and or the wrong fixation device was used then medical errors and causation would be linked.
What makes you a good expert for this case?
I been in practice over 20 years. I have seen my fair cases of multitrauma in patients and understand what it takes to get the best results even in the worst fractures.
How often do you encounter cases similar to this one in your practice?
I am no longer working at a trauma center. My first 5 years in practice was at a level 1 trauma center where these condyle fractures came in every night as well as my entire training I was at level 1 trauma centers. For the last 15 years I been treating fractures on a more elective basis but many have issues of comminution and rotation just as this case.
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