Limping Grand daughter. [Archive]

Curious Pax

2nd Aug 2006, 10:34

As Belfast Child mentions it could be Perthes - although 3 is young that is the age when my son was diagnosed with it. If it is that then young is good as they seem more likely to recover without intervention.

Perthes is where the ball at the top of the thigh bone that fits into the hip bone crumbles - sounds frightening at first, but the bone slowly grows back, and the child is monitored with x-rays to ensure that the new bone is developing with the correct shape. Diagnosis is also easy because an x-ray of the hip shows it clearly.

My son is now 6, and since it was diagnosed he has had no further problems - his gait is slightly funny when he runs, but nothing much. The consultant he sees every year believes that there is no reason to think that this episode will make him any more susceptible to arthritis in the joint when he is older. I suspect that if he had the genes to be a top athlete it could prove a hinderance, but he takes after me in that respect, so not a concern for us!

Apparently Perthes is most prevalent in the North of England among low income and under nourished children, although we only ticked the first box.

Hope it proves to be something trivial - best of luck.

Jimmy The Big Greek

2nd Aug 2006, 14:44

It could also be that one leg is longer than the other. Anyway the soultion is to go to an orthopedic and not to an aviation forum for advice.

Mac the Knife

2nd Aug 2006, 14:50

This sort of story always makes my alarm lights flicker. Limping without a firm history of injury in a child usually means significant pathology.

It could be lots of things, some trivial and some not at all trivial.

"...her GP say: 'She's putting it on.'" - I don't buy that at all except for an hour maybe - kids of that age don't have the ability for sustained deception (or the need, either).

Suggest your friend gets an appointment with a pediatric surgeon or orthopod soonish.

TheFlyingPhysio

2nd Aug 2006, 15:58

Interesting and all sorts of possibilities (foot, ankle, leg, knee, thigh, hip, spine) as to cause.

Seat1APlease makes a good point but if she limps barefoot then it is unlikely to be a shoe problem.

In a nutshell it appears to be a movement problem.

Solution. See a movement specialist i.e. a good physiotherapist.

Cheaper than a orthopod and more likely to offer a practical approach.

cavortingcheetah

2nd Aug 2006, 16:22

:)

Thank you again gentlemen. I was rather hoping that some who have answered would have done so. The information has been most gratefully received by the worried grandfather.
I am reliably informed that the little girl in question now has an overwhelming urge to become a pilot. There will be some out there who may have some idea as to what I may think of female pilots but I shall no doubt be dead before this three year old achieves her newest ambition..:E
I hope that such a connection, slim as it may be, will assuage the ire of those whose sense of place and propriety might best situate them on the other side of the Bosphorous in relation to their antecedents, from whence they may wave forlornly at the Hellespont.:p
Thank you one and all.
cc.

Mac the Knife

2nd Aug 2006, 17:48

....if she limps barefoot then it is unlikely to be a shoe problem.

In a nutshell it appears to be a movement problem.

Yep, I'd figured that out!

Solution. See a movement specialist i.e. a good physiotherapist.

Cheaper than a orthopod and more likely to offer a practical approach.

But less likely, I submit, to diagnose a pelvic Ewing's or a distal femoral osteosarcoma or an aneurysmal bone cyst or......well, you get the idea.

Mac :ok:

PS: As part of an orthopaedic oncology team I regularly reconstruct legs, pelvises and whatnots after bone tumour resections.

TheFlyingPhysio

3rd Aug 2006, 11:42

What a relief you figured the shoe problem out but why potentially scare the patient and the patient's family with nasties when a lot of simple things can be eliminated first. The physio, more often than not, has far greater experience at looking at limps and other apparent musculoskeleatal problems than the GP or junior hospital doctors for that matter.

Now, I don't disagree that movement problems can be due to nasties BUT you do physios a disservice by suggesting we are not competent to recognise scope of practice. Although I cannot state the case for South African physios, Aussie physios have had first contact rights for over 30 years and in the UK it has been at least 25 years. We do appreciate when the symptoms and signs do not fit a mechanical problem and are more than happy to refer on for a specialist diagnosis. In fact physios in the UK now work in Orthopaedic Clinics (as well as others e.g. Rheumatology) so that the valuable time of Orthopods is put to better use ! The results to date show that clinic throughput has been improved and waiting times to see the Orthopod reduced.

Finally, I would humbly suggest you note Chap 63 Grieve's Modern Manual Therapy 2nd Ed. The Vertebral Column edited by Boyling and Jull and published by Churchill Livingstone in 1994. You would be surprised to see what physios pick up and send back to the GPs or other specialists for their opinion.

Move well. Stay well. The Flying Physio :ok:

BelfastChild

3rd Aug 2006, 12:03

why potentially scare the patient and the patient's family with nasties when a lot of simple things can be eliminated first. :ok:

why not get an xray when a lot of nasties can be eliminated first?

TheFlyingPhysio

3rd Aug 2006, 14:03

why not get an xray when a lot of nasties can be eliminated first?

So you want to shoot first ? Why not use some clinical reasoning before subjecting someone to radiation ?

Mac the Knife

3rd Aug 2006, 20:58

TFP, I have the greatest respect for physios and work very closely with them in all my reconstructive work. They are skilled and dedicated paramedical colleagues. I couldn't do my thing properly without them and they have often given me valuable insights into difficult problems.

"The physio, more often than not, has far greater experience at looking at limps and other apparent musculoskeleatal problems than the GP or junior hospital doctors for that matter."

You may well be right there, especially with junior doctors, though I'd expect an experienced GP would also have adequate knowledge.

I'm not familiar with "first contact rights" but presumably you mean that patients contact physios first before being referred on to GPs or specialists as required. Well, people do that here too, but I'm a little uneasy with the idea that physios should be the first-line referral point for people with musculoskeletal symptoms. While I appreciate that many of these will be strains and sprains that respond to physiotherapeutic measures, a significant number are not and will not. By the time that your treatment has failed and the patient has been referred onwards, significant time may have been lost. Are you really comfortable performing a medical diagnostic function which your training, no matter how admirable, is not primarily directed towards? Are you sure that you would pick up, say, a slipped capital femoral epiphysis in an adolescent with knee pain? Being untrained in physiotherapy, I certainly would not attempt to usurp your functions.

