Any deviations in the standard of care for a 21-degree malrotation in this tibial surgery? For failing to document and likely perform and intraoperative rotational alignment assessment by surgeon?
On June 14, 2024, (50 y/o female) suffered a mechanical fall while rollerblading on wet pavement, sustaining an acute right lower extremity injury. She presented to the ER with severe right leg pain and inability to bear weight. There was no foot/ankle surgeon available, necessitating transfer to another facility.
A CT was done which revealed the following: Traumatic spiral comminuted intra-articular fracture of the distal tibial diaphysis with extension into the tib-fib joint. No significant displacement of the intra-articular component; moderate displacement of the comminuted diaphyseal component. Slightly comminuted spiral fracture of the proximal fibular diaphysis with a posterior butterfly fragment.
On June 17, 2024, Surgeon completed a right tibial closed reduction with intramedullary nail fixation + fixation of right nondisplaced tibial plafond fracture. Suprapatellar approach — clamp on patella, entry through knee joint. Plafond lag screw placed first: 46mm partially threaded cannulated screw, posteromedial to anterolateral. Nail: 9mm diameter, 31.5cm length, impacted. 2 proximal interlocking screws (5.0mm); A-to-P distal interlock then ML distal interlock.
Critical documentation: "The fracture was well reduced on all views." — AP and lateral fluoroscopy only. No documentation of rotational alignment assessment (thigh-foot angle, clinical comparison to contralateral limb, or fluoroscopic rotational protocol) anywhere in the operative note.
Nursing documented uncontrolled pain on POD#1 with continued need for IV morphine. RN called Dr. Vosseller requesting continuation of morphine and again reiterated swelling unchanged. Surgeon issued a verbal order by phone. No in-person physical exam was performed by the operating surgeon on POD#1. Discharged the next day.
Seven months post-surgery, on January 29, 2025, client was evaluated by a different orthopedic surgeon. She had an antalgic gait. Unable to bear weight. 10–15-degree external rotation. Tenderness at right tibial tubercle near screw head and at fracture site. Diminished sensation in deep/superficial peroneal and saphenous distributions on RLE. On March 13, 2025, CT scan showed an incomplete union distal tibia and proximal fibular fractures; corticated margins along oblique shaft and metaphyseal lucency; partial osseous bridging at proximal/distal portions of fibular fracture. Intact hardware.
On June 10, 2025, client had a bilateral CT scan. The right tibial torsion was 31-degrees external. The left tibial torsion was a 10-degree external. There was a 21-degree external malrotation of the right tibia relative to the left.
On June 16, 2025, client underwent the following:
Removal of hardware: Arthrex tibial IM nail + interlocking screws + independent cannulated partially threaded screw
Supramalleolar osteotomy right distal tibia (multiple drill hole technique, completed with osteotomes); Right mid-shaft fibula osteotomy — 1cm fibular segment resected to allow for compression at osteotomy site; Application of computer-assisted stereotactic circular hexapod external fixator (two 150mm rings, 6 struts, HA-coated half pins). Correction programmed at ~1°/day; planned under-correction to ~15° initially with reassessment. In October of 2025, the external fixator was removed.
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Do you believe there might have been medical error?
Yes, a rotational deformity of this magnitude is large and can result in ongoing pain and disability, even after fracture healing.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A rotational deformity of this magnitude would result in altered gait, pain, and necessity for revision surgery.
What makes you a good expert for this case?
I have more than 10 years of clinical experience in Orthopedic Surgery. I have served as an expert in over 70 medicolegal cases including personal injury and medical malpractice. I hold a faculty appointment at George Washington University School of Medicine and am well versed in the standard of care for this fracture pattern.
How often do you encounter cases similar to this one in your practice?
3-4 cases like this per year. I treat multiple fractures throughout the body on a daily basis, particularly lower extremity fractures, such as tibia.
Do you believe there might have been medical error?
