The author of this column was privileged to attend a workshop at the Eastern Orthopedic Convention on October 17, 1985. The workshop was "Complications of the Modern Management of Fractures of the Lower Extremity" and the participants were Drs. Zickel, Rosen of New York and Tom Ruedi from Switzerland.
The major thrust of this workshop was not the management of the complications but the understanding of what complications are. All of the participants agreed that the management of complications of fractures of any extremity is basically a problem of understanding that the complication exists. In order to manage a complication and have the patient understand its management and to avoid the liability for the complication, it is a requisite that the physician knows that the complication exists. The physician and his patient must understand that certain complications are unavoidable and are part and parcel of the original trauma and care involved. He must also know that certain complications are avoidable, recognizable and treatable. He must understand that certain injuries are too severe to attempt reconstruction and that it is the wise surgeon who appreciates the severity of the original injury and the risks, accepts them and instructs his patient by not attempting fruitless, complicated, prolonged and dangerous surgery which is to no avail.
The practicing orthopedic surgeon should also recognize that other injuries are above and beyond his expertise and the correct therapeutic approach by the primary physician is a referral to a physician with expertise in a trauma center. Legal liability can also be avoided by doing a complete assessment of extremities including consultations and appropriale invasive and non-invasive studies, x-rays, angiograms, tomograms, electromyographic studies, or what ever is indicated in a particular patient to completely evaluate the situation and be aware of any complicating factors which may interfere with a planned mode of treatment.
Dr. Rosen stated that to treat a patient one must know the patient, his desires, expectations and ability to cooperate with the planned treatment. The physician must know his hospital and what facilities are available and not available, what equipment including operating room instrumentation, x-rays and assistants are available and not available. A physician must know what he is capable of performing and what he is not capable of performing because of lack of training, experience or general inability. He must know his plan for the operation and what can be accomplished and what is unaccomplishable. He must know the limitations of the instrument to be used and the hardware itself. To expect internal fixation of fractures to hold when such equipment is not designed to hold and will never hold, is opening oneself up for legal liability.
A typical example is the treatment of a subtrochanteric fracture with a long side plate and nail, realizing that proximal to the fracture there is one screw fixation and one cortex, the hip nail. All orthopedic surgeons with a little cognizance realize that one screw, no matter how large, on one side of a fracture will never hold a fracture. One must further know the limitations of the surgical procedure planned as well as the limitations of the postoperative facilities including nursing, physical therapy, x-rays and assistants.
Therefore, how can we easily distinguish inevitable complications from the evitable? Inevitable complications are those which are not amenable to treatment. Evitable complications or avoidable complications are those fractures which are treated with poor reduction, poor fixation, the wrong equipment, performed at the wrong time, wrong soft tissue care or poor planning. This all boils down to the fact that physicians must be realistic about their capabilities. They must know what realistic expectations are and what can be done for a patient and what cannot be done in their own hospitals and with their own staffs; this must be conveyed to the patient. The typical example of an unrealistic expectation is the compound, comminuted, dirty, grade IV, fractured tibia and fibula, where the treating physician expects to have a good result. Is there one case where the fracture has healed with no shortening, no angulation, no rotation, no deformity, no muscle atrophy and a normal gait? I challenge the readers of this column to show one case where such has occurred by primary healing and no residual osteomyelitis, drainage or cosmetic deformity. In other words, is there a grade IV comminuted, compound fractured tibia and fibula which has healed with a normal extremity to the patient's satisfaction that it is as good or equal to his normal opposite extremity?