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An unavoidable amputation

01 September 2013

Mrs N was a 26-year-old researcher with a four-year-old daughter. She enjoyed dancing and went to a salsa class with her husband each week. Her right knee was slightly painful so she missed a class to see if it improved but it got gradually worse over the next few weeks.

She made an appointment with her GP, Dr B, to discuss her knee pain and seek his opinion on a skiing holiday she had booked. His notes commented on her right knee pain which was “possibly due to dancing”. He documented some tenderness over the tibial insertion of the medial collateral ligament. He noted that the joint was stable and that there was no effusion. Dr B prescribed diclofenac and explained that he felt her skiing holiday did not need to be cancelled, but that it may not help matters.

Mrs N enjoyed her holiday but was becoming aggrieved by the knee pain, which was troublesome most of the time and when dancing. She saw Dr B and explained that the pain had been ongoing for four months with no improvement and that she couldn’t remember any specific injury. Dr B documented the history and referred her to physiotherapy. His completed musculoskeletal referral form did not highlight any red flags including intractable night pain, weight loss, systemic illness or previous history of cancer.

While she was waiting for her physiotherapy appointment Mrs N rang the surgery again asking for a GP appointment. This was the first appointment she was given with Dr G. Mrs N explained that she had not taken the diclofenac because she was nervous about possible side effects and she felt the pain was getting worse. Dr G’s records stated “history as above” and also noted that there was no locking or giving way. His examination notes were thorough. He documented that she was able to weight bear, that there was no swelling and that the knee was stable with a normal range of movement. He noted mild tenderness medially. He encouraged her to take the diclofenac and to rest, ice and elevate the knee. He advised buying a tubigrip to offer some compression to the knee. He gave safety-netting advice: asking her to return if things got worse while waiting for physiotherapy.

Mrs N saw the physiotherapist, Mr Y, who noted her four-month history of gradual onset knee pain. He recalled the patient saying that the pain intermittently flared. His examination noted a limping gait and an inability to extend her right knee fully due to pain. He noted slight swelling and that the knee was very warm to touch. Mcmurray’s test was positive. Mr Y’s initial thoughts were an injury, mono-arthritis or cartilage damage. He advised a review after two weeks of anti-inflammatories and ice. At the review it was noted that there was swelling most days and the pain was worse. Mr Y was concerned that there was an inflammatory cause and suggested inflammatory marker blood tests through Mrs N’s surgery. These were found to be normal but Mr Y referred her to a consultant rheumatologist because her knee was still hot and swollen with no obvious cause.

Mrs N was seen urgently in the rheumatology clinic. Blood-stained fluid was aspirated and an x-ray arranged. The x-ray reported “possible tumour” and a subsequent MRI scan and biopsy confirmed the diagnosis of osteosarcoma of her right tibia.

Mrs N sustained a tibial fracture and was given chemotherapy. She struggled with nausea and fatigue and was devastated when she was told that she needed an above knee amputation because the tumour was aggressive and had not responded to chemotherapy. She later had a prosthesis fitted.

Mrs N was extremely upset and made a claim against Dr G. She felt that there had been a delay in the diagnosis of her tumour and that earlier diagnosis could have saved her leg from amputation. Mrs N claimed that the first time she had seen Dr G, she had complained of severe pain in the day and night and that the knee was hot and swollen at that time.

Expert GP opinion was sought. It was felt that the history obtained by Dr G was reasonable and appropriate although he could have asked directly about nocturnal pain. Dr G stated that he had asked about aggravating and alleviating factors and that he would have recorded any history of nocturnal pain if it had been given. It was felt that Dr G’s examination was of a good standard and that his actions were reasonable. The decision to wait for the physiotherapy appointment with the safety net of reattending if symptoms worsened was found to be reasonable. No indication could be found to arrange an x-ray, blood tests or referral at Dr G’s initial consultation.

It was noted that Mrs N was still dancing at this point and had just returned from a skiing holiday, which would not raise alarm bells. It was also noted that Mrs N was not taking the diclofenac, so it was reasonable to think that her pain was manageable.

Expert opinions were sought from a consultant orthopaedic surgeon, a professor of medical oncology and a consultant radiologist. It was their agreed view that an amputation would have been needed even with an earlier diagnosis, because of the tumour’s poor response to chemotherapy and its aggressive nature.

The case was successfully defended and Dr G was not found to be in breach of duty. MPS took steps to recover their costs.

Learning points

  • Although the patient’s circumstances were very tragic, this did not equate to negligence.
  • This case reflects the importance of strong expert opinion. The successful defence hinged around the experts’ opinion.
  • Good note-keeping is important for good medical practice and essential in defending a case.
  • If a patient attends multiple times with the same problem, alarm bells should start ringing. It is useful to stop and think “what could I be missing?”
  • Always try to exclude the worst case scenario. It is useful to document the absence of red flags.