Persistent knee trouble

A 12-year-old boy visited his GP complaining of a few weeks’ history of a painful right knee, following a sporting injury. On examination, there was some tenderness of the medial aspect of the knee. The GP arranged an x-ray of the knee, which was reported as normal.
Six months later, the patient attended again, complaining of ongoing right knee pain. On examination, the knee was slightly swollen. The GP recommended simple analgesia and further review if the symptoms did not settle.

The patient returned to the surgery ten months later with right knee pain as well as a limp which had been present for several months, but which did not affect his sporting activities. The GP felt that while there was some tenderness of the knee on examination, immediate orthopaedic referral was not necessary. He decided to review the patient and if the condition did not improve or worsened, he would refer him at that stage.

Two months later the patient’s condition had not improved and the GP referred him to an orthopaedic surgeon, who diagnosed a right slipped upper femoral epiphysis.

The patient underwent internal fixation of his slipped epiphysis. At review several months later, he had some deformity of the hip and a reduced range of movement. However, he was able to undertake sporting activities normally, and had no ongoing symptoms.

The GP later received a claim from the patient alleging that he should have examined the patient’s right hip on each occasion he attended the surgery and that he should have been referred to an orthopaedic surgeon earlier. It was alleged that as a result of the failure to do so, the patient experienced an eighteen-month delay in the diagnosis of his slipped upper femoral epiphysis and that had the diagnosis been made earlier, the patient would have avoided the deformity of the right hip and reduction in the range of movement.

The outcome

The MDU sought expert advice from a GP and orthopaedic surgeon.
The GP expert advised that the initial management by the GP was reasonable but that ideally the GP should have considered a hip problem at the second consultation. However, on this occasion, the GP did find some abnormality of the knee on examination, and the expert advised that overall his management on this date was reasonable.

When the patient attended for the third time with ongoing knee pain and a limp, the GP expert advised that the MDU member should have examined the right hip and should have requested an urgent orthopaedic appointment.

The expert orthopaedic surgeon advised that during the period between the first attendance with the GP and the surgical treatment, the upper femoral epiphysis would have undergone gradual displacement. Had the diagnosis been made following either of the first two attendances, it is likely that fixation would have resulted in a well-functioning hip with no deformity.

Had the diagnosis been made following the third attendance at the GP, the patient would still have been left with ongoing deformity of the hip, although less than he ultimately had.

In light of the expert advice, the MDU admitted that referral to the orthopaedic surgeon should have been considered following the third attendance at the GP. It was denied that referral at this time would have resulted in a hip with no deformity but the MDU accepted that diagnosis following the third consultation with the GP would have resulted in less deformity of the patient’s right hip, and that he would have avoided a short period of pain and suffering.

In view of this, the MDU settled the claim on behalf of the GP

This page was correct at publication on 21/05/2009. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.