Three-year-old Matthew was brought to the local A&E department by his mum, Mrs U. She told Dr M, the attending doctor, that Matthew had fallen from a chair three days ago and, although he seemed unharmed at the time, he was now refusing to walk. She told Dr M that Matthew was normally very active but was unusually quiet today. When Dr M asked Matthew where it hurt he pointed to the foot and knee. The examination was very difficult as Matthew screamed throughout. Dr M thought that the foot was tender and arranged for an x-ray. This was reported as normal.
Dr M wrote “sprain“ in the notes and discharged Matthew home. The following day Mrs U brought Matthew in again. She told Dr S, a registrar in emergency medicine, that he was still refusing to walk and wanted to lie down all the time. Matthew had not eaten anything in two days. Dr S examined Matthew’s leg but he was again very uncooperative. Dr S felt that the problem might be coming from the hip so he arranged for a pelvic x-ray, which was normal. Dr S made a diagnosis of “possible transient synovitis” and advised Mrs U to return if he was not better in a week.
Matthew was brought back within 48 hours. His mum mentioned that he was not well and he kept having shivering episodes. He was very upset when his leg was touched in any place. His temperature was 38.5°C and Dr A, a junior doctor, sent Matthew for an urgent ultrasound of his hip. This was reported as “moderate amount of fluid in the hip joint”. Matthew had some blood taken just before going for the scan. His creactive protein (CRP) was 80mg/l; (Normal <10mg/l) and his white cell count was 18 x 109/l.
Matthew was referred to the orthopaedic team with a diagnosis of “probable septic arthritis”. Shortly afterwards he was taken to theatre for a hip washout and started on intravenous antibiotics. The culture of hip aspirate came back positive 24 hours later. Matthew stayed in hospital for ten days and subsequently attended two return appointments. He was finally discharged from the orthopaedic clinic after six months with no long-term consequences.
Matthew’s parents made a claim against Dr M and Dr S, saying that they caused an unnecessary delay in the diagnosis leading Matthew to become more seriously ill and suffer unnecessary pain. They were concerned that their son’s life may have been at risk.
Expert opinion
An expert in emergency medicine agreed that the management by Dr M and Dr S was inadequate. Dr M failed to take a satisfactory history so he did not realise that the limping was not related to trauma. Dr S failed to notice that, according to the history given by Mrs U, Matthew was now generally unwell. On both occasions they should have taken a timely history, recorded a temperature and examined the child fully. The experts agreed that the doctors should have realised earlier that Matthew required further investigations to exclude septic arthritis.
The claim was settled for a moderate amount.
Learning points
- A child with an unexplained limp is always a diagnostic challenge. A variety of pathologies can present with a limp (eg, transient synovitis, septic arthritis, malignancy, osteomyelitis, meningitis, Henoch-Schonlein purpura and non-accidental injuries).
- Taking an accurate history is always essential. Small children are prone to falls and small accidents so it is usual for the parents to recall a recent trauma and relate it. Great attention must be paid to the timing of the events.
- Small children find it difficult to localise the pain and they can have referred pain from the hip into the knee.
- Full examination is required. This should involve checking for abdominal masses, enlarged lymph nodes, ENT, involvement of other joints and presence of unusual or multiple bruises and rashes. The affected leg requires careful examination for tenderness, pain in any joint or restricted movement.
- It is essential to check the temperature in all children with an unexplained limp. A high temperature and a raised inflammatory marker (CRP, ESR or PV) are significant predictor factors for septic arthritis.
References
Kocher MS et al, Validation of a Clinical Prediction Rule for the Differentiation Between Septic Arthritis and Transient Synovitis of the Hip in Children, J Bone Joint Surgery Am 86:1629–35 (2004)
Caird MS et al, Factors Distinguishing Septic Arthritis from Transient Synovitis of the Hip in Children. A Prospective Study, J Bone Joint Surgery Am 88:1251–57 (2006)
Lalanda M, Alonso JA, Improving the Management of the Child with an Unexplained Limp, Clinical Governance: An International Journal, 11(4) 308–15 (2006)
Anthony S, Getting to Grips with Children’s Hips, Casebook, 12(3) 7–12