A 21 degree external rotation deformity is outside of the scope of a standard error and acceptable alignment. This is a large degree of malrotation that was likely produced at the time of surgery by malalignment and fixation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It appears likely that there was causation, as the complication of symptomatic malrotation was likely attributable to a direct medical error. There is also the issue of the possible ignored compartment syndrome with nerve palsy as a possible consequence.
What makes you a good expert for this case?
I am a double board-certified orthopedic surgeon with extensive experience in Level One trauma settings where tibia fractures are treated routinely.
How often do you encounter cases similar to this one in your practice?
Malunion cases approximately once per month
Do you believe there might have been medical error?
The surgeon ordered IV pain medication on POD #1. He did not see the patient despite being called by nursing about pain. There should be an exam by an APP at the minimum as compartment syndrome cannot be excluded. The operative report should indicate a check for restoration of length and rotation. The post op follow up clinic notes should also comment on that.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There was a 21 degree malrotation from the IMN procedure. There was also healing issues. The surgeon controls the reduction-which resulted in malrotation and nonunion. There was a revision surgery performed which was extensive (though surgeons could have addressed the deformity with different techniques).
What makes you a good expert for this case?
I am an orthopaedic trauma surgeon with 25 years of experience. I am well published with over 260 peer reviewed publications. Thus I am aware of standard of care and current techniques.
How often do you encounter cases similar to this one in your practice?
Tibial nailing is a common procedure I perform on a regular basis with over 400-500 cases annually and regular IMN of tibial shaft fractures.
Do you believe there might have been medical error?
Without seeing the X-rays the description reveals an intra articular fracture at the distal tibia. This was reduced with 1 screw then a nail with a butterfly fragment. This is difficult to control rotation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again the tibia went onto a non union and malunion necessitating further surgery. Radiographs should be taken during the post operative period to include AP and LAT of the rib rib as well as dedicated ankle views to include mortise views.
What makes you a good expert for this case?
I have 26 years experience as an orthopedic surgeon. I have managed fractures throughout the career
How often do you encounter cases similar to this one in your practice?
Tibia fractures requiring nails approx 10 per year.
Do you believe there might have been medical error?
When the physician was placing the nail he/she should have been cognizant of the rotation of the foot before putting any of the screws in to lock the nail in place. He/she also should have checked the direction of where the feet were pointing prior to leaving the operating room.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The rotational deformity was causally related to the fracture pattern and the operative procedure.
What makes you a good expert for this case?
My fellowship is in post-traumatic reconstruction, ie, non unions, malunions etc. I have also been in a general orthopedic practice over 25 years.
How often do you encounter cases similar to this one in your practice?
Once in a while but I am knowledgeable on this topic.
Do you believe there might have been medical error?
Unless the patient had a pre-existing rotational deformity (would be ascertained from other past medical records), a "21-degree external malrotation of the right tibia relative to the left" is likely due do the tibia being malrotated at the time reduction/nailing/placement of interlocking screws.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The surgeon needs to ensure that the fracture is aligned within acceptable tolerances prior to placement of the IM nail and interlocking screws (which "lock in" in the rotation as there is no turning back). Malrotation is a known complication/risk of the surgery, and some fracture patterns make it more likely, e.g. comminution. If deemed appropriate intra-operatively, the surgeon can/should still identify the complication postoperatively and discuss options with the patient at that time. E.g. the surgeon could take the patient back to the OR, remove the interlocking screws, re-reduce the fracture into acceptable rotation by comparing to the contralateral leg, pre-op templating, etc. and then replace the interlocking screws.
What makes you a good expert for this case?
I'm a board-certified double fellowship trained orthopedic surgeon. I've been in practice since 2017 and have performed similar surgeries in practice. I'm an associate professor at a reputable tertiary care center.
How often do you encounter cases similar to this one in your practice?
A few times per month cases such as this are either performed by myself or reviewed at weekly postop conferences. Additionally our institution reviews all M&M cases monthly.
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