Hip pain in children can be serious

[Badri]

A few years ago a 9 year old child had a fall and complained of severe pain in his right leg. The pain was so severe that he was unable to bear weight on that leg. The mother took him to the accident and emergency department where he was examined and discharged with a diagnosis of torn quadriceps muscle. No x-rays were done but was advised not to bear weight on that leg for 2 weeks.

As he was still no better 3 weeks after the incident his mother took him to see the Family Practioner. Doctor "A" saw him and recorded only tenderness. He suggested NSAID gel and paracetamol. After one month as the child was still complaining of thigh and knee pain, the mother took him back to see his GP. This time he was seen by Dr "B" who assessed him and diagnosed "Musculoskeletal pain" and arranged for an x-ray of the knee.

X-Ray was reported as showing osteoporosis and possible traumatic injury of proximal tibial growth plate. The radiologist also suggested an urgent orthopaedic opinion.

The orthopaedic surgeon noted an externally rotated shortened right leg. An urgent MRI revealed a slipped upper femoral epiphysis on the right side. The child required surgery to stabilise it. Because of the delay in treatment, the displacement required further osteotomy of the femoral neck to address the residual deformity.

Despite extensive surgery the child was left with a shortened leg and by age 16 was very incapacitated with increasing pain. The surgeon informed the mother that her son was going to need a total hip replacement in about 10 years and perhaps a further revision 20 years later.

The mother sued the family practice and the hospital for poor assessment and treatment.

The Expert opinion was that the assessment and investigation by doctors A & B was below standard. They were also critical of the unacceptably brief documentation by the doctors. The experts also indicated that assessment and management by the hospital was below standard and not acceptable. The case was settled for a very high sum (shared between the family practice and the hospital)

(The Case was presented in the case Book of MPS)

Learning Points:
1. Any growing child with leg pain must be taken seriously whether there was trauma or not.
2. The hip must be examined and x-rayed even when they complain of knee pain.
3. Hip pathology can give rise to pain in the thigh or knee (irrespective of patient's age)
4. Hip infection, inflammation, avascular necrosis, Perthes disease and Slipped Upper Femoral epiphysis can all cause leg and hip pain.

Points to remember about Slipped Upper Femoral Epiphysis:
1. Can occur with or without trauma
2. Age group usually between 10 to 16 and boys more often than girls
3. Inspection when child is lying down may suggest an externally rotated leg.
4. There are 3 grades of slippage that can be noted from x-ray. Gr I <33% slip, II - 34 to 50 & III >50%
5. If treated within 24 to 48 hrs by pinning before slip increases prognosis is good
6. Some amount of reduction of the slip can also be done if treated immediately after it occurs
7. When treatment is delayed the epiphysis gets fixed in the slipped position causing hip deformity
8. Remember the epiphysis can slip until growth of femoral head ceases at around 16 years

Attached illustrations can be viewed only by registered members when they login

[uamohammed]

Thank you Badri for this excellent account of slipped diagnosis on the part of the doctors and thereby causing untold misery and pain for this young child during most important part of his period. The theory part and the illustrations are very informative.
can you tell us where this incident took place, India or abroad?

UA Mohammed

[Badri]

Hi Mohammed,
Thank you for your compliments. This happened in UK where the health service is considered as one of the best in the world. So things can go wrong even in the best systems. This is yet another reason why practising doctors should keep up with CME.

I am sure you know how the GP service is set up in UK. Every citizen in the country is registered with a General Practice. The practice usually consists of several doctors who are trained to spot or suspect a problem from any speciality (medical or surgical) that their patient will present with. If it is a minor problem they would deal with it themselves. If it is something more serious needing x-rays etc they will refer the patient to a specialist at the NHS hospital. So the general practioner should know a little bit about everything. If he has any doubt about the diagnosis he must refer the patient to the hospital. This is where they made the mistake here. Two of them in the practice failed to take the child's symptoms seriously enough. In addition to this the A & E dept at the NHS hospital also missed the problem. That is very serious as no will will excuse the hospital for the blunder.

Slipped Upper Femoral Epiphysis is something that every GP is trained to look for in a child with a painful leg. If they suspect, they must refer the child immediately to hospital. I have dealt with several children with Gr I and sometimes Gr II slip. If spotted immediately, fixing the head with a screw is all that is necessary. It is a simple procedure taking less than 30 minutes. Once the epiphysis fuses with the rest of femur we will remove the screw. They usually do not have any problem after that.