I don't suggest that physios in general are not competent to recognise scope of practice, but merely point out that when the borders of scope of practice start to become blurred, that it is easy to find oneself in tiger country.

No one is perfect, we often see serious musculoskeletal pathology whose early symptoms have been dismissed by medically qualified people - not infrequently, I may add, because an X-ray has not been requested or the report not looked at.

Finally, though I have not read the publication you refer to, I am not in the least surprised at "what physios pick up and send back to the GPs or other specialists for their opinion" for I frequently see such patients.

BelfastChild

4th Aug 2006, 07:03

So you want to shoot first ? Why not use some clinical reasoning before subjecting someone to radiation ?

Can't really use any clinical reasoning here because never seen the patient. Therefore I can only speak in general terms.

In general, ANY young child with an unexplained limp should have an AP pelvis xray. It is **** all radiation. I think that not doing an xray in a young child with an unexplained limp constitutes medical negligence. I am sure a lot of my colleagues would agree.

FTP - I would be more than happy for a physio to take over management of the child AFTER I have excluded any serious pathology.

Mac the Knife

4th Aug 2006, 10:02

In general, ANY young child with an unexplained limp should have an AP pelvis xray. It is **** all radiation. I think that not doing an xray in a young child with an unexplained limp constitutes medical negligence. I am sure a lot of my colleagues would agree.

Well, this one does.

Mac

slim_slag

4th Aug 2006, 11:24

:uhoh:
A friend of mine, caught up in the National Health in England, has a three year old grand daughter who has suddenly developed a pronounced limp.
This cause her no pain and her GP say: 'She's putting it on.'Have her walk backwards in a figure of eight and note her limp, even the most devious adult malingers have difficulty working out which side to limp on. If she limps on the same side then go back and teach the GP some medicine :)

Flyin'Dutch'

6th Aug 2006, 23:05

Have her walk backwards in a figure of eight and note her limp,

Slim, the kid is 3!

Anyway nice to see that even good physiotherapists can come up with some rubbish reasoning!

Kids don't limp other than for good reasons.

Limping kid = Xray.

Not to investigate this is dicey.

As for putting it on. Any kid that limps for a second day after a night's sleep has a problem until the contrary is proven.

slim_slag

7th Aug 2006, 08:20

Well, I guess if you define 'have' (the child walk backwards in an eight) so narrowly to only mean 'tell' you might face difficulties. When they start paying by the word to post here then one might go into more detail :)

If playing a game by leading the child doesn't work, then just backwards in a straight line should give a reasonbly good idea whether the GP is right or wrong. NOte I didn't say "definitely" whether the GP is right or wrong, just a good idea. An adult malingerer could easily fake a limp going just backwards, not a three year old child, a backwards figure of eight will usually catch the lot of them.

It looks like the GP is a roadblock in the mind of the poster, who knows the poster might just be right. We can b0llock on about what we would do but that is no use if the GP isn't having it. As they don't appear to have private medical insurance then the way forward is to attempt to show the GP that the child is not putting it on.

I'd usually defer to the opinion of a physio, that's because they were trained in physio and I wasn't. That's why they are invited onto business ward rounds.

Anyway, the above is my story and I'm sticking to it :) Cheers,

Mac the Knife

7th Aug 2006, 15:30

Kids don't limp other than for good reasons. Limping kid = Xray. Not to investigate this is dicey.

As for putting it on. Any kid that limps for a second day after a night's sleep has a problem until the contrary is proven.

Agree, but do look for obvious things like thorns and verrucas!

The late great clinician Richard Asher had a wonderful story about a weeping, limping child with a scissors-gait, whose symptoms miraculously improved one her knickers had been removed (she had both legs in the same opening...)

As I said, "kids of that age don't have the ability for sustained deception" and I think it's true. They certainly do have the ability to sustain phantom companions and the like for long periods, but that's another story.

Clinical diagnosis is a wonderful art that is hardly taught anymore. To be really good demands an enormous depth of knowlege and the nose of a Sherlock Holmes. I was lucky enough to be taught by some of the grand masters of yesteryear and I hope a bit rubbed off!

:ok:

gingernut

10th Aug 2006, 10:12

Sorry to hear your opinion about the NHS-(some(most) of us are dedicated to improving it.)

I would agree, a limping child would ring some alarm bells, but a adopting a position of "watchful waiting," may be reasonable, depending on the story the patient and relatives give. (In particular, the time of onset of the symptoms.)

I don't know the full facts of this case, but it sounds like the communication between gp and parent was not ideal, clinically, we do have a responsibility to get to the root cause of the symptoms, whilst at the same time, protecting the child from a high dose of ionising radiation.

Unfortunately, if you ask 10 different professionals, the likely result is 10 different opinions-find a professional you trust to inform you of the reliable options. (GP's are generally very good at this)

Interestingly, the Royal College of Radiologists suggest that an X-ray is not routinely indicated initially in a limping child, only if symptoms persist. The evidence for using U/S is actually higher.

If your not happy, seek a 2nd opinion.

Nice to see the big boys back and scrapping on the forum :)

Mac the Knife

10th Aug 2006, 18:49

"..protecting the child from a high dose of ionising radiation."

While I agree that you shouldn't expose kids (or anyone) to radiation without good reason

Total effective doses:
Single exposure extremity - about 0.005 milliSieverts/0.5mre
Single exposure hip - 0.8mSv/83mrem

Less in a child.

This is NOT a "high dose of ionising radiation" fachrissakes!

Things are getting completely absurd now, people are so **** scared of being sued for something that they're scared to do investigations when indicated. And they're scared not to investigate in case they get sued for that, and finally they're scared to make any kind of working diagnosis in case they're wrong and sued for that! Pathetic!

No wonder the physios are taking over.

"Feeling sick?
Call your lawyer!"

