This case involves a middle-aged man who tripped, fell into a curb, and sustained a comminuted intertrochanteric fracture of the proximal right femur. A hand surgeon who was on call for the facility performed the surgery and placed a right femur intramedullary rod. Per the physician’s note, the fracture was reduced to near anatomical alignment and fixed in place with nails and screws. At the time of the surgery, an x-ray was performed and revealed intramedullary nail fixation with good reduction of the hip. There was no comment on rotational or anatomical alignment.

Over the next 9 months, altered gait and internal foot rotation, with atrophy of the vastus lateralis and bursitis were noted. During this post-operative period, the patient consulted another orthopedic specialist who noted the patient’s right foot in an internal rotation with ambulation, along with pain. This physician reported possible trochanteric bursitis and suggested a second opinion.

One month later, the patient visited a third orthopedic specialist. A CT scan was performed that revealed a 35-degree rotational femur deformity. Following this finding, the surgeon performed an osteotomy of the right femur with hardware removal. Surgical notes document normal femoral anatomical repositioning and determined the original fracture was healed. The diagnosis was an internal rotation defect of the distal femur. An immediate improvement in the patient’s symptoms and mobility post-surgery were noted.

Prevention of malrotation during femoral nailing is crucial for successful operation outcomes. When rotational malalignment is suspected, prompt diagnosis and adequate surgical treatment are necessary to overcome this known complication. The exact definition of a mal-rotated femur is widely determined to be a rotational malalignment and <10° is considered normal while >30° is a deformity requiring correction. Patients with a mal-rotated femur suffer hip and knee pain and difficulty in ambulation. Surgical correction is necessary, and many techniques and devices for the procedure are available involving derotation, changing the locking screws, and maintaining the nail.

The surgeon must be aware of the tendencies towards internal rotation with the femur in traction on a fracture table, and external rotation with the free leg on a flat table in different positions of the patient. The high incidence of femoral malrotation after nailing is due to the difficulty in accurately assessing the torsion alignment of the femur during the operation. Many techniques currently exist to determine the femoral ante torsion intraoperatively and, in this case, the surgeon failed to perform adequate intra-operational and post-operative care.

An orthopedic surgeon can opine on the standard of care for the repair of a femur fracture including the necessity of an experienced surgeon, the importance of assessing rotational alignment during surgery, and the deviation from the standard of care in this case.

What is the standard of care as it relates to obtaining the correct anatomic and rotational alignment of the femur after this type of fracture?

What is an acceptable degree of rotational deformity after a femoral fracture repair?

When should rotational alignment be assessed?

Is a hand surgeon qualified to repair a femoral fracture?

Here is what an orthopedic surgeon had to say about this case:

I see patients for femur fractures requiring operative repair approximately 100 times a year. I have treated between 800 and 1000 patients in total with this injury. The standard of care is to obtain an acceptable alignment within clinical reason, rotational deformity should not exceed around 10 degrees. At first glance, this procedure was probably performed on a fracture table, and in the process the patient's leg was rotated internally, causing the malrotation. This would be below the standard of care, and I am interested in discussing this case further.

The patient, who sustained a femur fracture that required surgery, reported post-operative pain and consulted another physician who determined a surgical revision was necessary to correct a rotational femur deformity from the initial operation.

Operative Repair of Femur Fracture Leads to Surgical Revision

A middle-aged woman with a past medical history of back surgeries underwent a lumbar discectomy and spinal fusion. Her orthopedist then prescribed her in-home physical therapy. The physical therapist instructed the patient to perform a modified push-up against the resistance of the physical therapist pushing down on her back. The exercise stopped when the patient heard a pop. Afterward, she experienced difficulty walking and subsequently contacted her surgeon, who felt that the physical therapist had done something inappropriate. Upon examination, the patient was found to have suffered a traumatic pelvic fracture. As such, the patient required numerous surgeries, including the placement of stabilization hardware. Currently, she is functionally bedridden due to pain and weakness caused by the injury.

Physical therapists are negligent when they fail to exercise the level of care that a reasonably prudent physical therapist would perform under similar circumstances. The most common forms of negligence committed by physical therapists include leaving patients unsupervised on equipment, therapy deemed inappropriate, aggressive maneuvers, ignoring patient’s complaints of pain, using broken equipment, failing to supervise, over-extending limbs, and failing to take the patient’s physical condition into account prior to administering treatments. When physical therapists deviate from accepted standards, they can easily cause injuries. Physical therapists who perform inappropriate care can result in patients suffering severe injuries including lower back injuries, spinal cord injuries, fractures, strains, sprains, and stroke.

These injuries can be even more dangerous as patients age due to a weaker skeletal structure and other medical conditions. Improperly performed or inappropriate techniques are the most common issues for a malpractice claim. In spinal fusions, heel slides, wall squats, and straight leg raises are commonly utilized exercises. They are also some of the most effective rehabilitative exercises to incorporate into a spinal surgery recovery regime.

Improper management and exercises that stress the skeletal area above and below the fusion can subject the patient to further injury. In this case, an inappropriate manual physical therapy maneuver breached the standard of care and led to damages and disability.

An expert in physical therapy can review records and determine the appropriateness of the therapist’s maneuvers and standard of care regarding the patient’s past medical history.

What precautions do physical therapists take for patients with previous back surgeries to avoid similar complications while performing this maneuver?

Under what circumstances should physical therapists perform resistance maneuvers post-discectomy?

Did this physical therapist deviate from established therapy standards?

Here is what the expert in physical therapy in this case had to say:

I have over 30 years of practice experience with a significant number of patients matching the case outlined. I have encountered many such cases both in outpatient care, sub-acute rehab, and a couple myself in home care as a clinician. Low back pain is my specialty, and I teach this subject area in physical therapy at the university level. A person as described will have a weakened musculoskeletal system and rehab proceeds fairly slowly, though gentle resistance against a movement is not unusual and should not be a concern for regular bone fractures. I wonder if the person had an underlying condition of osteoporosis making the pelvis brittle since normal manual resistance should not cause a fracture unless the bones are unusually fragile. This, of course, depends on how the pressure was applied and exactly where. A traumatic fracture will normally only occur under significant pressure or if bones are weak.

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Operative Repair of Femur Fracture Leads to Surgical Revision

Physical Therapy Maneuver Disables Patient

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