Case Summary
Allegations: Failure to diagnose a developmental dysplasia of the right hip. Failure to properly examine; failure to conduct appropriate tests resulting in dislocation, 3 cm shortening of right lower extremity and numerous surgical procedures.

The infant was born 1/10/84 by NSVD and was examined by a board certified pediatrician shortly after birth, and on discharge from the hospital nursery. The exam was documented as being "within normal limits" and under the heading of extremities is noted, "no defects." The infant continued to be seen by this physician for routine pediatric care.

At his deposition, the pediatrician testified that he performs routine hip exams in the following manner: "with the child laying down, the legs are bent at the knee and to check for resistance, the legs are abducted to the table with the examiner grasping the knees." He stated that he also listens for a click - or "a noise." The legs are then extended up to check length and the skin folds are checked for symmetry. He routinely examines the hips every month during routine exams until one year of age. Each exam follows the above routine. He does not make any attempt to dislocate the hip during the exam.

The pediatrician saw the child over 27 times, from January 1984 through September 1986, for routine physical exams and a variety of childhood illnesses. Samples of the pediatrician's office records for this child are attached as Figures I, II and III. The notations concerning the hip examinations are circled.

Review Figure I; the notation regarding the hip exam is as follows: "hips good position. No click." This information is recorded in a manner that is not in keeping with the remainder of the entry and gives the appearance that it was added subsequent to the visit.

Review Figure II; this entry documents a complete physical exam. During the pre-trial investigation of the claim, the pediatrician reported that he only records abnormal findings, therefore, it is difficult to explain why the only specificallyrecorded physical exam finding in this entry is "Hips ok."

On 1/15/85 the following entry is recorded by the nurse - "check feet, when walking drags right foot." The pediatrician notes, "Complete physical - right foot in. Hips seem okay - to see [Orthopedic consult]."

Between January 1985 and August 1985 the patient is seen 6 more times. No mention is made of the orthopedic referral.

At the visit of 8/13/85, the following is noted: "Mumps vaccine. Note: Patient did not see [orthopedist] yet."

The child was finally seen by the Orthopedic consult, for the first time on 11/4/85, almost 10 months after the initial consultation. His note read as follows:

11/4/85 exam:

• Spine - straight
• Pelvis - intact
• Hip - Full ROM
• Symmetrical thigh folds
• No evidence of tibial torsion
• Feet - No metatarsus adductus
• Gait revealed no toeing in
• Normal orthopedic evaluation.
• Instructed to avoid any internally rotated hip posture when sitting.
• To return in 3 months for final check-up.

(No x-rays were performed).

NOTE: The patient did not show for the follow-up visit with the Orthopedist on 2/10/86.

The pediatrician continued to see the patient on 12/18/85, 2/12/86, 4/30/86, 5/14/86 and 8/20/86 for minor childhood illnesses.

On 9/8/86 she was seen by a second Orthopedic consult on referral by another physician. This orthopedist found an approximately 3cm shortening of the right lower extremity. The patient was ambulating with a marked gluteus medius lurch on right. The x-rays revealed congenital dislocation of the right hip with a poorly formed right acetabulum. The patient was referred for hospital admission, traction and surgery.

At the deposition, the patient's mother testified that the pediatrician routinely examined the child's hips as part of his regular physical exam. She claimed that she first noticed the child's foot turning in at approximately 1 year of age when the child began to walk. She acknowledged referral to an orthopedic consult by the pediatrician. Her reason for delay was inability to pay for the consult.

Comments
The experts who reviewed this case, offered the following:

• The defense of the orthopedic care was felt to be difficult, in the face of failure to take an x-ray at the initial visit and evidence that this was a long-standing problem, which should have been diagnosable earlier.
• It was felt that pediatric care could be defended except that key entries in the record (See Figures I, II, III) gave the appearance that they may have been added later, raising a question of authenticity.
• Recent orthopedic literature has challenged the traditional term congenital dislocation of the hip (CDH) or congenital dysplasia of the hip, since only about 5% of neonatal dislocated hips precede birth and are truly dysplastic. A newer preferred term, developmental displacement of the hip, (DDH), has been proposed as a more realistic appraisal of the disorder encompassing hips that can dislocate anytime during the first year of life.
• The typical scenario is that of a normal neonate who has a hip that can either be found dislocated or dislocatable after birth. This hip is usually easily reducible in the first several days. If the hip remains out of the socket, significant dysplasia can develop as early as three months. It is, therefore, important to diagnose this condition early.
• The diagnosis must be actively looked for in every infant examined. The following questions must be answered at each exam: Are the hips in the socket? Do they stay there?

CLUES THAT SUGGEST DISLOCATION:

• "Clicks and clunks"- may be found from birth to 1 month of age.
• Limited abduction is the most reliable sign in the older infant. Bilateral dislocations are easier to miss than unilateral ones.
• Clinical examination of the hips should include looking for the following:
  • Skin fold irregularities: These may be useful in a unilateral dislocation, but maybe a normal finding.
  • Shortenings: Look for a shortened femur with the knees flexed, or a shortened extended leg.
  • Ortoloni sign: Reducing a dislocated hip by bringing the trochanter forward into the acetabulum (gives the "clunk" noise). The hips should be flexed to a right angle with the fingers over the lateral aspects and thumbs anteriorly.
  • Barlow signs: Provoking reduced subluxable or dislocatable hip to become dislocated by applying stress. It has been suggested that this maneuver can contribute to hip instability and should be abandoned.
  • Limitation of abduction: Particularly if unilateral, should be considered significant.

Case Disposition
The case was settled on behalf of both the pediatrician and the orthopedic surgeon.

Risk Management Points
The records in the figures shown, fail to document an adequate exam including pertinent negative findings concerning the infant's hip.

The entry on 1/25/84 regarding the absence of a "click" (Refer to Figure I) appears to have been added after the fact and served to erode the pediatrician's credibility.

The pediatrician did not have any mechanism to follow up on the referral to the Orthopedist. Although the patients mother later acknowledged that she did not see the Orthopedist as recommended, the patient may have received care earlier if the pediatrician had a mechanism to follow up on the referral.

The physician stated that he only documents abnormal findings. However, in the sample record shown, normal findings are noted on certain exams. This damages the physician's credibility on this point. All findings (positive and negative) should be documented.