TheFlyingPhysio

10th Aug 2006, 19:35

Now Mac, I 'm back from flying and I was just about to thank you for your earlier comments (3/08/06) but you have gone and spoilt it by saying the physios are taking over ! Perhaps we are just getting better and better at what we do. :)

Regarding diagnosis, didn't McGill do a classic article on diagnosis and prolapsed intervertebral disc that showed the pitfalls of a diagnostic approach. Anyway, I would not dream of going down that route because from my perspective it is not what we do. However, I was taught to examine thoroughly and you will find that musculoskeletal physios work with symptoms and signs that generate a clinical impression. Those would tell us what to do or not do as appropriate. As for knee pain, if that is where the symptoms are but there are no signs then clinical reasoning tells you to rule out other possible sources such as the hip. Sherlock would have said "Elementary my dear Watson !"

"Rubbish reasoning ?" Flying Dutch what are you trying to say ?

At least Slim_slag is moving with the times. :ok:

Mac the Knife

10th Aug 2006, 20:33

TFP, I wasn't serious (well, only a teeny bit). I was (and still am) irritated by the increasing pusillanimity of the medical profession today. I chose to refer to that other thread to illustrate that if doctors become too cowardly to do their job properly that other people will start doing it (or trying to do it) for them. Peace.

But I'm not sure that you mean by "..the pitfalls of a diagnostic approach.." - what other approach is there? Pendulums? Telepathy? Iridology? But I'll be charitable and assume you mean a purely mechanistic analysis, in which case you can be reassured. The true art of medical diagnosis (for it is an art, albeit containing elements of science) considers every aspect of the patient, physical, mental and environmental.

It is unfortunate that the extraordinary advances in diagnostic imaging these days have led to an atrophy of the old skills of clinical diagnosis that go back to Hippocrates and further. And it is regrettable that our paramedical colleagues should have come to assume (with some justification, I may add) that they discovered the "holistic" approach and are the only persons capable of exercising it.

Many of my patients, alas, has illnesses of the soul which may or may not coexist with or aggravate their physical problems. I need to be aware of these so I may better separate out the tares and the wheat. Sadly, while I may comfort the spirit, I am not often in a position to heal it.

Davaar

10th Aug 2006, 23:14

[QUOTE=

As for knee pain, if that is where the symptoms are but there are no signs then clinical reasoning tells you to rule out other possible sources such as the hip. Sherlock would have said "Elementary my dear Watson !"

:ok:[/QUOTE]

I enter this one with trepidation. To start with, though, never in the entire Holmes canon does the great one say:"Elementary my dear Watson!"

For the past several years I have sat as (lawyer) chair of a three-person disability review board (physician/nurse/physio/pharmacist and layman or woman.

"As for knee pain ... rule out ... the hip".

Well now, one would think so. Consider the man in his thirties, married, two young children. Graduate. Well qualified. Athlete. Just starting to make progress in his career. Bright guy. Wife, also bright young graduate, quits job, look after children. Happy family.

Works with the intellect. Starts to feel great discomfort in the thoracic region. Ah! It'll get better. No it does not. Becomes progressively worse over several years. Suspected lung cancer or other lung disease, but difficult to be sure. Many X-Rays and "tests". Many consultants. Heavy thinkers. (Hey! Maybe he is malingering? Whaddaya think? No?). Exploratory surgery. Reports upon reports. Fellows of this College and that. Meetings. Consultations. Chiefs of staff acquire lines of worry. Nothing revealed. What can it be?

Debilitating insomnia. Progressive inability to concentrate. Does his work worse and worse. Understanding employer puts him on less demanding work, then part time. Yip! Gotta real problem with those lungs. People are human after all, and this becomes quite tedious. He has to stop work. Wife goes back to job. Daycare for the children. Marital strains. Prognosis gloomy for survival, quality of life and marriage.

In the midst of all this merriment he goes for a routine dental check. It is not that he has toothache. He does not. No toothache. Just time to go. The dentist by accident knocks a probe against a crown or filling. The crown or filling falls off in his mouth. Right there and then it just falls off. The chap's mouth, and also the room, as he told us, are instantly "filled with the stink of the most awful drains".

Dentist does whatever dentists do in such circumstances. Within a month chap is well on the way to recovery. There was nothing wrong with his knee ...Ooops! ... lungs. There was everything wrong with his tooth, and it apparently had the effect of poisoning his whole body. Seems he'll soon be able to go back to work! Thinking of skiing, maybe next year.

I can now virtually tell as soon I see who are on the panel how they will interpret the evidence, who will be dogmatic, who cautious. If an applicant claims to have pain and take oxycontin or Tylenol 3, one member will insist on seeing the prescription for the laxative, because "everyone knows" (Well, she does) that pain killers are constipating. No laxative, no genuine pain. Well it is not so. Not always. Not for everyone.

Some demand "objective evidence". What's that? Ultrasound, perhaps? Yeah. How much of the result depends on the skill of the technician or radiologist to interpret and the fatness of the patient when the pictures were taken?

Old lady falls. X-Ray of hip. Great! She is Okay. Good. A week later she is still in agony. Ambulance. Admitting physician at Emergency reviews her and X-Ray plates from last week. There we are! See! See! Look there! See the crack! She has had a broken hip for eight days, was sent home with it.

We are not talking a new X-Ray, but last week's.

BelfastChild

10th Aug 2006, 23:53

this thread has certainly ignited a lot of passion! Mac - thanks for looking up the radiation doses - you saved me from doing it!

I don't think anyone here is suggesting that you whip a child off to the radiographer the second they start to limp. But if it continues and is unexplained, not doing an x ray is inexcusable. I can tell you now that if you pick up an orthopaedic text book and looked up 'limping child', you won't see 'putting it on' high up there in the list of differential diagnoses.

Now please remember, none of us can really comment on this particular case because we have never seen the child. Maybe if we did our own history and physical examination then we might think differently.

Finally, I think it depends on your philosophy of practice. Personally, whenever I see a patient, the first thing I want to do is rule out anything that can kill or maim. If the problem will do neither, then we have a bit more time to sort it out. Too bad if this child turns out to have a pelvic osteosarcoma and dies or has SCFE and needs a total hip replacement at age 20 because we never did an x ray. We could write it off and say 'oh well, she was unlucky because only 1 in 1000000 people get osteosarcoma but at least we saved her from a small dose of x ray'. Tell that to her parents.

gingernut

11th Aug 2006, 07:46

And they're scared not to investigate in case they get sued for that, and finally they're scared to make any kind of working diagnosis in case they're wrong and sued for that! Pathetic!

