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A chair and not a couch

01 September 2010

Over a few days, ST felt an ache developing in his left thigh. He was a 14-year-old goalkeeper in a local team. The previous weekend, while making a save, he had landed awkwardly and blamed the pain on his fall. When it had not settled ten days later ST decided to visit his GP, accompanied by his mother.

Dr F was the duty doctor that day and it was a busier morning than usual. One of his partners had called in sick: the sick doctor’s patients were shared out amongst the remaining doctors and Dr F was running behind.

Dr F listened to the history and assessed the boy. According to ST’s mother, he appeared to be very hurried and “didn’t seem impressed with the story”. She reported later that the doctor examined ST while the boy was sitting in the chair and told them that he had just a “simple bruise”. The doctor’s records were brief and sparse on details. In particular, there was no mention of an examination of the range of hip movement.

Two weeks later the boy was back on the football field, playing in goal. At half-time he felt like he may have sprained his hip again and left the match with his mother. He told her the pain was much more severe this time, and seemed to be increasing and moving into his groin. The next day, she brought him to the local Emergency Department. Pelvic x-rays were ordered which showed slipped upper femoral epiphysis (SUFE). ST was taken to theatre immediately for pinning and stabilisation. Unfortunately, by that time there was already avascular necrosis of the left femoral head.

Four years later, ST had a leg length discrepancy of 3cm and walked with a marked limp, of which he was extremely self-conscious. He made a claim against Dr F, who had now retired.

Expert opinion was that at the time of the initial presentation, it would have been very difficult to adequately assess the full range of movement of the boy’s hip while he was sitting on a chair. Also, it was suggested that it was very likely a chronic slipped epiphysis could have been diagnosed at the first presentation and therefore the subsequent injury avoided. This acute injury was the one believed to have caused the avascular necrosis of ST’s femoral head.

Learning points

  • SUFE incidence is still low (1-2: 100,000) but important due to the consequences of missed diagnosis.
  • It mainly affects adolescents aged 10 to 15 years, and is more often associated with boys, obesity and immature bone growth. (Endocrine and mechanical factors are thought to be responsible.) 
  • Unstable SUFE is often complicated by avascular necrosis of the femoral head and chondrolysis. 
  • The history is typically of a long episode of mild to moderate hip or knee pain, followed by a more recent deterioration.
  • Remember to always properly examine the hip of a young person presenting with thigh and knee pain, and to compare with the other hip. 
  • There is no excuse for compromising your examination technique. Having a full waiting area will be poor justification if something serious is missed.
  • When assessing a patient in surgery after any trauma, a detailed history and examination of the affected area is vital. 
  • This case highlights the importance of occurrence-based indemnity, as claims can be made many years after treatment has taken place, and after retirement.