This case involves an 8-year-old medically complex child with developmental delay, hypotonia, nonverbal/nonambulatory status, suspected seizure-like or dystonic episodes, genetic findings noted in the chart, and repeatedly documented poor bone quality/osteopenia. Before the April 2024 surgery, imaging described diffuse osteopenia, gracile long bones, and a significantly displaced/angulated proximal right femur fracture, with radiology also raising concern for a possible pathologic fracture and additional stress-type findings in the left femur.
During that admission, endocrine and other services were involved because the chart described severe osteopenia and multiple fractures over a short time period.
Please see attached OP notes for reference.
On 4/6/24, the patient underwent operative fixation of the right femur by the initial orthopedic surgeon. The operative note states that the child had a displaced proximal/subtrochanteric femur fracture and that operative fixation was selected over casting because casting was felt likely to cause skin breakdown and not adequately control the proximal fracture pattern. The surgeon documented that attempts at lateral-entry antegrade nailing were made, that the proximal fragment was unstable, and that poor bone quality made fixation technically difficult, ultimately requiring open treatment. A 7 x 240 mm antegrade femur nail with proximal and distal interlocking screws and a flush endcap was placed. The operative findings specifically documented poor bone quality, and the postoperative plan allowed weight bearing as tolerated with no motion restrictions.
Subsequent inpatient orthopedic notes continued WBAT to the right lower extremity, with a knee immobilizer at night or as needed for comfort.
About one month later, in early May 2024, the patient returned with new right leg/hip pain. The history documented that the mother reported 5–7 days of pain that had been treated with Tylenol, with worsening pain after rolling in bed/posturing, and no clearly identified new traumatic event. The chart notes that this was reportedly the third fracture in roughly eight weeks and that the patient had already been diagnosed with osteopenia. Imaging on 5/7/24 showed that the intramedullary rod remained in place, the original femoral shaft fracture was healing, and there was a new acute right femoral neck/peritrochanteric fracture with superior and lateral displacement; the bones were again described as osteopenic.
The patient then underwent revision surgery on 5/10/24 by a second orthopedic surgeon. The revision operative note lists both the original subtrochanteric fracture and the new pertrochanteric/peritrochanteric fracture, along with osteopenia of multiple sites and the child’s broader medical issues. The procedure included removal of the prior antegrade femoral nail, treatment of the peritrochanteric fracture with a GAP nail, treatment of the subtrochanteric shaft fracture, and a distal femoral osteotomy for placement of the straight nail. The revision surgeon’s operative findings documented a peritrochanteric fracture with bone loss of the greater trochanter in a femur previously treated with the Orthopediatrics 7 mm nail.
The implant record shows explantation of the 4/6/24 nail and screws and implantation of a different construct on 5/10/24, including a 7.2 mm x 260 mm nail, lag screws, and a short fixation plate.
The central orthopedic questions are:
-If original decision for surgery was appropriate in this medically complex child with markedly poor bone quality
-Whether the initial implant/construct selection was appropriate for the anatomy and bone biology,
-Whether the subsequent proximal femoral/femoral neck fracture is more consistent with unavoidable fragility fracture progression versus a complication related to the initial fixation strategy.
Files:
Q: Are there radiographs to review
A: —
Do you believe there might have been medical error?
Overall, I think this case is defensible and I do not see a clear departure from the standard of care — but there is one area maybe worth flagging. XR pics would be quite helpful here. The decision to proceed with operative fixation was appropriate and well-documented. Casting or conservative management of a displaced proximal/subtrochanteric femur fracture in a nonverbal, hypotonic, nonambulatory child with documented skin breakdown risk is a recognized poor option — operative stabilization was the right call. The implant selection is where I'd expect scrutiny. For a proximal/subtrochanteric pattern in a child with severe documented osteopenia, a cephalomedullary or reconstruction-type nail — one with femoral neck fixation — provides more robust proximal purchase and better protects the femoral neck against the kind of fracture that occurred five weeks later. A standard antegrade nail without neck fixation is not unreasonable in a normal-bone pediatric femur, but in this anatomy and bone biology, a plaintiff's expert could credibly argue that a recon-type construct was the more appropriate choice. The subsequent peritrochanteric/femoral neck fracture at the proximal nail zone is the fact that gives that argument legs.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
see above The implant selection is where I'd expect scrutiny. For a proximal/subtrochanteric pattern in a child with severe documented osteopenia, a cephalomedullary or reconstruction-type nail — one with femoral neck fixation — provides more robust proximal purchase and better protects the femoral neck against the kind of fracture that occurred five weeks later. A standard antegrade nail without neck fixation is not unreasonable in a normal-bone pediatric femur, but in this anatomy and bone biology, a plaintiff's expert could credibly argue that a recon-type construct was the more appropriate choice.