Easy tiger, were all on the same side.

Hip x-ray (albeit on an adult) equates to about 20 chest x-rays. I'm not sure at what point you class exposure as "high," but the Royal College reckons medical x-rays probably trigger 200 cancers per year in the UK.

I can't help feeling we're missing the point though. The evidence (not opinion) suggests that and X-Ray is not the initial investigation of choice for a limping child. Unless you know different.

As for; I chose to refer to that other thread to illustrate that if doctors become too cowardly to do their job properly that other people will start doing it (or trying to do it) for them.

Perhaps not a bad thing.I come across this secondary care mentality every day, but I prefer to concentrate on whats best for the patient, (whether or not it's a nurse/doctor/surgeon providing the service), rather than what's best for the professional.

Mac the Knife

11th Aug 2006, 09:24

"...other people will start doing it (or trying to do it) for them."

"Perhaps not a bad thing"

What on earth are you implying? That paramedics should replace traditionally trained doctors (in which case we can close down the medical schools)? That nurse practitioners should be resecting colon cancers or doing hip replacements?

Goodness me - I'm sure that in a few months you could train me to fly an uncomplicated approach in quiet airspace, but that hardly enable me to fly into Canarsie on a cold dark windy night.

There's a nice story about, I believe, Sir Heneage Ogilvie, the great Victorian surgeon. He was called one day to the house of some wealthy people to see the Grandpa - after suitable deliberation he left, saying that there was nothing to be done. The family were unhappy, some days later, to recieve a bill for 50 guineas and said so, "After all," they said, "You did nothing!"
The surgeon apologised and gave them an amended bill, it said:

For doing nothing - no charge
For knowing that there was nothing to do - 50 guineas

;)

gingernut

11th Aug 2006, 10:00

What on earth are you implying? That paramedics should replace traditionally trained doctors (in which case we can close down the medical schools)? That nurse practitioners should be resecting colon cancers or doing hip replacements?

Compliment rather than replace.

Times are changing, and there isn't a lot of room for professions jealously guarding their professional boundaries in a modern health service. It's about what's best for the patient (or population), rather than what's best for the professions.

And the evidence I've seen suggests that allowing "paramedics" to develop and expand their role benefits patients in terms of access, satisfaction, quality, and perhaps most importantly, health outcomes.

Shouldn't orthopaedic surgeons spend their time doing what they're best at- operating on patients, rather than spending 70% of their time in outpatients?

slim_slag

11th Aug 2006, 10:13

Yeh, putting health care into the community and the increased use of nurse practitioners is a good thing overall. But sometimes only a hospital specialist opinion will do, and people should keep some cash in a piggy bank to obtain one when situations occur like this thread has possibly highlighted. Of course the average Joe doesn't have this sort of cash available, and there are going to be a lot more medical negligence cases coming along in the next ten years.

BelfastChild

11th Aug 2006, 14:45

I can't help feeling we're missing the point though. The evidence (not opinion) suggests that and X-Ray is not the initial investigation of choice for a limping child. Unless you know different.

Let's see your evidence. What is best then? I refer all who don't want to do an x ray to an excellent article in The Journal of Paediatric Health Care. It is entitled The Limping Child by Leung et al and is in 2004 Sep-Oct;18(5):219-23. I would post it here but don't think I can for copyright reasons. It can be accessed through pubmed or medline. Basically it states unexplained limp equals x ray,

By the way gingernut - not wanting us to do x rays, promoting the 'benefits' of nurse practitioners (don't get me started on that one!!!) - you're not an NHS manager by any chance are you?

gingernut

11th Aug 2006, 15:20

"Making the Best Use of a Department of Clinical Radiology - Guidelines for Doctors 5th Edition " page 136.

I will have a look at Leungs article though- what grade of evidence is it ?

No I'm not an NHS manager, I am at the frontline.

I do spend some time travelling the country demonstrating how developing a whole system approach, (and that includes expanding the role of nurses, pharmacists and physio's), can improve the quality of care we give to our patients.

I haven't been to Belfast yet, but I did recently talk to a group of pharmacists from Northern Ireland, who made it clear that there are some terrible gaps in health care provision, which they are keen to address.

It sounds like you havn't yet been to one of my conferences- perhaps you may benefit from attending one :)

have a good weekend.

gingernut

11th Aug 2006, 15:24

Thanks for the reference, I have looked at the reference, Leung actually states, In most cases, a diagnosis can be made from the history and physical examination.

I can suggest some rather good texts on critical appraisal. Take care:)

Mac the Knife

11th Aug 2006, 19:12

Shouldn't orthopaedic surgeons spend their time doing what they're best at- operating on patients, rather than spending 70% of their time in outpatients?

So the orthopaedic surgeon then becomes a technician, operating on patients whose diagnosis and management have been determined by a paramedic?

Fascinating. This sort of statement by someone who is, "travelling the country demonstrating how developing a whole system approach" demonstrates a horrifyingly complete misunderstanding of role of the surgeon.

This view sees the surgeon as primarily a theatre technician, whose main ability is to perform surgical procedures, which are again seen as repetitive set-pieces rather like tasks in an assembly line.

If this were so (which it isn't), then it would make a great deal more sense to train theatre porters to do the operations (rather than someone who has spent 10 years or so training in medicine and surgery) and send the ex-surgeon to the outpatient clinic.

The fact is that of equal or greater importance to the actual surgery, is the diagnosis and the often very difficult decision WHAT to do. To treat medically or to operate - and, if operation is decided on, exactly which of a whole variety of procedures and their individual variations will the the best for THAT particular patient.

Faced with a proliferating barrage of this sort of ludicrous perception of the role of the surgeon, I find myself feeling quite glad that retirement is not too far off.

If the public continue to swallow this flood of Press and Government propaganda, designed to depict all medical practitioners as inept and venal at the best and potential Shipmans at the worst then they will eventually get the doctots that they deserve - and good luck to 'em.

Good day to you Sir! :*

Davaar

11th Aug 2006, 19:41

Compliment rather than replace.
Times are changing, and there isn't a lot of room for professions jealously guarding their professional boundaries in a modern health service. It's about what's best for the patient (or population), rather than what's best for the professions.

