Wednesday, December 14, 2011

Infections During Pregnancy

Several years ago, when my wife was pregnant with our son, I contracted a human parvovirus. Having assisted on a few cases involving gestational infections, I was quite concerned and sought treatment immediately. We also notified my wife’s obstetrician and took steps to avoid transmission of the virus to her and the developing child. Thankfully, our doctors took this situation seriously and followed us closely to be sure that there was no risk to the pregnancy. Pregnancy often leaves the mother with a weakened immune system. Infections can be a great risk to the fetus. Therefore it is an important responsibility of the obstetrician to avoid and treat infections in a timely manner.

I have participated in a variety of medical malpractice cases involving maternal infections that were not adequately treated and therefore allowed to infect the child, either in the womb or during delivery. In those cases, I have seen that there are three basic ways that the baby may become infected. 1) Congenital infections are infections that pass from the mother to the child across the placenta while the baby is womb. 2) Perinatal infections are infections of the birth canal that spread to the child during labor or delivery. These infections may cross the fetal membranes or invade after the membranes are broken to infect the baby in the womb, or infect the baby as it passes through an infected vaginal canal during delivery. 3) Postnatal infections spread to the baby after delivery, primarily through the mother’s breast milk.

Congenital infections can be caused by protozoan parasites as in toxoplasmosis, bacteria as in syphilis, or by a variety of viruses such as rubella, cytomegalovirus, herpes or human parvovirus. Each different microbe is a risk to the developing fetus at different stages of development. Some may interfere with development leading to deformities or developmental abnormalities. Others may lead to fetal death and miscarriage. It is important that the mother be monitored for infections throughout the pregnancy and that any infection be treated promptly.

Perinatal infections are caused by bacteria such as strep or viruses such as herpes or the human papilloma virus that may be present in the vagina during labor or delivery. These infections include many sexually transmitted diseases that can infect the baby during delivery. Another risk comes from fecal material that may contaminate the birth canal during labor. As mentioned above, some of these infections may cross the fetal membranes and infect the fetus in utero. Others may move into the womb after the membranes are disrupted (water breaks). Certainly the fetus is exposed to any infections within the vagina during the process of delivery as the baby passes through the birth canal. Once again, it is the responsibility of the obstetrician to recognize and treat any vaginal infections prior to delivery to avoid this contamination.

Postnatal infections involve many of the same bacteria or viruses mentioned above and can pass from the mother to the child through the breast milk. These infections can be easily avoided if the mother has been properly diagnosed and breast-feeding is delayed until after treatment is complete.

In each case of fetal infection that I’ve worked on over the years the issue being litigated is either the failure to diagnose a maternal infection or a failure to treat the infection or take steps to prevent contagion. If, in future cases, you encounter issues of fetal deformity or fetal demise, it would benefit you to do a thorough examination of the medical records to see if there is any evidence of infections that existed in the mother that may have contributed to the outcome of the pregnancy.

Thursday, November 3, 2011

Intramedullary Fixation

I'll never forget the first orthopedic surgery I observed while at medical school training for my medical illustration degree. I was shocked at the crude brutality of the procedure with all the hammering, sawing, drilling and reaming. It seemed more like carpentry than what I had envisioned as modern medicine. If nothing else, orthopedic surgery is certainly dramatic and perhaps this inherent drama is what makes it such a popular subject for demonstrative evidence. Because of that popularity, I have selected one orthopedic issue as our topic for the month. Let's learn a bit about intramedullary fixation.

We'll begin with the basics. When a bone is broken, the body has a remarkable ability to repair itself by producing new bone to knit the fracture back into a solid structure. This can only occur successfully if the fractured edges of bone are in contact with one another and if the fracture site is immobilized during the healing process. That is the primary goal of the orthopedist when dealing with a fracture: to align and stabilize the fracture site. In many instances, this alignment and stabilization can be done without surgery. Non-displaced fractures can be stabilized in a splint or cast. Some displaced fractures can be realigned externally before stabilization. More complex or severe fractures must be aligned surgically and held in position with fixation hardware to provide the stabilization required for healing.A variety of fixation techniques and types of fixation hardware have been developed over centuries. Orthopedic surgeons may use wires, staples, plates, screws or rods to hold fractures in position as they heal. One of the most popular techniques for fixation of large long bone (extremities) fractures is the insertion of an intramedullary rod inside the length of the bone. Long bones in the arms, legs, feet and hands consist of a hard compact outer layer that forms a tube surrounding a hollow chamber called the medullary cavity containing the bone marrow. This hollow chamber is ideal for the placement of a fixation rod allowing for the stabilization of the entire length of the bone.