What makes you a good expert for this case?
My clinical practice focuses on medically complex pediatric patients — including nonambulatory, hypotonic, and neurologically impaired children with underlying metabolic bone disease and osteopenia — which maps directly to the patient population and clinical circumstances at issue in this case. I routinely manage fracture risk, bone quality considerations, and surgical decision-making in children with conditions analogous to those documented here, and I have working familiarity with intramedullary fixation constructs and their limitations in poor-quality bone.
How often do you encounter cases similar to this one in your practice?
very often, see above My clinical practice focuses on medically complex pediatric patients — including nonambulatory, hypotonic, and neurologically impaired children with underlying metabolic bone disease and osteopenia — which maps directly to the patient population and clinical circumstances at issue in this case. I routinely manage fracture risk, bone quality considerations, and surgical decision-making in children with conditions analogous to those documented here, and I have working familiarity with intramedullary fixation constructs and their limitations in poor-quality bone.
Do you believe there might have been medical error?
There was thoughtful decision making and providing the choice of fixation for a proximal femur fracture. When weighing the patient's baseline characteristics including significant osteopenia and history of fragility fractures, as well as abnormal tone including dystonia, it is advisable to provide a rigid locked intramedullary implant. (Example https://pubmed.ncbi.nlm.nih.gov/37867374/) Application of a spica cast in would have been challenging, and maybe difficult in a patient with dystonia as severe pain as spasm exacerbate dystonia after which skin sores can occur. Stable fixation in the form in locked intramedullary fixation is the optimal choice for this clinical scenario (which the treating physicians initially chose). Plate fixation is much more prone to periprosthetic failure. Non locked intramedullary fixation may not be adequate for unstable proximal femur fractures as they do not provide sufficient stability. The choice of fixation was appropriate. The fact that the patient had a difficult closed reduction to allow passage of intramedullary guidewire may arise from difficult anatomy, positioning, contractures, amongst others that can often necessitate open reduction to achieve adequate reduction of the fragments. The periprosthetic fracture / femoral neck fracture was more than likely secondary to the patients underlying medical condition, tone, and poor bone quality. Weight bearing as tolerated after rigid locked intramedullary fixation is standard of care, which allows for ease of patient care in the setting of comorbid conditions
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Every method of femoral fixation needs to enter the bone and has risk of periprosthetic fracture. The surgeons utilized a implant strategy that was appropriate for the case, which is actually lower risk of periprosthetic fracture than other methods of rigid internal fixation. Rigid femoral fixation using the original implant utilizes a small (approx 9 mm) entry to the greater trochanter, with additional locked screws along the femoral shaft. This is actually much lower risk of periprosthetic fracture compared to plating of the femur which often requires six or more screws along the femoral shaft.
What makes you a good expert for this case?
I am a pediatric orthopedic surgeon with over 10 years of experience in practice, with majority of my time serving in a level 1 pediatric trauma center.
How often do you encounter cases similar to this one in your practice?
At least several per year. Treatment of femoral shaft fractures in children are common amongst academic pediatric orthopedic surgeons.
Do you believe there might have been medical error?
This patient is medically complex with a complex proximal femur fracture in the setting of osteopenia. While I haven't personally visualized/interpreted the plain radiographs, based on the description, the original decision for surgery seemed appropriate and a shared-decision making conversation seems to have taken place based on the "indications" section in the attached document. The initial choice for an intramedullary nail depends on the fracture pattern. As long as there isn't comminution that could affect stability, the implant allows early range of motion, weight-bearing, and avoids immobilization. Severe osteopenia and potential peri-implant fractures can happen regardless of the internal device. Based on the operative report, it's unlikely a complication related to the initial fixation strategy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It's unknown if the subsequent fracture was unavoidable or present/unrecognized at the initial surgery, or an unfortunate complication in a medically complex child with poor bone quality.
What makes you a good expert for this case?
I am a board-certified associate professor of pediatric orthopaedic surgery at a large academic children't hospital with experience with fracture management in medically complex patients.
How often do you encounter cases similar to this one in your practice?
I work at an academic tertiary children's hospital with a large geographic referral network. Complex fractures like this are commonly seen and continue to increase due to medical advancements.
Do you believe there might have been medical error?
This patient would not have done well with non operative treatment. Periprosthetic fracture is a known complication in osteoporotic bone. The initial surgery was indicated and the least invasive surgery was performed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The surgery was indicated and the least invasive procedure was chosen
What makes you a good expert for this case?
Pediatric Orthopedic Surgeon. Treated multiple syndromic cases in fellowship
How often do you encounter cases similar to this one in your practice?
rarely, these are uncommon in private practice
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