The scene

A patient attended their local hospital with left hip pain following a fall. An X-ray taken at the hospital did not show any fractures, and the patient was advised that the symptoms should improve but to see their GP if they didn't.

A month later the patient attended an MDU GP member, reporting considerable pain from their left buttock to their left knee and that they were having difficulty walking. On examination there was no local tenderness and the passive range of movement of the hip was noted to be normal. The GP diagnosed that the hip was symptom free and the pain was radiating from the lumbar spine. They prescribed NSAIDs and advised the patient to return for review if the symptoms had not improved in two to three weeks.

The patient returned to the GP practice two months later and saw a different GP, saying that the pain had been present since their fall and that the NSAIDs had not helped. This second GP noted that there was tenderness over the left sacroiliac joint and ischial tuberosity, and prescribed analgesics. They also arranged an X-ray to rule out a missed bone injury, and this confirmed a fracture of the left femoral neck which had developed since the previous X-ray. The patient subsequently underwent a left total hip replacement.

The claim

The patient instructed solicitors to make a claim against the MDU member, making allegations about the thoroughness of the examination that was undertaken and the failure to refer for an X-ray.

The MDU instructed an independent GP expert to comment on the allegations. The expert was of the view that it was mandatory to undertake an examination that would have detected any abnormalities associated with a hip fracture, which might include shortening, adduction and external rotation of the affected leg, with pain aggravated by flexion and rotation of the leg.

The MDU member recalled that the examination was carried out while the patient was in a chair. The expert's opinion was that the GP would have been able to assess internal and external rotation using the lower leg as a lever while the patient was seated, but also that it would have been difficult to measure hip length accurately with the patient seated, and that these examinations should have been carried out with the patient lying down.

The MDU also obtained causation evidence from a consultant orthopaedic surgeon. The consultant agreed that no fracture was evident on the X-ray taken at the hospital appointment immediately after the fall, but was of the view that on the balance of probability, the fracture occurred during the fall and was not caused by a separate incident in the intervening period. The patient would have required a hip replacement in any event, as they presented to the MDU member a month after the fall.

The outcome

In light of the unsupportive evidence from the GP expert about the adequacy of the examination, and with the member's consent, the MDU made an offer to settle the case. This offer took into consideration the pain the patient was in from the date they saw the MDU member to the time of the referral, and an allowance for the additional time it took the patient to recover from the surgery due to the delay. The patient's damages amounted to around £4,000 but the legal costs were much higher, and although the MDU's claims team worked hard to negotiate them down, these still amounted to just over £12,000.

This case highlights the importance of considering hip fracture where patients have ongoing symptoms following trauma even where initial X-rays are reassuring, and of taking steps to position the patient appropriately for any examination.

Missed hip fracture

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