Case 28 A limping elderly woman after a fall

May was a 79-year-old clerk. Three years previously she had had a right total hip replacement for osteoarthritis. Whilst visiting her daughter in France she had tripped in the garden and landed awkwardly on her left hip. Following the fall she was able to walk, although her left hip was rather painful. May found the journey home rather difficult and on her return requested a home visit because of the pain and bruising of her hip.

Dr Ali called later that day. Dr Ali noted that on examination there was bruising over the left buttock and that the left hip was tender. May was able to walk using a stick. The range of movement of the left hip was normal and there was no shortening or external rotation of the left leg. Dr Ali did not think that May had done any serious damage to herself but that the fall might have caused a flare of osteoarthritis.

May was still in a lot of pain a week later. She contacted the surgery and spoke to Dr Ali who prescribed some co-dydramol because the paracetamol and ibuprofen May had tried was not providing any relief.

Ten days later another home visit was requested. May did not feel well and had taken to her bed. Dr Grant elicited a history suggestive of a UTI. May did not look unwell and had a normal temperature, pulse and blood pressure. Dr Grant prescribed trimethoprim and asked May to contact the surgery if her symptoms did not settle over the next week. May also asked Dr Grant about her hip. It was still painful and she still had to use a stick. On examination the hip was ‘normal’. Dr Grant thought that May had lost confidence and suggested referring May to physiotherapy.

Would you have done anything differently?

May was seen by the physiotherapist two weeks later. Initially her hip pain and walking seemed to improve. However on her third visit to the physiotherapist she stumbled as she left the department. The pain in her hip was much worse that night and she contacted the surgery. Dr Ali visited May again. He noted that she was still getting pain weight bearing and that the pain was worse after stumbling the previous day. Dr Ali referred May for an X-ray that was done two days later. This showed an impacted sub-capital fracture of the left femur. May was admitted from X-ray and had a left total hip replacement.

It was alleged that the actions of the general practitioners were negligent in that they should have referred May for an X-ray earlier.

Do you think her claim will succeed?

Expert comment

In retrospect May fractured her left neck of femur when she fell in France. It is also clear that when she was assessed by Dr Ali she was able to walk, weight bear and had a full range of hip movement.

Fractures of the femur are common in the elderly, particularly in women because of their low peak bone mass and accelerated bone loss for four to five years after menopause. There are 70 000–75 000 hip fractures annually in the UK and this is the commonest reason for admission to an orthopaedic ward (NICE, 2011). The average age of sustaining a fracture is 77 (NICE, 2011). Delay in surgical treatment has been shown to adversely affect rehabilitation (Villar et al., 1986).

Usually a patient is unable to weight bear following a hip fracture. On examination the affected leg is shortened and externally rotated. Active and passive movements of the hip are extremely painful and limited. However, occasionally an elderly patient sustains an impacted, undisplaced fracture. In these circumstances the diagnosis is often delayed because there are no clinical signs (Williams et al., 1984; McRae, 1981; Aston & Hughes, 1983).

One study of 1108 consecutive patients at Peterborough General Hospital with fractured neck of femur found that the diagnosis was delayed for more than 24 hours in 154 patients (14%) (Pathak et al., 1997). In 91 of the cases of delay the patient had been seen by a doctor (either in A&E or their general practitioner) and the fracture was not suspected. In another study the diagnosis of a hip fracture was delayed in 10% of cases (Eastwood, 1987). In this study elderly care physicians and general practitioners had often made an alternative diagnosis such as a flare of osteoarthritis and had not X-rayed the patient.

These and other studies indicate that delayed diagnosis of clinically ‘occult’ hip fractures in the elderly is not uncommon.

Current data suggests that significant falls occur annually in 35% of those aged 75 or over (Tinetti et al., 1988). Of these 6% have fractures. A study in Newcastle found that, in one year, 4% of patients aged over 65 requested an ambulance because of falls (Newton et al., 2006).

To avoid the delay in diagnosis it would be necessary to carry out X-rays in all elderly patients who have a history of fall whether or not they have clinical signs of a fracture. If such a recommendation were followed it would result in huge numbers of X-rays because falls are very common indeed in the elderly.

This raises a number of issues:

• There are often significant logistical difficulties of requesting X-rays in these circumstances. It is often necessary to request an ambulance because the elderly often do not have means of transport even if they are mobile.
  
• Hip and pelvic X-rays do carry a significant radiation dose with them (approximately equivalent to between 15 and 35 chest X-rays).
  
• It would also impose an enormous load on secondary care services.

The guidance document: Making the Best Use of a Department of Clinical Radiology was produced by the Royal College of Radiologists. This document recommends (4th Edition, 1998, recommendation D18, p. 43) that X-rays for hip pain when there is a full range of movement are not routinely indicated. (It is not clear whether a history of fall is considered to be significant with this recommendation.)

To assess whether a practice of X-raying all elderly patients with significant falls would be reasonable, it would be necessary to consider how many X-rays would need to be carried out to detect one clinically occult fracture in these circumstances (a sort of ‘NNT’).

In this case although May had had a fall she was able to walk and had managed the journey home. Dr Ali made and recorded a full history and examination. May had no features to suggest a fractured neck of femur.

Given his findings the previous week it was entirely reasonable for Dr Ali to provide a prescription over the telephone a week later.

When Dr Grant visited May had features consistent of a UTI that were appropriately assessed and treated. He also examined the hip which was ‘normal’ although it would have been helpful for his defence if more details of the examination had been recorded. Many general practitioners would have organized physiotherapy as Dr Grant did. Some general practitioners may have organized an X-ray at this stage.

When Dr Ali visited May after she stumbled in the physiotherapy department he did not document an examination of the hip. Given the history of worse pain following a stumble having had a previous fall Dr Ali should have referred May for an X-ray that day if examination of the hip was not normal. He referred her for an X-ray which was performed two days later. The fracture was impacted and a two-day delay, if such it was, would not have had any consequences.

Legal comment

Based on the expert opinion above, the case seems defensible. Dr Ali’s and Dr Grant’s treatment of May was appropriate up until Dr Ali’s final visit, when he perhaps should have arranged an X-ray that day. However, even if his treatment was substandard in this regard, the delay of two days would have made no difference: May would still have required the hip replacement.

However, the lawyers representing May will undoubtedly question the telephone call, when May reported that ibuprofen and paracetamol were not relieving her pain. They will ask their GP expert whether Dr Ali should have visited May. Even if they conclude that he should have done, Dr Ali can defend himself by pointing to Dr Grant’s later examination. But there are question marks over Dr Grant’s home visit. We do not know how carefully he examined May’s hip. May was in bed with what appeared to be a UTI. Did Dr Grant ask her to get out of bed and weight-bear?

If May’s GP expert criticizes these earlier consultations, then orthopaedic experts will need to comment on what difference intervention would have made at those times: would May have been spared her left total hip replacement? If she would have needed the hip replacement anyway, then damages will be limited to a small figure representing pain and suffering during the period when the condition went undiagnosed: at most a little over a thousand pounds.

The lawyers for May will also wish to investigate the liability of the physiotherapist. Perhaps she should have recognized a problem earlier?

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