Case Summary
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.
Case Theory
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.
Expert Witness Specialty
Orthopedic Surgery
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.
Questions for the Expert Witness
- 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?
Expert Witness Involvement
Here is what an orthopedic surgeon had to say about this case:
Expert Witness Response E-055218
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.