This implies as I read it that patient = population. There I disagree. The first is people, the second is statistics.

I am an active member in my own profession of law and a patron (giving of my time and various body-parts) spectator in medicine.

I try to be self-critical in my profession. When I was very new, long ago, a client presented me with a problem. So soon in practice and I knew the answer! "Lookin' good", as the sports commentatiors say. I knew he would lose. I told him so. He asked me to reconsider. Very well, then. I consulted my betters in the office. They told me: He will lose. I told him so. He said: Yes, but go ahead anyway. Foolish fellow. I told him I had to take the opinon of counsel, given my view that he would lose. Go ahead, he said. I did. Counsel heard the tale, frowned in that impressive way they have and said: "Mr Davaar is quite right. You will lose." Go ahead anyway, he said. Do you want other lawyers, we asked? No. I like you guys, but: "Go ahead anyway!". We wrote a letter from him to us, telling us to go ahead against our own judgment. He signed. We brought the appeal. We won.

Given the same problem today, I'd give the same advice. I think he would lose, but I can't be dogmatic. I have more experience now.

Now to your profession. The files cross my desk. Successful patient, live-wire, good job, active in community. Feels poorly. Goes downhill. Loses job. GP A diagnoses condition X. Consultant B confirms diagnosis of condition X. A and B agree patient is very ill.

Insurance company requires independent diagnosis. Eminent physician and Associate Professor of Medicine C, MD, the Fellowships, the years of experience, the chairmanships of this federal and that provincial board, is consulted, diagnoses condition Y. Lemme tell you, that loopy-doopy pair A and B could not unassisted find their way to lunch.

Their diagnosis of condition X is wrong, upsets the patient for all the wrong reasons, and does the greatest disservice. C tells of his many differential tests, some with placebos, some not, and we are looking here at condition Y, no question. What's that? Oh! Sure. The patient is very ill.

A, B, and C all agree the patient is very ill. But of what?

The correspondence digresses. A and B reveal that C's mother wears army boots. Fact. Known throughout the profession. C confides that A and B do their diagnoses by way of Ouija Board.

Which is right? Who am I to say? I had a view, certainly. At the very least we were dealing with people who had spent hard and difficult years learning their trade.

What of the paramedics and the nurses?

I think God must have a special part of Heaven where he makes paramedics. I have been a frequent user, and I say they are the most wonderful people. They have a sub-group called "Big Bob/Dave/Bill down in Emergency". When the nurse has spent half an hour stab, stab, stabbing away ("Don't know what's wrong with your veins today" as "We just do the blood work"; delete "we" insert "I") for the blood and quits, she says "We'll have to get Big Bob from Emergency. He arrives. He obviously plays a lot of hockey. Huge. Built like a bus. He has fists like hams and he is as gentle with a needle as the fondest Mamma ever was. The nurse can't find the vein. Bib Bob can find the vein. And I do not want any innuendo about sexual orientation.

Nurses too are great, though not so great as thirty years ago when you actually got to know their names. Still, when she sits with you through those long night hours between life and death, and does for you things you don't want anyone to do for you, she is more than something special. God Bless you, Sister Bernadine.

But when a visit to Emergency notoriously entails a wait of 7 hours, and a diagnosis of acute coronary disease entails a wait of undefined months for surgery, I view with scepticism any argument for "nurse practitioners". This is a solution for one problem, no other: the shortage of physicians. Please do not try to convert it into a virtue.

Just as many physicians cannot hit a barn door with a hypodermic, so neither the paramedic nor the nurse is a diagnostician.

What happens in a consulting room? A patient, self-selected, looks for words to explain his understanding and observation, both of which may be mistaken, of a malaise or pain to a hurried, often harried, man or woman in a position of unquestioned authority in this one important context, namely what to do.

That is, what to do with and to me?

Should I tell this man (woman) that I had such and such a symptom? Well, last week, anyway. it seemed to go away, and if it has really gone away it may never come back, so why tell him? If I tell him he, or worse still she, will poke around where I'd rather he or she not poke.

What in any case of the Brusque Physician? That James Robertson Justice professor figure in the old Doctor movies exists in real life. Is he listening to me anyway? Is there any meeting between my words and his comprehension? Hope so. When I tell him his pills do not seem to do me much good, and he snaps that he does not appreciate patients who do their own diagnoses, what do I reply? (No reply. He was wrong. I collapsed a few days later and was admitted straight from the ambulance to the OR).

The whole process is so cumbered with risks that I'd rather not go there at all, and if I must, at least I want one of those wretched bullying chaps rather than a nurse who tells me, as one did: "Orthopaedic surgeons are just carpenters anyway".

MORAL: In everything there is a whole lot of uncertainty. Knowledge and experience are helpful in resolving uncertainty and being right in that resolution.

BelfastChild

12th Aug 2006, 00:20

Hi Gingernut. Leung does make a very good point in saying that in most cases the diagnosis is obvious from the history and clinical examination. However, I would like to point out that I am referring to the unexplained limp, ie we have done a history and clinical examination and still not sure what the diagnosis is. It is then, and only then, that we do an x ray.

I am not sure why we need to argue this point. It seems bleedingly obvious. Let's not get distracted about nurse practitioners, physios, the NHS (I'm a bit guilty of that from a previous post :O ). I am going to put it out there now to everyone - you do a history and clinical examination of a limping child and you don't know what the diagnosis is.....what would you do?

and by the way, here is another article saying that an x ray is the first investigation you should do in a child with an unexplained limp.

Myers MT, Thompson GH. Imaging the child with a limp. Pediatric Clinics of North America. 44(3): 637-58, 1997.

Perhaps those of you who seem to know better should enlighten us with your evidence to the contrary

Charlie Foxtrot India

12th Aug 2006, 14:45

Interesting what Davaar said about the bad tooth, we had a student who we thought just had terrible posture, which affected her flying. When she was flying the Cub the instructor in the back noticed that she was always leaning to one side, which hadn't been noticed in a side-by-side aircraft.

It turned out that she, too, was being "poisoned" by a bad tooth and is now fine!

