Spinal cord injuries in the absence of post-traumatic radiographic anomalies (SCIWORA): the traumatic moment between patient anterior state and efficient/concurrent causes of injury.

BACKGROUND AND AIM: Spinal Cord Injury without Radiographic Abnormality (SCIWORA) represents acute traumatic myelopathy in the absence of instrumental evidence of fractures and/or dislocations of the cervical vertebrae. METHODS: In this article we present 4 cases of SCIWORA that came to our observation and the medico-legal implications associated with them. RESULTS: In defining the compensation in the context of a private accident policy for traumatic pathologies of the spinal cord, an in-depth medical-legal assessment is essential, based on an accurate examination of the health documentation including the instrumental investigations performed, the anamnesis and an accurate evaluation of the trauma dynamic. The paraphysiological deterioration of organ-tissue structures, identifiable in the concept of "natural variability of biological risk", should be included in the same definition of insured risk by age group, with the consequence that physical conditions that fall within the physiological or paraphysiological definitions, although potentially contributing to injury, do not necessarily exclude compensation. A different concept dominates the variability of the compensation according to a paraphysiological pre-existing condition. The two arguments therefore call for thorough consideration of both the paraphysiological contributing causes of injury and/or impairment as necessarily subject to a preliminary study, which through the clinical and instrumental investigation method, will define the perimeter of functionality.

Brachial plexus paralysis in a patient with clavicular fracture, medico-legal implications.

Clavicular fractures make up 2.6-4% of all fractures in adults. The most frequent mechanism of injury is a fall with direct trauma to the shoulder during sports or road accidents. These fractures can have acute complications such as vascular lesions, nerve injuries, pneumothorax, and musculoskeletal injury. Primary brachial plexus injuries are rare events, both in the adult and paediatric population, have an incidence of less than 1% and are usually caused by direct compression of the fragments. We describe a case of midshaft clavicular fracture treated conservatively with a figure-eight bandage, associated with acute brachial plexus injury, and possible medico-legal repercussions thereof. It is important to recognize the progression of neurological deficits early on, in order for appropriate treatment to be undertaken promptly. Patients must be monitored and re-evaluated within few days after the injury to check the correct positioning of the brace, its degree of tolerability, and the possible onset of neurological deficits, because some clavicular fractures can be associated with compression of the brachial plexus.

Atrophic pseudarthrosis of humeral diaphyseal fractures: medico-legal implications and methodological analysis of the evaluation.

Humeral shaft fractures account for 1- 3% of all fractures and about 20-27% of those involving the humerus. In the past they were often conservatively treated, with an acceptable consolidation rate. Open reduction and internal fixation (ORIF) is the best choice in polytrauma patients, in complex or pathological fractures and in those associated with vascular injuries. Regardless the type of fixation used, these fractures can evolve into delayed union or pseudarthrosis (PSA). It should be noted that the humeral shaft itself has a high intrinsic healing potential, due to the blood supply provided by the surrounding muscles. The aim of this work is to evaluate whether the causes that led to the development of atrophic pseudarthrosis in a humeral diaphyseal fracture are attributable to inadequate management of this fearful complication and to highlight the possible medico-legal repercussions. We will try to verify whether the currently used forensic evaluation parameters of permanent disability are appropriate and adequate in relation to the complexity of such injuries. This complexity also includes the repercussions on the ergonomic efficiency of the entire limb, the relative possible postural alterations, the inevitable extension of the period of traumatic illness and the relative repercussions on the overall compromised structure of the subject.

Spinal cord ischemia complicating treatment of abdominal aortic aneurysms: a legal overview.

BACKGROUND AND AIM: Spinal cord ischemia following open or endovascular aneurysm repair of the abdominal aorta is rare but highly disabling complication. The aim of this work is to report on its occurrence and its legal consequences. METHODS: We report a case of spinal cord ischemia complicating an endovascular aortic repair, its management and sequalae, comparing it with the existing literature and we examine its legal consequences resulting in a malpractice lawsuit and the final decision of the judge. RESULTS: Although the causal relation between SCI and the neurological deficits reported were assessed by the Court, no element of responsibility imputable to the Hospital or the Medical Staff were found, since the defendant had made every effort to prevent it in the preoperatory setting, and to treat it once it established in the post-operative phase. CONCLUSIONS: predictable but unpreventable complications of necessary interventions rule out medical malpractice, as long as the patient is fully informed about the risks and benefits of the treatment, and provided that in the perioperative setting all due measures are taken in order to prevent it and treat it.

Pelvic ring and acetabular fracture: Concepts of traumatological forensic interest.

Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage. Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.

Prosthetic joint infections and legal disputes: a threat to the future of prosthetic orthopedics.

Prosthetic joint infections (PJI) represent one of the major problems in orthopedic prosthetic surgery. The incidence of PJIs varies according to the site of intervention, and different published case studies report occurrence at 0.5 to 3.0% in the event of first implants, with a significant greater risk in the case of prosthesis revisions. The diagnosis of prosthetic infections is seldom simple, needing a multi-specialist approach, which includes the accurate collection of patient anamnesis, its clinical evaluation, the evaluation of inflammation biomarkers, and the use of imaging techniques. It is essential to identify the bacteria responsible for the infection not only for an accurate diagnosis, but also to select the correct antibiotic treatment. Failure to identify the bacteria involved makes it impossible to establish targeted systemic antibiotic therapy. In developed countries such as Italy, the right to health is guaranteed by the Constitution, where the institutions that provide health services must be staffed by a team of medical professionals that can guarantee the safest possible health pathways. Risk management represents the set of actions aimed at improving the quality of the care provided, the adherence to guidelines and good care practices with the final objective of guaranteeing patients' safety. All hospitals, including the ones where prosthetic orthopedic surgery is performed, must adopt clinical risk management procedures which, through prospective tools aimed at preventing errors and complications and by retrospective methods, permit the identification of critical points in the different phases of the process and propose actions for improvement. The constant increase in litigation for malpractice in Western countries, especially in Italy, calls for special attention to the problem of PJIs and the in-depth assessment of medico-legal problems, also considering the new legislative initiatives in the field of medical malpractice. Hospitals need to tackle the onset of PJIs in a transparent and linear fashion by constantly informing the patient on their progress.