Knee X-ray
17. Mrs O complains about the Trust’s decision to only X-ray her son’s knee on 5 July 2023. She considers his symptoms should have led staff to X-ray his entire leg. She is concerned the Trust failed to follow NICE guidance and missed an opportunity to prevent her son’s broken femur and diagnose Ewing Sarcoma sooner.
18. She refers to ‘NICE guidelines for acute childhood limp’ which say ‘Children presenting with knee pain may have referred pain from the hip. Examine the joints adjacent to the affected joint to rule out referred pain.’
19. Our ED adviser said there are no specific standards or guidelines on the assessment of knee pain and limp in children who present to hospital. The ‘guidance’ Mrs O refers to is NICE’s Clinical Knowledge Summary on ‘acute childhood limp’. These are not standards or guidelines but a source of information for primary care practitioners (non-hospital clinicians such as GPs) to consider when managing common conditions.
20. In lieu of specific guidelines, the GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients they must adequately assess the patient's conditions, take account of their history and where necessary examine the patient.
21. The GMC guidance explains doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer to another practitioner when this serves the patient’s needs.
22. Mr O attended the ED on 5 July with leg pain. He had slipped whilst caving and fell onto his right knee. ED staff felt he may have fractured his knee and arranged a knee X-ray. This showed no evidence of a fracture.
23. An ED doctor carried out an assessment of Mr O alongside his X-ray results. They noted the injury from the fall as well as a three-week history of knee pain and limping. The doctor carried out a physical examination which involved moving Mr O’s right leg. Notes from this examination show he had a good range of movement in his hip and only his knee was painful. They discharged him to await outpatient orthopaedic follow up.
24. We understand that ED staff provide care based on the symptoms a patient presents with. Whilst Mr O did have a history of limping, this is not why he attended hospital. In this case Mr O’s main presentation was knee pain following an accident and our ED adviser explained this is why clinicians focused investigations on his knee.
25. Our ED adviser noted Mrs O’s concerns about her son’s knee pain coming from his hip. They said that whilst pain can be referred from other areas of the body, this is a not a reason to scan whole areas. The ED doctor carried out a physical examination of Mr O’s leg which involved moving the hip and no pain or abnormality was seen in the hip or any areas apart from the knee. Our ED adviser explained this meant only a scan of his knee was necessary.
26. We recognise Mrs O feels the doctor’s physical examination of her son’s leg was insufficient. Our ED adviser explained this was clinically appropriate. They said further investigation of other areas of Mr O’s leg would only be necessary if there was pain or trauma to other areas. In this case he had fallen onto his knee, and this was the area that was painful.
27. Whilst NICE clinical knowledge summaries are not guidance, it is useful to note that it says best practice when assessing acute childhood limp includes: • asking the child or parents about the duration of the limp • arrange an X-ray if there is a history of trauma • perform a careful examination • document the child’s medical history.
28. It says if X-ray results are normal, refer the child to paediatric orthopaedics for further investigation.
29. Our ED adviser said that in this case, good medical practice is similar to the clinical knowledge summary. They said ED staff should have: • carried out an assessment • documented Mr O’s medical history • carried out a physical examination • investigate the affected area • referred to a specialist for further investigation.
30. Mr O’s clinical records show ED staff carried out all above steps. Our ED adviser confirmed that clinicians assessed and examined Mr O, carried out suitable investigations and arranged follow up. We are reassured this was in line with GMC guidance.
31. We have not seen any evidence that Mr O required a full leg X-ray on 5 July and therefore the decision to solely X-ray his knee was clinically appropriate. We have seen no indications of failing. We recognise this will be disappointing to Mrs O who strongly asserts that staff should have X-rayed her son’s whole leg.
Knee MRI
32. Mrs O also complains about an orthopaedic surgeon’s decision not to arrange a whole leg MRI scan.
33. In its response to the complaint the Trust said the MRI was a follow up from Mr O’s knee injury. It explained that the orthopaedic surgeon focused on the trauma to Mr O’s knee as a full physical assessment did not raise any other concerns.
34. Clinical records from 13 July show an orthopaedic surgeon reviewed Mr O. The surgeon felt Mr O had clinically improved as he was no longer using crutches and fully weight bearing. They recommended Mr O have a knee MRI to ensure there was no injury to the internal structure of his knee.
35. Our orthopaedic adviser explained there are no specific standards or guidelines on follow up investigations following a knee injury. As with the above section of the complaint, the relevant guidance is therefore GMC guidance.
36. Mr O’s main presentation on 13 July was knee pain and this was why the orthopaedic surgeon focused his knee. Our orthopaedic adviser said based on the information available at the time, which was that Mr O had injured himself during an accident, leading to knee pain, there was no clinical indication for the surgeon to scan other areas. Our adviser explained the decision to arrange a knee MRI was clinically appropriate.
37. Our role is to consider whether there is an indication that something went wrong with the care or service provided. In this case whether, based on the information available at the time of events, the Trust should have scanned Mr O’s whole leg on two occasions.
38. Having done so we have seen no evidence that Mr O required a full leg scan during the period of complaint. We consider the Trust’s decision making around scanning was in line GMC guidance which says doctors must provide or arrange suitable investigations where necessary.
39. We understand that Mr O broke his femur whilst walking on 20 July, after which a scan saw lesions which subsequently turned out to be Ewing Sarcoma. We recognise an earlier scan of Mr O’s whole leg may have diagnosed his cancer sooner, the evidence suggests this was not clinically necessary during the period of complaint.
40. We recognise how distressing Mr O’s poor health has been for his family and the extent to which being wheelchair bound and unable to attend school has impacted Mr O. We have seen no indication of failing in this complaint and for this reason are not continuing our consideration.