Mac the Knife

12th Aug 2006, 17:43

Oooh! I loved Davaar's story! Reminds me of a classic Poe story that horrified me as a child - "The Facts In The Case Of Mr Valdemar" - ".....there lay a nearly liquid mass of of loathsome, of detestable putrescence".

Let me tell you another story that a friend told me who'd heard it from a real pilot. Once upon a time there was an aircraft, a 747 Classic to be precise, that led an entirely blameless life until one day when the Flight Management Computer started to misbehave. Whatever destination you entered, it would obediently follow for a while and then start drifting off. If you reset it, it would behave for while and then this strange behaviour would start again. This was most upsetting for pilots and the company and many things were tried to correct it. After much harrumphing the engineers replaced the entire unit, but to their surprise the navigational drift in the FMC persisted! Much consternation! Further data analysis revealed that the aircraft keep trying to pursue a heading of 45°24' N 75°40' W ! Most mysterious! But as luck would have it, the A/C was due for a D check and was trundled of to a hangar where everything was taken apart from inspection. After everything was stripped down and inspected, a most strange thing was found! Behind a blank panel in the avionics bay they found the dead body of a Canadian beaver! This was removed, the D Check completed and the aircraft returned to service. Now the FMC behaved perfectly and the aircraft obediently went wherever it was told with no more fuss.

The only explanation that they could come up with was that the beaver had stowed away to get home but expired enroute. However it's corpse still wanted to go home and was somehow mysteriously influencing the FMC! Isn't that amazing!

;)

mini

12th Aug 2006, 23:13

With the greatest respect...

Its not called Practice for nothing...

gingernut

16th Aug 2006, 10:31

This implies as I read it that patient = population. There I disagree. The first is people, the second is statistics.

I'm not sure I can agree withn this statement. I've worked at both ends of the spectrum, both in Secondary Care, and Primary Care.

One startling difference I noticed in the transition from Secondary to Primary, was that at one time I may have spent days, sometimes weeks, devoting a whole load of resources at one time, to only perhaps only one or two patients. (Totally necessary at that time.)

It did take a while to adapt to primary care, but I soon came to realise, that my responsibility wasn't just to the patient sat in front of me, nor to those sat outside in the waiting room. My team, and I, were actually responsible for the health of the 15,000 patients who we served in our community.

Our patients were dying of diseases, the mortality and morbidity of which, could be reduced by effective, systematic care, which, sometimes doesn't exist.

(Remember the "Rule of Halves," for patients suffering with hypertension.)

We have the magic bullets to treat diseases and prevent diseases, and the evidence to support these interventions, but unfortunately, we continue to deliver the magic bullets in a haphazard unsystematic way.

We have to think imaginatively (whether that means expanding the roles of nurses, pharmacists, prescribers, health care assistants), if we are to make a real difference to our populations, and patients, health.

The medico-legal arguments against expanding roles of "para" medics is an interesting one, and not my area of expertise. I'm not aware of any evidence to suggest safety has been compromised by professionals exploring their boundaries.

Mac the Knife

16th Aug 2006, 19:00

Interesting post gingernut.

"Approximately 3.3 million (30%) deaths annually were due to heart disease, 2.3 million (21%) to cancer, 1.5 million (14%) to stroke, 0.9 million (8%) to chronic respiratory diseases, and 0.8 million (7%) to violent causes (i.e., intentional and unintentional injuries). An estimated 1.5 million (14%) deaths annually are attributed to cigarette smoking." Recent WHO figures for the Developed World.

"Clearly, heart disease and cancer exact a tremendous toll on public health, together causing over half of all deaths in the United States each year. However, homicide among black males and unintentional injuries among white and black males cause the greatest years of potential life lost before age 65."

What's changed? Well, infectious diseases are almost off the map, though RVD (retroviral disease, a nice way of saying AIDS) pushes the figures up a bit.

Where are TB, cholera, diphtheria, polio, puerperal fever, typhoid, typhus, pneumonia, tetanus, gastroenteritis and septicaemia?

It is important for people to realise that the major determinants of decreased morbidity and mortality since the nineteenth century come not from medicine, but from improvements in public health: Better sanitation, sewers, water closets, Clean Air Acts, Safety in the Workplace, literacy and numeracy, regulation of food production and adulteration, safety glass, fire-resistant nighties, better housing, less overcrowding, mass miniature X-rays, slum clearance, minimum wages and National Insurance, pensions, electrical/mechanical/heating safety regulations, and building codes to name but a few.

Enter obesity and all it's sequelae (diabetes, cardiac disease, stroke), homicide, motor vehicle accidents, drug abuse, depression, anxiety and the accidie of modern society.

We have the magic bullets to treat diseases and prevent diseases, and the evidence to support these interventions, but unfortunately, we continue to deliver the magic bullets in a haphazard unsystematic way.

Yes, we do have _some_ magic bullets (the recent virtual elimination of peptic ulcer disease by treatment of helicobacter pylori springs to mind), but the magic bullets we need now (apart from for cancer) are largely those that will change negative patterns of human behaviour rather than anything else.

Doctors are involved with disease, not health - we're not very good at health because that isn't our job. Yes, we can participate in screening programs. Yes, we can promote health by encouraging healthy behaviour when we meet our patients, but there's little we can do before they get sick. That is the job of government and the community.

Disease is the doctors problem. Health is the wider community's problem.

And there's the rub. To make much further impact we have to change people and people's behaviour, which is a far more difficult thing. Much of mankind's foolish behaviour is intrinsic to being human - to change this is no small thing. Aggression and competition are particularly male components of behaviour - how can we curb and channel these without demonising these energising principles? Nurturing and the desire to have children are particularly female components - how can we attune these to 21st century realities without desexing women? The impulse towards pleasure is universal - how can we ensure that this powerful urge is exercised in a responsible way?

The current European belief that such changes can be legislated into existence is absurd. The ever increasing crop of laws that would seek to regulate the smallest corners of our lives brings the law itself into contempt and worsens our problems. The absence of codes of Good Citizenship, the cult of the individual, the abolishment of the doctrine of personal responsibility and the idea that it is always someone else's fault erode our society and make improving public health in the larger sense almost impossible.

I am encouraged (for my society) by the emphasis my son's South African school places on manners, fairness, kindness, tolerance, responsibility and hard work as being the pillars of our nation.

