The Complicated Orthopedic Case: Warning Signs

Sarah Stiner was a star soccer player in high school. During one game early in the season, a fellow player kicked her in the knee with sufficient force to break her knee cap. The wound did not heal, despite many courses of antibiotics to treat brewing osteomyelitis.

After ordering 18 months of treatment, Sarah’s orthopedist explained that the only long-term solution was an amputation. At the age of 19, Sarah lost her leg. Sarah’s attorney hired me as a Rule 1006 expert witness to explain her pain and suffering endured during her treatment and adjustment to being an amputee.

A fractured bone may sound straightforward: diagnose the fracture, stabilize it, allow time for healing, and restore function. But legal nurse consultants know that orthopedic injuries can become far more complicated.

Sarah’s injury initially appeared straightforward. She had small grass and mud-stained wound, and her injury initially appeared manageable. But it led to repeated surgeries, prolonged antibiotic treatment, chronic pain, impaired mobility, permanent disability, and years of additional medical care involving her prosthetic limb.

When reviewing an orthopedic case, the LNC needs to understand not only the original injury but also what happened during the weeks, months, and sometimes years that followed.

Several complications deserve particular attention.

Complicated Orthopedic Cases: Open Fractures and the Risk of Osteomyelitis

An open fracture occurs when a wound communicates with the fracture site. The injury creates an opportunity for bacteria and other contaminants to reach bone and surrounding tissue.

These cases require careful review of the initial emergency care.

• How contaminated was the wound?
• What did the diagnostic studies reveal about the extent of the injury?
• When were antibiotics administered?
• Were the correct antibiotics given?
• When was irrigation and debridement performed?
• Was additional debridement required?
• How was the fracture stabilized?

One of the most serious complications is osteomyelitis, an infection of the bone.

Osteomyelitis can be remarkably difficult to eradicate. Poor blood supply to damaged bone may limit the effectiveness of systemic antibiotics. Devitalized tissue can provide an environment in which infection persists. When hardware is present, bacteria may form biofilms on its surface, making infection even more resistant to treatment.

The patient may face weeks of IV antibiotics, repeated cultures, surgical debridement, removal of infected or dead bone, additional hospitalizations, and further reconstruction.

For the LNC, the timeline becomes particularly important. Look for increasing pain, wound drainage, erythema, fever, abnormal laboratory values, positive cultures, selection of antibiotics for which the organism is sensitive, imaging findings, and documentation of delayed wound healing. Compare those findings with when the healthcare team recognized and responded to them.

When the Fracture Doesn’t Heal: Malunion and Nonunion

Fracture healing is a biological process influenced by blood supply, stability, infection, the severity of tissue damage, and patient-specific factors.

A malunion occurs when the fracture heals in an abnormal position. Depending on the location and degree of deformity, the patient may experience the need for more surgery, altered gait, reduced range of motion, weakness, pain, limb-length discrepancy, or abnormal stresses on nearby joints.

A nonunion occurs when the fracture fails to heal adequately.

Nonunion can result in persistent pain, instability, impaired function, and the need for further surgery. Treatment may include revision fixation, bone grafting, bone stimulation, or correction of underlying infection.

When reviewing these cases, LNCs should resist looking only at the final diagnosis of “nonunion.” Trace the healing process.

• What did serial X-rays or CT scans show?
• Was there progressive callus formation?
• Was hardware loosening or failure visible?
• Did the patient repeatedly report pain at the fracture site?
• Were there signs suggesting infection?

The medical record may reveal a progression that becomes much clearer when placed into a detailed chronology.

Plates, Screws, and the Need for Hardware Removal

Orthopedic hardware is intended to stabilize injured structures while healing occurs, but it can also become part of the patient’s later complications.

Plates, screws, rods, and other fixation devices may cause irritation or become painful. Hardware may loosen, break, migrate, or become associated with infection. I saw this firsthand when I reviewed dozens of product liability cases of pedicle plates and screws which broke in the patients’ backs.

In some patients, prominent hardware irritates soft tissue or interferes with normal movement.

Removal is not a minor procedure, bringing risks of anesthesia, infection, and further scarring.

The surgeon must weigh the benefits of removal against the risks of another operation, including infection, bleeding, nerve injury, anesthesia complications, and possible weakening of the bone. When hardware is removed because of infection, treatment may become considerably more complex. The patient may require staged procedures, temporary stabilization, prolonged antibiotics, and later reconstruction.

The LNC should identify why removal became necessary and whether the record documents earlier signs of a developing problem.

A Different Kind of Orthopedic Emergency: Spinal Epidural Hematoma

Some complicated orthopedic cases leave little room for delay.

A spinal epidural hematoma is bleeding into the epidural space surrounding the spinal cord or nerve roots. As blood accumulates, pressure can compress neurological structures, causing paralysis.

The consequences can be devastating.

A patient may develop sudden severe back or neck pain followed by weakness, sensory changes, difficulty walking, bowel or bladder dysfunction, or paralysis. Depending on the location and extent of compression, neurological deterioration may occur rapidly.

These cases often require close attention to timing.

• When did symptoms begin?
• When did the patient first report weakness or numbness?
• Were serial neurological assessments performed?
• Were abnormal results promptly acted upon?
• When was the physician notified?
• When was MRI imaging ordered and completed?
• When was the diagnosis recognized?
• If surgical decompression was indicated, how much time passed before the patient reached the operating room?

Minutes and hours can become major points of contention.

A chronology that simply says “patient developed weakness” is not enough. An LNC reviewing a spinal epidural hematoma case should reconstruct the neurological changes as precisely as the documentation permits. A chart audit may be needed to review for any evidence of after the fact added documentation.

Complicated Orthopedic Cases Require More Than Reading the Operative Report

Complicated orthopedic cases can generate enormous medical records: emergency department notes, orthopedic consultations, operative reports, imaging, nursing documentation, rehabilitation and nursing home records, infectious disease consultations, wound care notes, laboratory results, and repeated follow-up visits.

The LNC’s value lies in connecting those pieces.

• Did the fracture appear to be healing normally before progress stalled?
• Were early signs of infection present?
• Did imaging findings match the patient’s complaints?
• Did treaters appropriately react to the findings?
• Did neurological symptoms change before someone acted?
• Why did a patient who was expected to recover instead require three additional operations?

Those are the questions that can help an attorney understand what really happened.

Strengthen Your Orthopedic Case Analysis Skills

Orthopedic cases can involve infection, failed healing, hardware complications, neurological emergencies, repeated surgeries, and permanent functional losses. Knowing what to look for—and how to organize the medical evidence—can make your analysis much more useful to the attorney.

We’ll be examining damages at the 15th LNC Success® Online Conference in March 2027.

Join us to sharpen your ability to analyze these challenging cases, identify significant details in the medical record, and recognize the clinical issues that may shape liability, causation, damages, and case strategy.

Register for the 15th LNC Success® Online Conference and build your confidence in analyzing complex orthopedic cases. Use this link: http://LNC.tips/March27