Case 11 A boy with a limp

Teddy is 11. He is brought to Dr Hayward by his mother because he has a limp. He was playing football 2 weeks earlier and thinks that he sprained his right knee in a tackle. He is otherwise well with no history of recent illness. On examination he is noted to be obese with a weight of 74 kg. He is apyrexial. He has a slight limp. Dr Hayward notes that Teddy’s knee is not swollen but is slightly tender on full flexion.

What is the differential diagnosis and what would you do now?

Dr Hayward diagnoses a knee sprain and advises paracetamol and review in 10 days if the problem has not resolved.

Ten days later the Teddy returns. He is still limping and his pain has not improved. Teddy’s right knee seems to be completely normal but Dr Hayward notes that Teddy grimaces when his right hip is fully flexed. Internal rotation is also painful and slightly restricted compared with the left. Dr Hayward requests a FBC, CRP and ESR which are all normal and requests an X-ray of the right hip which is reported as showing no abnormality. She diagnoses a sprained muscle or a transient synovitis and prescribes ibuprofen and arranges to see Teddy again in a month.

Do you agree with the diagnosis? Would you have managed the case differently?

Teddy does not attend the review appointment but then returns three months after the initial visit because he still has a limp and the pain has got significantly worse. Dr Hayward is concerned about the length of time that the limp has lasted for and the degree to which Teddy is limping. She refers him to the paediatric rapid referral clinic where he is seen the next day.

In the paediatric clinic Teddy is apyrexial and is noted to have a limp and a leg that is flexed and externally rotated. There is left hip tenderness and a significantly restricted range of movements. There are no other signs.

The paediatrician asks the radiologist to report the X-rays urgently. The radiologist diagnoses a left-sided slipped upper femoral epiphysis (SUFE) which is clear on the pelvic X-ray and frog leg views.

Teddy’s parents bring a case against Dr Hayward alleging that she should have suspected the diagnosis initially and referred him for specialist assessment.

Do you think his claim will succeed?

Expert opinion

A child with a limp is a common occurrence in general practice and causes significant anxiety in both parents and doctors. The problem is commonly due to a minor self limiting condition such as transient synovitis of the hip. However, rarely there is a significant underlying problem and these can be quite easily missed as the initial features may be subtle.

The age of the child determines what serious causes are most likely.

In a child aged under 3, septic arthritis, developmental disorder of the hip or a ‘toddler fracture’ need to be considered.

In the 3–10 year old, transient synovitis is common but Perthes and septic arthritis also need to be considered.

In the 10–15 year old, a slipped upper femoral epiphysis (SUFE) needs to be considered (particularly in boys), as does Perthes and a septic arthritis.

A slipped upper femoral epiphysis in a teenager is a very rare diagnosis in general practice. However, despite the rarity general practitioners are aware of the diagnosis because of the ease with which the diagnosis can be missed and the potentially serious consequences of late diagnosis. The diagnosis is easily missed because the condition is very rare, the symptoms may be mild, and the pain may be in the knee rather than the hip.

A 2004 review in the BMJ about the assessment of hip and knee pain notes the following about the differential diagnosis of hip or knee pain in children (Hamer, 20041):

A child with hip disease may not present with pain or a history of trauma but with an unexplained limp. Unexplained knee pain should raise the suspicion of a hip abnormality …

Slipped upper femoral epiphysis is typically seen in overweight, hypogonadal boys, who often present with pain referred to the knee, although girls can also be affected. Diagnosis can be difficult, but a ‘frog lateral’ radiograph will show the deformity. Surgical stabilization is needed urgently to prevent further slippage of the epiphysis …

Transient synovitis or ‘irritable hip’… [is quite common]

In this case Dr Hayward made several errors which led to a delay in diagnosis. Teddy had a limp and pain in the knee but, as is often the case, the pain was referred from the hip. Teddy grimaced when his knee was flexed because that also involved hip flexion. Once Dr Hayward realized that the problem was in the hip she requested an X-ray but was unaware that a standard AP view is relatively insensitive for detecting SUFE and Perthes. Dr Hayward should have either requested AP and lateral or ‘frogs legs’ views of both hips or sought urgent specialist assessment.

Legal comment

Dr Hayward appears to be in breach of her duty of care to Teddy because she did not request the right X-ray views. The next question is what damage did that breach cause? We know that about 2½ months passed before Teddy got the right diagnosis. During that time he certainly suffered pain, for which some (relatively modest) compensation (perhaps £2000–£3000) might be paid. If surgery then completely resolves Teddy’s problems, this will be a small claim. But if Teddy is left with some residual problems, which he would not have had if the diagnosis were made before, then the claim will be more valuable: probably in excess of £100 000. Dr Hayward’s legal team will arrange for Teddy to be assessed by an orthopaedic expert who will report on his condition and prognosis. The value of the claim will depend on the findings reported by this expert.

Claims settled on behalf of children are subject to the Court’s approval. This is a procedure to make sure the child’s interests are properly protected. There will be a hearing at which a District Judge considers all the medical evidence before confirming that the settlement is appropriate.

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