A few years ago a 9 year old child had a fall and complained of severe pain in his right leg. The pain was so severe that he was unable to bear weight on that leg. The mother took him to the accident and emergency department where he was examined and discharged with a diagnosis of torn quadriceps muscle. No x-rays were done but was advised not to bear weight on that leg for 2 weeks.

As he was still no better 3 weeks after the incident his mother took him to see the Family Practioner. Doctor “A” saw him and recorded only tenderness. He suggested NSAID gel and paracetamol. After one month as the child was still complaining of thigh and knee pain, the mother took him back to see his GP. This time he was seen by Dr “B” who assessed him and diagnosed “Musculoskeletal pain” and arranged for an x-ray of the knee.

X-Ray was reported as showing osteoporosis and possible traumatic injury of proximal tibial growth plate. The radiologist also suggested an urgent orthopaedic opinion.

The orthopaedic surgeon noted an externally rotated shortened right leg. An urgent MRI revealed a slipped upper femoral epiphysis on the right side. The child required surgery to stabilise it. Because of the delay in treatment, the displacement required further osteotomy of the femoral neck to address the residual deformity.

Despite extensive surgery the child was left with a shortened leg and by age 16 was very incapacitated with increasing pain. The surgeon informed the mother that her son was going to need a total hip replacement in about 10 years and perhaps a further revision 20 years later.

The mother sued the family practice and the hospital for poor assessment and treatment.

The Expert opinion was that the assessment and investigation by doctors A & B was below standard. They were also critical of the unacceptably brief documentation by the doctors. The experts also indicated that assessment and management by the hospital was below standard and not acceptable. The case was settled for a very high sum (shared between the family practice and the hospital)

(The Case was presented in the case Book of MPS)

Learning Points:
1. Any growing child with leg pain must be taken seriously whether there was trauma or not.
2. The hip must be examined and x-rayed even when they complain of knee pain.
3. Hip pathology can give rise to pain in the thigh or knee (irrespective of patient’s age)
4. Hip infection, inflammation, avascular necrosis, Perthes disease and Slipped Upper Femoral epiphysis can all cause leg and hip pain.

Points to remember about Slipped Upper Femoral Epiphysis:
1. Can occur with or without trauma
2. Age group usually between 10 to 16 and boys more often than girls
3. Inspection when child is lying down may suggest an externally rotated leg.
4. There are 3 grades of slippage that can be noted from x-ray. Gr I <33% slip, II - 34 to 50 & III >50%
5. If treated within 24 to 48 hrs by pinning before slip increases prognosis is good
6. Some amount of reduction of the slip can also be done if treated immediately after it occurs
7. When treatment is delayed the epiphysis gets fixed in the slipped position causing hip deformity
8. Remember the epiphysis can slip until growth of femoral head ceases at around 16 years

Attached illustrations can be viewed only by registered members when they login