Back to Basics Missed Osteomyelitis

According to the patient, she had injured her left leg playing netball three days earlier. The GP arranged for x-rays of the patient’s leg to be performed and recommended that she take Panadol.

Case history

The patient returned to her GP on the 7th and 8th March 2006, complaining of swelling and pain in her left upper leg. The patient’s leg was bandaged, she was advised to rest her leg and to return for review if her symptoms did not improve.

On the 15th of March 2006, the patient again presented to her General Practitioner. She was limping and complaining of increased pain in her leg. The patient was afebrile and a provisional diagnosis of ligamentous injury was made. She was referred for an urgent CT scan and arrangements were made for her to be seen by an Orthopaedic Surgeon.

On the 25th of March 2006, the patient presented to the Orthopaedic Surgeon, for review. She was mobilising with crutches, as she claimed to be unable to bear any weight on her left leg. On visual examination the Orthopaedic Surgeon noted there was no evidence of any effusion, nor was there any redness of the left upper leg. However, it was not possible for a detailed examination to be performed, because of the patient’s significant distress, due to her pain. As the patient’s CT scan and x-rays showed no evidence of abnormality, a referral was provided by the Orthopaedic Surgeon for an MRI  scan of  the patient’s left leg.     

Later that day, the patient’s father went to the GP’s practice, and requested that the patient be provided with analgesia. The patient remained in her father’s car, as she was too sick to walk into the practice. She was therefore not examined by the GP, but a script for pain relief was provided.

On the 31st of March 2006, the patient was again seen by her General Practitioner. She had a tender and swollen left upper leg, and had lost weight. The patient complained of fever and rigors. The GP advised the patient to attend the Emergency Department (ED) of the local Hospital, for assessment and treatment.

Later that afternoon, the patient presented to the local Hospital’s ED. She was significantly distressed, her left upper leg was swollen, and hot to touch, and her temperature was 38.0°C. A provisional diagnosis of osteomyelitis was made. The patient was subsequently taken to theatre, and half a litre of pus was drained from her left upper leg. Cultures taken intraoperatively revealed the presence of MRSA. After a stormy postoperative course, the patient remained in hospital for three weeks.

In March 2007, the patient commenced legal proceedings against her General Practitioner. She alleged that her General Practitioner’s management was negligent, on the grounds that her GP had:

• Failed to appropriately examine her during her consultation on the 15th March 2006;
• Failed to perform investigations such as CRP, ESR, WCC, and blood cultures, following her complaints of chills and fever made during the consultation on the 15th of March 2006;
• Failed to consider an alternative diagnosis (other than a ligamentous injury) at the consultation on the 15th March 2006.

The Solicitors acting on behalf of the General Practitioner wrote to the Orthopaedic Surgeon in June 2007. They foreshadowed that the General Practitioner would be seeking a contribution from the Orthopaedic Surgeon (in relation to any damages awarded to the patient), on the basis that the Orthopaedic Surgeon had failed to properly examine the patient’s left leg, to take her temperature, or to organise appropriate investigations, such as blood cultures, to be performed. The Orthopaedic Surgeon immediately sought assistance from MDA National.

An expert Orthopaedic Surgeon instructed on behalf of the GP was critical of the Orthopaedic Surgeon’s management. According to the expert, further investigations in the form of a Full Blood Count, ESR and  CRP should have been undertaken, a limited examination of the patient’s left leg should have been performed, and the patient’s temperature should also have been checked. Further, the expert believed that the level of the patient’s symptoms should have caused the Orthopaedic Surgeon to consider a diagnosis other than a resolving ligamentous injury at the consultation on the 25th of March 2006.

The Orthopaedic expert qualified by MDA National agreed that the Orthopaedic Surgeon should have taken the patient’s temperature, and ordered blood tests, to ascertain whether the patient was suffering from an infection. In the circumstances, a decision was made to attempt to resolve the claim for contribution, on the best possible terms. The GP’s Solicitors had initially sought a contribution of 60% from the Orthopaedic Surgeon. The claim was resolved on the basis that MDA National (on behalf of the Orthopaedic Surgeon) would contribute 22.5% towards the total damages paid to the patient.

Discussion

The importance of undertaking basic observations on an acutely unwell patient is highlighted by this case. Although the Orthopaedic Surgeon’s recollection was that the patient was afebrile and had not complained of fever or chills during her consultation, this had not been documented in the notes.