This nurse review related to a trip-and-fall injury.  A simple trip and fall developed into Avascular necrosis (AVN).  The claimant reported tripping and falling onto her left shoulder, sustaining a left comminuted, non-displaced fracture of the humeral head.  The claimant was treated conservatively with a sling, pain management, and physical therapy.  However, she was non-compliant with her home exercise program and missed several physical therapy sessions.

Ultimately she developed adhesive capsulitis.  Later in the treatment timeline, she was noted to have avascular necrosis (AVN) and a partial tear of the subscapularis but declined any surgical intervention.

The plaintiff attorney alleges that the claimant tripped over a pipe and sustained a left humeral fracture which has altered her ability to function.  A demand was a high dollar amount.

Mechanism of Injury (MOI)

The nurse review notes that there was no incident report included.  In addition, the claimant’s description of the MOI does not completely align with the plaintiff attorney demand letter. According to the medical records, the claimant reported tripping over a piece of wood at home.  The plaintiff attorney’s description of the event was a bit different, drawing into question the actual events.  For the purposes of the medical review,  the nurse reviewer assumed the medical records and the claimant’s version of the event were truthful and accurate.  Her initial subjective and objective complaints aligned with a fall on to the shoulder.

Avascular necrosis (AVN) is the death of bone tissue due to a loss of blood supply. If it isn’t treated, AVN can cause the bone to collapse. Here’s a quick review of the imaging used to diagnose AVN.


The humeral head is the second most common site of AVN, with the first being the femoral head.  Some populations (e.g., autoimmune, sickle cell disease, chronic use of corticosteriods and alcoholism) are more susceptible to the development of AVN. Unfortunately, the diagnosis is often made late because of non-weight bearing nature of the shoulder.  Diagnostics can include plain films, MRI and bone scans. If diagnosed early, there are limited treatment options which can include core decompression of the head and bone grafting to dead bone area. However, arthroplasty remains the most effective treatment.  This can include hemi-arthoplasty or total shoulder replacement.   The later the diagnosis is made, the worse the outcome.  Long term outcomes can include arthritis, diminished ROM, chronic pain and subsequent surgeries.

Comparison of pre and post Date of Loss (DOL)

According to the nurse reviewer, no pre-DOL records were included.


Medical records document that the claimant was non-compliant with the home exercise program provided by the physical therapist.  Her shoulder became increasingly more painful and stiff, and within three months, she developed adhesive capsulitis.

This case study flagged several data points relating to the claimant’s non-compliance:

  • The claimant stopped going to physical therapy after five months of treatment and did not call to cancel.
  • There was a four-month gap in care after the last physical therapy visit.
  • After the gap in care, the claimant returned to orthopedics with continued complaints of left shoulder pain, popping, and stiffness.  An MRI revealed avascular necrosis, partial tear of subscapularis tendon, and some degenerative arthritis.

The claimant was offered surgery for rotator cuff tear and avascular necrosis, but the claimant declined.


Based on the records, the claimant sustained a left humerus fracture after a fall.  There may be some mitigation if the location of the fall was not where the plaintiff attorney alleges.

The claimant’s recovery was extended due to her non-compliance with physical therapy exercises.  Because of this, she also placed herself at risk for long-term complications and potential need for surgery.


  • The big lesson here is that cases involving long bone head (humeral and femoral) fractures should be evaluated very carefully when determining values, future medicals and reserve setting.
  • Depending on the fracture, age and co-morbidities of the patient, a more aggressive treatment plan may be instituted early on.
  • Follow up compliance by the injured party is critical to insure optimal outcomes. Non participation and or compliance  can negatively impact patient recovery and certainly influence decisions by all involved parties.
  • The big lesson from this case is to carefully read medical and physical progress notes to assess participation in the treatment plan.