The surgical technique for intramedullary fixation includes the access of the end of the broken bone through a small open incision. A hole is created through the hard outer compact bone to expose the medullary canal. A guidewire is inserted down the length of the bone to insure alignment and to identify the medullary canal. A drill-like reamer is advanced over the guidewire to clear the marrow and open a pathway for the fixation rod. Finally, the rod itself is hammered into position. Locking screws may be placed at either end of the rod to hold the rod in position. This fixation rod may be left in position permanently or may be removed at a later date following the full healing of the fracture.

Beyond the great stability offered by intramedullary fixation, there are other advantages to utilizing this technique. Intramedullary fixation can be accomplished with a much smaller incision than the large open incision required for the placement of fixation plates across the external aspect of the fracture. This reduces post-operative pain and recovery time and also involves lower risk of damage to vessels and nerves that may lie in the region of the fracture. Also, because the open incision is not at the actual site of the fracture, there is no additional disruption and risk of infection that would prevent bone healing.

Larger bones are more commonly treated with intramedullary fixation. This includes the femur (thigh), the tibia (shin) and the humerus (upper arm). Smaller bones such as the fibula (smaller lower leg bone), metacarpals (hand), metatarsals (foot), phalanges (fingers and toes) and even the clavicle (collar bone) can be fixated with smaller intramedullary rods or pins, but this is less common than the use of small plates and screws. Another term you may run across is "retrograde". Retrograde fixation means that the rod is placed through the distal end of the bone extending upward rather than into the proximal end and extending downward.

If you handle any personal injury cases in your practice, you'll eventually run across a case involving an intramedullary fixation. Hopefully this overview has helped you to better understand these dramatic orthopedic procedures.

Thursday, September 29, 2011

Stations of Presentation

In the past few weeks I have had calls from three attorneys with traumatic birth injury cases. Each one needed last minute help with demonstrative evidence to illustrate the basics of labor and delivery. They had all waited to the last minute, thinking they didn’t need anything very specific and that they could get something very quickly. Unfortunately, each of these clients was unable to answer one vital question about their case, which forced them to rush back to their experts for more information and nearly prevented them from acquiring their exhibits in time. The vital question they could not answer was, “What system of classification was used in this case to notate the station of presentation?”
If you’ve ever taken part in any litigation regarding labor and delivery, certainly you’re familiar with stations of presentation. Basically, this system allows the healthcare provider to record the progress the baby makes down through the birth canal during the process of labor. It is vital to chart this progress because any deviation from the normal range can give vital clues that there is a problem that might require action. Delays in fetal progress down the birth canal during labor could be a sign of a variety of problems including an insufficient size of the mother’s pelvis, inadequate contractions, shoulder dystocia or other serious complications. The records regarding this progression may be the only evidence of what was happening during labor in a case that eventually results in litigation, so the records of the fetal stations is vital. There are two separate systems in use out there and to get an accurate picture of what occurred, you must know what system was in use.

Fetal station refers to the level of the leading edge of the fetus within the birth canal (either the head in a vertex presentation, or the foot or buttocks in a breech presentation). This level is measured in relation to the location of small protrusions of the pelvis of the mother called ischial spines. The station refers to how far above or below the ischial spines the fetus has progressed. Unfortunately, there are two distinct systems for determining fetal station in use. We’ll refer to these two systems as the “thirds” system and the “fifths” system.

Traditionally, the thirds system of measuring the station of presentation was the standard. In this system the level of the birth canal level with the ischial spines is referred to as 0 station. Above the 0 station, the distance from the pelvic inlet at the top of the pelvis down to the ischial spines is divided into thirds and referred to as -3, -2 and -1 from top to bottom. Below the 0 station, the distance from the ischial spines down to the pelvic outlet where the baby emerges from the birth canal is also divided into thirds and referred to as +1, +2 and +3 as the baby progresses. So, you take the total distance between these landmarks and divide the distance into thirds.

