History
Records indicate that in February 1986, Jason Brookhouse experienced a wrestling injury to his mid-thoracic spine and ribs which led him to the care of chiropractor John Duke.
In the spring of 1987 Jason suffered a softball injury that stretched and pulled the left anterior musculature. The injury resulted in tightness when he flexed and extended his leg. The symptoms seemed to resolve themselves. In September of 1987 the pain again returned when Jason began running in the school's physical education class.
He sought care from Dr. Michael Hoffman for complaints of left hip and low back pain. No diagnostic x-ray examination, orthopedic or neurological examination was performed upon this patient. His primary complaint was leg pain. Dr. Hoffman obtained x-rays which consisted of an anterior-posterior (AP), a lateral lumbar, and an AP pelvis. Dr. Hoffman found the patient's complaint of hip pain to be rather vague and non-specific. Examination confirmed the presence of pain. Dr. Hoffman found no evidence of bony or joint abnormality and elected to provide chiropractic care. Dr. Hoffman provided 11 chiropractic treatments between September 18, 1987 and November 27, 1987. Jason reported improvement in his leg, hip, and lower back.
On October 21, 1987, the patient reported to Dr. Hoffman that he was well. Dr. Hoffman released him from chiropractic care. Jason informed Dr. Hoffman that he would be continuing with all his chores on the farm, and since it was harvest time, he would be climbing up and down tractors and throwing bales of hay on a daily basis.
He never returned for care to Dr. Hoffman. On December 15, 1987 Jason again sought care from Dr. Duke. His major complaints were left iliofemoral tightness when he flexed and extended his left hip. The patient attributed this tightness to a softball injury he suffered previously in the spring. He felt the pain had resolved in the summer but returned during the school year. Dr. Duke's notes documented left quadricep weakness and ilium tenderness, but there was no formal examination performed. Dr. Duke administered lumbar manipulation and electrical stimulation to the lumbar spine. Following this treatment, Jason had no relief and on December 17, 1987 x-rays were obtained which revealed a moderate right lumbar scoliosis. Jason reported improvement on December 18, 1987, and he continued with care through June 2, 1988. During the weekly treatments Jason continued to report general improvement but still experienced muscle tightness and stiffness.
On June 15, 1988 the patient sought orthopedic evaluation from an orthopedic surgeon. His notes showed that the patient complained of pain in his hips since a wrestling injury in March of 1987. Jason reported no pain when walking, but did experience pain while doing vigorous farm chores such as milking and lifting hay bales.
Outcome
The orthopedic surgeon noted that the patient walked with a limp and openly stated that, "The chiropractor didn't know what he was doing and hurt this boy." Examination revealed no rotation of the hip but that there was a full flexion and extension, and there was quadriceps atrophy. X-rays revealed a slipped capital femoral epiphysis posteriorly at 25 degrees. The joint appeared healed in the slipped position with no evidence of vascular necrosis. The orthopedic surgeon recommended a bone scan to determine the level of healing in the joint. Following the bone scan, it was concluded that there was a "hot epiphysis." The hip was fixed at 15 degrees external rotation, and Jason was instructed in passive and active exercises to increase his range of motion.
Prevention
Proper examination must be performed, whether physical, orthopedic, neurological, or radiological. They must also be interpreted properly. Both Dr. Duke and Dr. Hoffman were liable. Their histories were limited to non-existent examination. There was no evidence of an updated case history or exam when the patient returned to Dr. Duke for care with new symptomatology.
When a patient returns for care with a new condition, an updated history should be taken. When a patient is dismissed, a formal written dismissal is advisable.
This case study is provided from the claim files of the OUM Group Chiropractor Program. The study is based on actual incidents, but the circumstances have been changed.
Dennis Semlow, D.C.
Fremont, Michigan