Delayed Diagnosis of Hip Fracture Causes Avascular Necrosis

This case involves the failure to diagnose a hip fracture in a 49-year-old female who had recently started running and acutely developed severe groin pain. The patient was seen only by a physician assistant who performed a basic physical exam and did not order any supporting imaging studies. The patient was advised to use heat on the afflicted area and take NSAID pain medications as needed. She was not advised to avoid weight bearing activities and no crutches were provided or recommended. The client continued to walk on her leg and two weeks later she sustained a displaced hip fracture. Due to the delay in treatment, the patient developed avascular necrosis and required a complete hip replacement.

Question(s) For Expert Witness

1. What is the standard of care in examining patients who present with acute pain radiating from the hip?

Expert Witness Response E-000962

Patients with hip fracture typically present to the emergency department or their physician's office after a fall. They are often unable to walk, and they may exhibit shortening and external rotation of the affected limb. Frequently, they have hip pain. In some instances, however, patients with hip fracture may complain only of vague pain in their buttocks, knees, thighs, groin, or back. Their ability to walk may be unaffected, and initial radiographic findings may be indeterminate. In these patients, additional studies, such as magnetic resonance imaging or bone scanning, may be necessary to confirm the presence of a hip fracture. A high index of suspicion often is required for prompt diagnosis and treatment of an occult hip fracture but at the very minimum, a physician must give the patient a full physical exam to rule out such causes before sending a patient home. Simply allowing a PA to see the patient and promptly discharge would be inadequate.