In 1988, the American College of Obstetricians and Gynecologists began to change the system and divide these spaces into fifths. In the fifths system, the ischial spines still represent the 0 station, but the new system refers to the stations as -5, -4, -3, -2, -1, 0, +1, +2, +3, +4 and +5. More importantly, these stations are no longer just arbitrary divisions of the total space. In the fifths system each station is divided by 1 cm, so an actual measurement can be taken to more accurately determine the station, depending on how many centimeters above or below the ischial spines the leading edge has reached.

Although 0 station is the same in the thirds and fifths system, none of the other stations coincide, so it is important to know what system was used. Regretfully, no consistency is seen in the world of obstetrics and it depends on where and when the obstetrician was trained, as well as the standards of the hospital where the delivery is performed. Early in your research and discovery phase of the case, you must determine which system was in use in order to properly understand the stations that are recorded in the records. Certainly, if the time comes for you to depict the events of the case accurately in demonstrative evidence you must be sure that the illustrations you use reflect the proper system.

Monday, June 27, 2011

VBAC and Uterine Rupture

Of all the issues we regularly see in OB/GYN medical malpractice cases, those involving uterine rupture are often the most devastating. The rupture of the uterus during pregnancy or during delivery can lead to severe and even fatal complications for both mother and child. Uterine rupture can result from a variety of complications, but the most common that we see is the weakening of the uterine wall caused by a previous cesarean section (C-section). These weaknesses are most apparent during an attempted vaginal birth after cesarean (VBAC) when the uterus is under extreme stress.

The uterus is a thick-walled hollow organ made up primarily of interlaced bundles of smooth muscle that give the uterus the ability to expand dramatically in size as the fetus develops and to contract forcefully to expel the fetus during delivery. In a C-section, the muscular wall of the uterus is cut creating a large opening to allow the surgeon to remove the fetus through an abdominal incision when the fetus fails to pass normally through the mother's pelvis. While this procedure provides a relatively safe and effective means of avoiding complications in the initial delivery, it can set the stage for increased complications in later pregnancies.

Following a C-section, the cut edges of the uterus are repaired with sutures and this incision site will heal over time, but this healing is accomplished with scar tissue, not new pristine muscle. This region of scar tissue at the original C-section site can never regain the full strength and flexibility of undamaged uterine tissue. In future pregnancies and particularly in future deliveries, when the uterus is again placed under stress by stretching and contracting, there is a substantial risk that there may be tearing or a complete rupture at the previous C-section site.

Risks of uterine rupture can affect both the mother and the fetus. For the mother, there is a risk of significant hemorrhage. The uterus is a highly vascular organ and tears can stretch and lacerate vessels of a variety of sizes. If not recognized and repaired promptly, these vascular injuries could prove fatal. For the fetus, there are a variety of risks. If the tear happens to compromise the placenta or major vessels supplying the uterus, there could be an interruption of umbilical blood flow leading to hypoxia or reduced oxygenation of the fetus. Also, if the rupture is of sufficient size, the fetus could be expelled out into the abdomen of the mother. This expulsion can also cause a partial or complete detachment of the placenta leading to a complete loss of blood supply to the fetus resulting in complete deoxygenation. An immediate diagnosis of the rupture and a repeat C-section would be necessary to rescue a fetus in such a case.

Years ago, VBAC was not an option. Any woman would delivered via C-section would never have been given the option of vaginal delivery in future pregnancies. Advances in surgical techniques and other medical practices have now made VBAC a viable option, but not all risks have been eliminated. The risks for a VBAC are significantly higher than for a normal vaginal birth. Such a delivery must be monitored closely and adequate facilities must be on hand and available to deal with any sudden emergencies. Any uterine rupture may result in devastating consequences for both mother and child.

Wednesday, May 25, 2011

Building an Attorney’s Medical Reference Library

As I’ve been writing these various articles covering a wide range of medical-legal topics over the past few years, many readers have contacted me with questions regarding the references that I use. While some are interested in specific references for specific topics, I have noticed that most are just interested in building a good medical reference library for use in their practice. I believe that that is an admirable goal.

While my reference library is filled with a wide variety of anatomical atlases, cellular biology texts, chemistry texts and multiple surgical atlases, I would never dream of recommending that the average personal injury or medical malpractice attorney spend the money it would require to build such a library. I set out to try to come up with a comprehensive and affordable list and one of my first steps was to call Ms. Janabeth Evans Taylor, a widely known and respected medical-legal consultant to see if she had any recommendations. Luckily, I discovered that Janabeth has already written a great article on this topic and she has agreed to let me share it with you.

