Case 21 A limping young girl

Anna was born by full-term normal vaginal delivery. Her Apgar scores were fine and she was discharged three days after delivery, having been examined by the paediatric SHO. Dr Callard carried out her 6-week check, and noted her hips were normal. Her 9-month check was also normal.

At 15 months Anna’s mother brought her to see Dr James because she seemed to have difficulty walking. Her mother thought that she walked on the outside of her foot. Dr James examined Anna and could not detect any abnormality. He suggested that it was probably because Anna had only recently started walking and advised mother to see how things progressed and to bring Anna back if there were problems.

What would you do now?

Twelve months later one of Anna’s mother’s friends, who was a health visitor, suggested Anna was reviewed. Dr James referred her for physiotherapy. The physiotherapist noted that Anna limped, that the right leg was shorter than the left and that there was a restricted range of movement at the right hip. She was referred for an orthopaedic opinion and X-ray demonstrated a right dislocated hip. A month later Anna underwent an open reduction of the right hip, Salter osteotomy and was placed in a Spica cast.

Anna’s mother brought a claim against the hospital, the practice, Dr Callard and Dr James alleging that Anna’s Developmental Disorder of the Hip (DDH) should have picked up by the screening procedure and by Dr James’ examination when Anna was aged 15 months.

Do you think her claim will succeed?

Expert comment

Cases of delayed diagnosis of Developmental Disorder of the Hip (DDH) are relatively common causes of claims against general practitioners.

Since 1969 there has been a program in the UK for screening babies for Congenital Dislocation of the Hip (CDH).

At birth and six weeks the examiner carries out the Barlow and Ortolani manoeuvres. These tests aim to dislocate an unstable hip and relocate a dislocated hip respectively. By three months these tests do not work (due to contractures in the hip musculature).

It is estimated that only 35% of cases of CDH or DDH are detected by this clinical screening method without ultrasound (Dezateux et al., 2003). However, the concern is that universal ultrasound screening may lead to over diagnosis and treatment of children who would be better untreated. Consequently, routine ultrasound examination of the hips is only carried out in children with risk factors for DDH (a family history of the condition, infants presenting by the breech, other congenital postural deformities, such as those of the foot, oligohydramnios, a history of intrauterine fetal growth retardation).

In the unscreened population many cases of DDH will not be detected at birth or at the 6–8 week check.

In these children the condition may be noticed before the child is walking, because of asymmetry of skin creases at the buttocks and top of the thigh. The condition may also be suspected if the child is limping once he/she starts walking. At that stage clinical examination may demonstrate asymmetric skin folds, leg length shortening on the affected side and a reduced range of movement (particularly abduction) on the affected side.

If a general practitioner suspects DDH in a child in the first three months of life then urgent specialist referral is required because there is good evidence that delay in treatment affects outcome.

By the time the child is aged over 1 there is less urgency required in seeking specialist opinion but any general practitioner does need to have a high index of suspicion for DDH (as screening misses many cases). If the condition is suspected (with, for example, a limping child) the general practitioner must examine the child carefully, looking in particular for an abnormal gait, asymmetric skin creases, leg length difference but most importantly the symmetry and range of hip abduction.

If the examination is abnormal then a competent general practitioner would refer for a specialist orthopaedic opinion and may refer for an X-ray of the hip. If the examination is completely normal then a general practitioner should really arrange review in a few weeks to make sure that any gait abnormality has completely resolved and refer if it has not.

In this case it would be difficult to sustain criticism of the hospital, the 6-week check or the 9-month check. The sensitivity of the screening examinations is too low to conclude that, because the condition was missed, the examination was not carried out competently. Even in competent hands only 35% will be detected with clinical screening without ultrasound.

However, once a 13-month-old child is perceived to have an abnormal gait by her mother it is clearly necessary to consider the possibility of DDH since an abnormal gait when a child starts walking is a common presentation of DDH in those in whom screening has missed the condition.

It is necessary to examine the child’s gait, observe for skin crease symmetry, check for leg length differences and, most importantly, check that hip abduction is symmetric.

A difficulty in this case was that Dr James’s clinical notes were brief and merely recorded ‘O/E NAD’. An orthopaedic expert concluded that, when Dr James saw her at 15 months, Anna would have had a shortened right leg, asymmetric thigh and buttock skin creases and reduced right hip abduction. These clinical features should have been apparent in a competent examination by a general practitioner and so Dr James was considered in breach of duty.

The Claimant may have difficulty proving significant harm flowed from this breach of duty because DDH diagnosed at 15 months would still require operative reduction. The main causation case was dependent on proving breach of duty in the first 3 months, which was not done.

Legal comment

The expert opinion is that Dr James’s examination when Anna was 15 months old must have been negligent, because there would have been obvious signs of DDH. The excessively brief note made by him tends to confirm an impresson of a cursory examination.

However, as surgery was inevitable anyway by that time, it seems that the only harm done is that Anna may have been uncomfortable for longer than necessary.

So Anna’s mother should be advised that any damages payable are of a relatively small order. Her lawyers should encourage her to settle the case for a modest sum.

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