We have to think imaginatively (whether that means expanding the roles of nurses, pharmacists, prescribers, health care assistants), if we are to make a real difference to our populations, and patients, health.

I quite agree, but I think you are addressing the wrong problem. All these things are admirable but target only a small part of the health equation.

The medico-legal arguments against expanding roles of "para" medics is an interesting one, and not my area of expertise. I'm not aware of any evidence to suggest safety has been compromised by professionals exploring their boundaries.

Safety is compromised when doctors step outside their areas of competence and this is not a rare occurrence. Paramedical personnel are no different. That is why the General Medical Council, the Nursing Council and the Midwives Council have very strictly defined regulations about what you can and cannot do. Stay within these bounds and you need have no fear. The scope of practice of some other paramedical groups is far less well defined and the chance of finding oneself in difficulties if one "explores their boundaries" is correspondingly greater. These are matters of legal responsibility defined by Acts of Parliament and are determined by the electorate - they really have nothing to do with doctors.

A fascinating discussion.

TheFlyingPhysio

16th Aug 2006, 20:42

Safety is compromised when doctors step outside their areas of competence and this is not a rare occurrence. Paramedical personnel are no different.

Mac. I would have thought that safety is more likely to be compromised when doctors / nurses / physios / (insert any other profession) do not mantain their level of competence and dare I say it fail to use their brains.

Case referred to my clinic for management of musculoskeletal symptoms this week.
Patient falls off bicycle. Rear of helmet smashed by fall and patient sustains cut to back of head / neck at foramen magnum level.
Patient goes to hospital A. Glasgow Coma Scale (GCS) normal so patient sent home without further investigation. Patient wakes 3 or 4 days later in pool of blood and vomit.
Patient taken to hospital B by sister. GSC still normal and some investigations undertaken but patient sent home with advice not to be alone ! Two days later Hospital B calls and tells patient to return immediately due to investigations showing blood on brain plus collapsed lung.
Patient goes to hospital C now that they are at home with parents. Now one week post head injury and hospital C admits patient for one week. Patient spends it asleep most of the time.

Patient has had a suspected brain stem injury and will take many months to recover. It would appear that none of the hospital staff this patient saw stepped outside of their competence here. The question is did they really live up to it ?

Mac the Knife

16th Aug 2006, 21:52

Stepping outside your competence is completely different from negligence within it (which is what you describe).

The first is doing things you have not been trained to do and the second is failing to do what you have been trained to do.

I'm not quite sure why you are so resistant to the idea that physios and other paramedics may succumb to the temptation to step outside their sphere of competence. As I have tried to point out, none of us are immune to this.

You may personally feel that your own competence is sufficient to allow you to adventure further than your peers and you may be correct. However, if you get it wrong the courts are liable to take a dim view of it.

If you feel constrained by your role, why not study medicine? I have a surgical colleague who was a radiographer and my oncologist wife has two colleagues who in previous incarnations were a social worker and a laboratory technician respectively.

BelfastChild

17th Aug 2006, 00:04

No one denies there are incompetent or negligent doctors out there. Fortunately they are the minority.

Should we train flight attendants to start flying aeroplanes because there have been a few crashes caused by 'pilot error'???????

gingernut

17th Aug 2006, 08:57

It is important for people to realise that the major determinants of decreased morbidity and mortality since the nineteenth century come not from medicine, but from improvements in public health

I could not agree more. In fact a large part of my job is to keep patients (and the population), away from innefective medical interventions. (And to use effective ones when appropiate.)

Health itself is an interesting concept. As a clinician, my idea of health is sometimes very different than that of the patient (or population) I serve. Joe Bloggs sat in front of me, may not be too concerned about the fact his diabetic control is far from ideal, he may be more concerned about avoiding hypoglycaemic attacks which could result from tighter diabetic control.

Simillarly, if you asked me what the indicators of bad health are, I'd probably suggest tight BP control, healthy Body Mass Index, not smoking, healthy diet, moderate alcohol intake etc. If you ask our population, (and we have), they're more concerned with not having dog sh*t on the street, having more parks and feeling safe at night.

I'd agree that there is some "locus of control" within the patient themselves, but I don't really want to get into a victim blaming argument, suffice to say that the oppurtunities for me, as a middle class educated white man, are different than those afforded to my population.

I have to disagree about the doctor/nurse practitioner/physio/pharmacist argument. The "letting the stewardess fly the plane," argument is one I've heard before, (many times), but I think the case for "para" medics expanding their role competently is more complex.

The case for "para" medics expanding their role has come about for various reasons;

-Shift in patterns of demand/supply
-Information technology
-Changes in disease management

If you wish I could expand on each of these determinents, but perhaps I could give an oversimplified example;

20 yrs ago, if you developed hypertension, there may have been a good chance that you could have been managed by a hospital team. Years later, the same patient could have been managed by a primary care physician. Following the rules allowing nurses to expand their role, (and prescribing rights), the patient would then be managed by a primary care nurse.

Today, if you are a patient of mine, with controlled hypertension, you would be actively managed by a health care assistant, who, very safely and competently, manages, systematically, your condition.

We work well as a team, I am extremely confident that she manages our patients "better" than I ever did. This frees up my time to manage more complex cases, and the shift nudges up the chain up to the level of tertiary care.

Incidentally, the decision to explore our boundaries doesn't totally come from within- I have no desire to change my profession, and I could have opted to stay put in a more "comfortable," area-probably leading to an easier life- I have several colleagues who have chosen this route. The desire to explore and develop, comes with wanting to make a difference.

Of course it has to be safe- this is paramount, the key to this, as you have pointed out is competencty, and there are various mecanisms in place to ensure this.

The case presented by flyingphysio is interesting.I can perhaps second guess the outcome of this. Either hospital A, B, and C will blame each over, suggesting area's of incompetence for its partners, or the ranks will close, with neither A,B or C commenting on each others performance.

Its difficult for me to comment on the clinical aspects- it's not my area of expertise, but from what I see about this case, is that there is a golden oppurtunity for each team involved in the care of this patient to reflect and learn from the incident. Is this likely to happen- No. (Nurses are worse in this aspect than doctors.)

