Tripped up

Master Y, aged nine, was walking home from school when he tripped over and fell. He was usually very stoical but after the fall he cried with pain when he tried to stand on his right leg. His mother took him into the local A&E department where, after a brief examination, he was discharged home with a diagnosis of a torn quadriceps muscle. No x-rays were taken. He was advised to avoid weight bearing for two weeks.

Master Y was no better three weeks later. His mother rang their GP, Dr E, who saw him the same day. Dr E noted the history of a fall and recorded only “tenderness” and “advised NSAID gel and paracetamol”.

Master Y continued to complain of pain in his thigh and also his knee. One month later, he saw another GP, Dr B, who assessed him and diagnosed “musculoskeletal pain”. There was no record of any examination. Master Y’s knee pain continued over the next month. Dr B reviewed him and arranged an x-ray of his knee. The only entry on the records was “pain and swelling right knee”.

The x-ray showed signs of osteoporosis and features consistent with possible traumatic injury to the right proximal tibial growth plate. The report advised an urgent orthopaedic opinion, which Dr B arranged .

The orthopaedic surgeon noted an externally rotated and shortened right leg. An urgent MRI revealed a right-sided slipped upper femoral epiphysis and Master Y underwent surgery to stabilise it. The displacement was such that an osteotomy was required later to address residual deformity.

Despite extensive surgery Master Y was left with a short-legged gait and by the age of 16 he was increasingly incapacitated by pain in his right hip. Surgeons considered that he would need a total hip replacement within ten years, and that a revision procedure would almost certainly be required approximately 20 years after that.

A claim was brought against GPs Dr E and Dr B, and the hospital for failing to diagnose his slipped upper femoral epiphysis. It was alleged that they failed to conduct sufficiently thorough examinations, arrange imaging and refer for timely orthopaedic assessment. M

Expert opinion

Medical Protection instructed a GP expert who was critical of both GPs’ unacceptably brief documentation. He noted the discrepancy between what was actually written down by the GPs in the contemporaneous records and their subsequent recollection of their normal practice. The expert felt that their care fell below a reasonable standard.

Medical Protection also obtained an opinion from a consultant orthopaedic surgeon. The expert was critical of the assessment undertaken in the A&E department and advised that knee pain can be a feature of a slipped upper femoral epiphysis. The expert considered that the fall caused a minor slippage of the right upper femoral epiphysis, which was a surgical emergency and the appropriate management would have been admission for pinning of the epiphysis in situ. In the presence of a slight slip and subsequent fusion of the epiphysis, recovery without functional disability would have been expected. As a consequence of failure to diagnose an early slip, Master Y lost the chance of early correction. Instead, he developed a chronic slippage with associated disability that necessitated osteotomy. The case was settled for a high sum, with a contribution from the hospital.

Learning points

• A slipped upper femoral epiphysis is a rare condition in general practice. It usually occurs between the ages of eight and 15 and is more common in obese children. It should be considered in the differential diagnosis of hip and knee pain in this age group.
• Because patients often present with poorly localised pain in the hip, groin, thigh, or knee, it is one of the most commonly missed diagnoses in children.1 In 15% of cases, knee or distal thigh pain is the presenting feature. Referred pain can cause diagnostic error and orthopaedic examination should include examination of the joints above and below the symptomatic joint.
• The medical records were inconsistent with the GPs’ accounts. When records are poor it is very difficult to defend a doctor’s care successfully. The GMC requires doctors to ensure consultations are recorded “clearly, accurately and legibly”.2 
• Safety-netting is important and follow-up should be arranged if patients are not improving or responding to treatment. This should prompt a thorough review and reconsideration of the original diagnosis. 

References

1. Peck D, Slipped Capital Upper Femoral Epiphysis: Diagnosis and Management, Am Fam Physician 82(3):258–62 (2010)
2. General Medical Council, Good Medical Practice (2013)