February 2001 Bulletin

Femur fracture care frequent cause of lawsuit

A study of malpractice claims filed against orthopaedic surgeons found femur fracture ranks first on the list of most frequent and third on the list of most expensive suits by diagnosis.

There were 879 total claims involving femur fracture resolved by the Physician Insurers Association of America (PIAA) in 1985-1998. Of the 820 closed claims, 261 claims (32 percent) resulted in indemnity payments totaling $29.5 million or an average of indemnity of $113,147.

Technical problems in femur fracture management were the cause of suits five times more frequently than the next three causes (i.e., failure to diagnose, infection, death).

The data in the AAOS’s second edition of Managing Orthopaedic Malpractice Risk, prepared by the Committee on Professional Liability, is the result of detailed reviews of hundreds of malpractice claims relating to almost every facet of orthopaedic surgery. The objective of the publication, the committee says, is "to identify factors which may cause a patient to file a lawsuit," and to "identify procedures and diagnoses that have historically been the most common to produce legal action or which have proven most expensive to resolve."

In the chapter on "Femur Fractures Other Than Intertrocanteric," the committee observes closed treatment of children’s fractures resulted in the most frequent and expensive complications, including foot drop, skin loss, compartment syndrome, and malrotation/shortening.

In adults, the committee found common complications included poor technique (inappropriate fixation, early hardware removal, malrotation), infection (especially a problem when not recognized early and/or proper consultation not obtained), wrong-site surgery, fat and/or pulmonary embolism, and delay in diagnosis or treatment.

Additional complications resulted from the use of plates and screws for subtrochanteric fractures despite package insert warnings to the contrary, undersized intramedullary rods, and poor hardware selection (plates/screws) in other regions of the femur, the committee said,

The data revealed that fractures about the hip and femoral shaft in children produce the most expensive judgments. The number of cases of skin necrosis, foot drop, compartment syndrome and persistent fracture deformity led one reviewer to ask, "is it possible that with all the technology available today orthopaedists are forgetting the basic principles of fracture care?"

The committee cautioned that "closed management of these fractures requires close observation by medical personnel and immediate intervention for complications. This type of treatment demands a high degree of skill and adherence to sound orthopaedic principles."

Orthopaedic surgeons are advised by the committee to preoperatively engage in a "thorough discussion with the patient (or family, in the case of children) concerning the nature of the injury and proposed treatment, the alternatives available, possible complications and their consequences, and realistic expectations.

"This discussion is critical, because patient anger and informed consent issues are consistently noted in cases in which patients brought lawsuits. Be aware of and review all preoperative consultations and tests (laboratory, X-ray, cardiac)."

The committee also stresses that "internal fixation devices must be selected and used in accordance with manufacturers’ printed specifications and published data from texts and professional literature. Postoperative management of open fractures, or following open treatment, must include careful monitoring for possible infection. When in doubt, or in the face of established infection, obtain early consultation with an infectious disease expert."

10 most prevalent patient conditions orthopaedic surgery

Patient Condition

Total
claims

Closed
claims

Paid
claims

Total
indemnity

Average
indemnity

Femur, fracture of

879

820

261

$29,531,365

$113,147

Fracture of the tibia or fibula

760

689

204

$30,533,639

$149,675

Displacement of intervertebral disc

734

663

202

$46,086,474

$228,151

Osteoarthrosis, generalized or localized

699

627

196

$24,338,270

$124,175

Fracture of the radius or ulna

636

577

172

$12,618,199

$73,362

Disorder of the radius, not including arthritis

556

469

128

$13,436,002

$104,969

Fracture of medial malleolus closed

466

415

147

$19,184,075

$130,504

Tear of medial cartilage or meniscus of knee

452

419

125

$14,581,003

$116,648

Back disorders, including lumbago and sciatica

426

379

90

$18,458,511

$205,095

Humerus,
fracture of

357

307

97

$11,671,591

$120,326

Totals

5,965

5,365

1,622

$220,439,129

$135,906

Source: Managing Orthopaedic Malpractice Risk, 2nd Edition, American Academy
of Orthopaedic Surgeons


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