Janabeth Evans (Taylor), R.N., R.N.C., Paralegal, has been a successful medical-legal consultant since 1990. She has assisted attorneys in both state and federal court proceedings and is well recognized and highly respected for diligence, thoroughness, accuracy, and excellent communication skills. Ms. Evans (Taylor) has authored and co-developed a broad variety of publications and presentations for lawyers, paralegals and other professionals. Representative topics include medical research, internet search strategies, low speed vehicular crashes, drug litigation, soft tissue injury, placental pathology, and medical expert deposition preparation techniques.

Click here to read her excellent suggestions for Building Your Medical Library.

Monday, April 11, 2011

Custom Models for Litigation

Physical models have always been popular in education. We can all remember spinning a globe to learn our geography or building a volcano to better appreciate geology. Models became even more important for me as I began a more intense study of biology and medicine. When learning the structure of molecules, there was no substitute for our little set of balls and sticks and certainly having a full size skeleton model gave a better understanding of anatomy. Medical models of all types are often very helpful in grasping concepts of structure and proximity. For these reasons, physical models also have a long history of usefulness as demonstrative evidence in trial.

Although Medical Legal Art is not in the business of creating medical models, we have always made it a practice to resell a wide range of medical models for our clients who recognize the usefulness of these items. Regretfully, until recently, I have been unaware of any company in the country that was actively creating custom models for legal use. Often clients would call and request custom models that would not only show basic normal anatomy but also be able to show the case specific facts of their case. It was frustrating to have no recommendations for these customers.

But in the past few months I've been happy to get to know the people at Archetype 3D (, a company that specializes in custom models of all types. I'm thrilled that I now have a solution for those who call me requesting a source for custom models and I wanted to help them spread the news regarding their services. Click on the link below to learn more about Archetype 3D and their commitment to the use of scale models in trial. I'm sure that you will find them as pleasant as I have if you find yourself in need of custom models.

The Argument for Scale Models as Legal Props in the Courtroom

Tuesday, March 15, 2011

Understanding Common Ankle Fractures

In honor of Ms. Marianne Clark, our Senior Account Executive here at Medical Legal Art who recently suffered a slip and fall on the ice with a resulting trimalleolar ankle fracture, I thought it apropos to dedicate this article to these common orthopedic injuries that we so often see in personal injury litigation. Ms. Clark is back in the office now recovering from her fixation surgery, but you may have noticed that I was too busy to post an article last month while she was away. It's good to have her back with us.

When involved in litigation regarding an ankle fracture, you may be confronted with terms such as medial malleolus, lateral malleolus, bimalleolar, trimalleolar and syndesmosis. It is important to understand the anatomy of the ankle before we can fully understand the terms describing the various injuries. The ankle is a joint where the tibia and fibula of the lower leg articulate with the talus bone in the upper portion of the foot. The tibia is on the medial (inner/toward the midline) aspect of the ankle and the fibula is on the lateral (outer/away from the midline) aspect of the ankle. The ends of these bones form knobs or projections that you can easily see or feel on either sides of the ankle. These protuberances are called the lateral malleolus (fibula) and the medial malleolus (tibia). Each malleolus can be fractured independently (lateral malleolus fracture, medial malleolus fracture) but if both are fractured, it is called a bimalleolar fracture. There is also a posterior projection of the tibia called the posterior malleolus. If all three regions are involved in the injury it is called a trimalleolar fracture.

The syndesmosis is the articulation between the lower portions of the tibia and fibula where they come together and touch just above the ankle joint. This articulation is held in place with a variety of ligaments and a stable syndesmosis is important for proper pain-free weight bearing. In many cases involving fractures or severe sprains of the ankle, the syndesmosis becomes separated or unstable if the ligaments are stretched or torn.

Fractures of the various malleoli can often be treated conservatively with immobilization or casting of the ankle. Internal fixation surgery is also common when metal hardware is required to secure and stabilize the fragments while the fractures heal. A variety of screws or plates and screws may be employed based on the nature of the fractures and the preferences of the surgeon. This hardware is often left in place permanently although it is not uncommon for the hardware to be removed in a subsequent procedure if it causes any difficulties after the fractures have healed. Disruptions of the syndesmosis can also be repaired surgically. These procedures can include repair or reconstruction of the ligaments or the placement of long screws that traverse both the tibia and fibula to hold the distal ends of these bones together in proper alignment.