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A relative point of view

01 May 2009

Dr L, a junior doctor, was working on the afternoon shift in the emergency medicine department. He had started the job eight weeks before, but due to shift patterns this was only his second time in the children’s area.

The nurses asked Dr L to see SB, a 13-year-old boy whose mother, Mrs B, was complaining about the delay in being seen. The nurses told Dr L that there “didn’t appear to be anything wrong with the boy” and that “he could probably be sorted out quickly to free up space in the department”. Dr L agreed to see him next.

SB explained to Dr L that he had had quite a bad pain in his groin since playing football at break time that morning. SB found it too painful to walk on the leg and was unable to weight-bear. He admitted that the pain had subsided a little since he had taken some ibuprofen at triage, but he remained unable to walk.

Dr L examined SB thoroughly from hip to toe and reassured SB and his mother that it was likely to be just a sprain or a pulled muscle. Mrs B, however, remained anxious and requested an x-ray for her son. Dr L sent SB for a pelvic x-ray.

When SB returned from the radiology department, Dr L looked carefully at the x-ray, and considered that it appeared normal; however, he was conscious of his limitations and told Mrs B that he wanted to discuss the x-ray with a senior colleague. unfortunately, Mrs B could not wait any longer as she had to pick up her other children from school, and so Dr L gave them an appointment to return in two days’ time if SB’s condition had not improved.

SB was seen two days later in clinic by one of the A&E consultants. At this point SB remained unable to weight-bear. He was sent for further x-rays to exclude slipped capital femoral epiphysis. The anteposterior view appeared normal, but the “frog leg” lateral view confirmed the diagnosis. SB was operated on in the next few hours, but unfortunately subsequently developed avascular necrosis and required further surgery.

The final outcome was a shortening of the leg, with restricted movement, as well as the prospect of early arthritis and the likely need for a hip replacement. A claim against Dr L and the A&E department was brought which was eventually settled for a moderate amount.

Expert opinion

Orthopaedic and emergency medicine experts agreed that the care provided in this case was sub-optimal. The initial presentation of SB as a teenage boy with a traumatic, severe pain in the groin should have immediately triggered a concern about the possibility of a slipped capital femoral epiphysis.

The experts confirmed that an early diagnosis and emergency surgical treatment are usually directly related to the long-term prognosis of the pathology. They also agreed that two different x-ray views of the hip are essential to exclude a slipped epiphysis.

Learning points

  • When starting any new specialty, it is important to realise the limitations of your knowledge and experience. 
  • The indications to request any investigation need to be clear and should take into account the patient’s history and concerns of the patient or relatives. (The views requested will depend on the differential diagnosis being considered.) 
  • Knowing which x-ray views are required (in this particular case, always two views) is important, but understanding what it is that you are looking for is crucial. 
  • When patients are unable to wait they should be informed of the possible risks and consequences and advised of what to do in the event of further problems, to ensure that safe follow-up is available. 
  • All such discussions should be documented. Good documentation reflects good practice, and is the basis for a successful defence. 
  • If you feel uncomfortable about your ability to perform the tasks that you have been asked to undertake, take advice from senior members of staff and be aware of your responsibilities in relation to referrals.

References

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