The skills of the surgeon, physio, pharmacist and nurse, are all different- but I believe that the patient should follow the same care pathway, if he presented to any of these highly skilled, reflective clinicians with a presenting problem, if that clinician had the competences to deal with that situation. The bottom line, of course, is having the competency to know when you can't deal with that problem, or problms. Simplistic, I know, and I realise that patients (and their problems), don't always fit into neat little boxes, but I'm afraid the argument that clinical accumen saves life is rather dated and not reflected by the available evidence.

I think we (the health care system), have to get away from what's best for us, as professionals,and concentrate on what's best for the patient.

These are my views, feel free to disagree.

Have a good week, I'm off surfing :-) I'm sure its better for the mind& soul than all these crappy antidepressants we sometimes dish out a little too easilly, but perhaps that is a different argument.

Mac the Knife

17th Aug 2006, 20:10

Well, I DO disagree, fairly profoundly, on many points.

I'm not going to argue further, for I think that I have covered most of the issues in my previous posts. Anyway, I don't believe for a minute that anything I could say will cause gingernut to reflect more or deflect him from his mission.

Many years ago I worked as a GP down the Old Kent Road (a poor part of London). This was a salutary lesson to me, after several years of hospital practice. That was before the MRCPGP and all that. The senior partner told me, only half joking, "If they're sick, send them to hospital and if they're not sick, give them a certificate!". And indeed, the vast majority of patients that I saw were not sick in the sense that I was used to. Sprains and pains and scrapes, earache, rashes, the pill and the coil, gastritis, "back trouble", menstrual problems, coughs and colds, old age, school difficulties, maturity onset diabetes, pimples, the "drip", arthritis, tiredness, hypertension, enuresis and teenage pregnancies, teenage pregnancies. Never an osteosarcoma or a Horner's syndrome, only an occasional jaundice or rectal bleeding to sink your teeth into (except that lab results took weeks and we had no sigmoidoscope). It was a whole other world. We still did house calls, though I learned very quickly that trying to read an ECG by a 40 watt bulb at 2am in a dishevelled council flat reeking of cat urine was a largely fruitless exercise. Far better to call the emergency bed service and an ambulance. Still, I did beat the LAS to a couple of deliveries. None of my patients complained of their obesity and my advice about weight loss was usually greeted with wry amusement. No so my timid enquiries about alcohol use patterns in the patients who arrived reeking and demanding a "sustificate"! All the chron. brons. with their Old Holborn rollups and their Ventolin and their repeated courses of Amoxil....

And after a few months, the cheery greetings at the shops - "Hullo Doctor!", "My Ern's much better, thanks", "Them aintibioticts you gave me fer me' cold worked a treat!" A strange and wonderful life. No practice managers, occupational therapists, podiatrists, practice nurses, physiotherapists or social workers, you were on your own.

Could an experienced practice nurse have dealt with all this? I suppose so, with enough training, but by then he/she would be not far off a medical qualification and presumably would command a commensurate salary. The doctor could then (his contact with most of his patients having been removed) get on with the business of practice management, strategic planning and education. The doctor has become an administrator and the nurse a doctor. What has been achieved?

Still, with the dreadful state of medical education in the UK (I get lots of UK exchange students) and the continued assault on the independence and reputation of doctors by the press and government (coupled with an influx of even more indifferently trained doctors from the ex-Soviet bloc) this might not be a bad thing.

"I'd agree that there is some "locus of control" within the patient themselves, but I don't really want to get into a victim blaming argument, suffice to say that the oppurtunities for me, as a middle class educated white man, are different than those afforded to my population."

Possibly, but this is an extraordinarily negative, disempowering and patronising statement

"I think we (the health care system), have to get away from what's best for us, as professionals,and concentrate on what's best for the patient."

Speak for yourself gingernut. The canard that doctors do not have their patient's best interests at heart and are only interested in feathering their own nests is a vicious lie propagated by those who would see medicine relegated to the abject condition that it was reduced to in the USSR. The results are plain to see.

"I'm afraid the argument that clinical accumen saves life is rather dated and not reflected by the available evidence."

This breathtaking pronouncement at one stroke annuls the entire basis of medical education. If clinical acumen is worthless then why bother to train clinicians (of any kind) at all? But I sense that the removal of clinical responsibilities from persons who have graduated from medical school (one can't really call then doctors anymore) is gingernut's aim.

This is probably a bit unfair, but here goes. Recently I operated a teenage boy from Somewhereovia who had complained of ankle pain after gymnastics practice. Physiotherapy and rest produced some relief and this was continued. After 10 weeks swelling was obvious, a doctor consulted and an X-ray done. This showed an extensive distal tibial osteosarcoma. Despite chemotherapy and surgery he now has disseminated disease and his prognosis is very poor. Would an earlier diagnosis have changed this? Maybe. What price clinical acumen now?

Ah well...

TheFlyingPhysio

17th Aug 2006, 22:01

I'm not quite sure why you are so resistant to the idea that physios and other paramedics may succumb to the temptation to step outside their sphere of competence. As I have tried to point out, none of us are immune to this.

Strange thing Mac is I am not resistant. Being a realist I know full well they do.

If you feel constrained by your role, why not study medicine?

Mac, I am not constrained in the least. I am self employed and very happy with my freedoms and professional challenges as a physio so there is no desire to study medicine. However, there is a great desire to aviate and that I am doing as well. Oh for a bit of surfing too !

This is probably a bit unfair, but here goes. Recently I operated a teenage boy from Somewhereovia who had complained of ankle pain after gymnastics practice. Physiotherapy and rest produced some relief and this was continued. After 10 weeks swelling was obvious, a doctor consulted and an X-ray done. This showed an extensive distal tibial osteosarcoma. Despite chemotherapy and surgery he now has disseminated disease and his prognosis is very poor. Would an earlier diagnosis have changed this? Maybe. What price clinical acumen now?

Mac, I would think the above is only unfair in that the boy has not been given a fighting chance for reasons best known to those who treated him. In that sense I share your frustration.

On a postive note, I am glad you have moved on from the Old Kent Road. I was worried by your desire to get your teeth into some rectal bleeding !!

Keep up the good work in your field. :ok:

slim_slag

18th Aug 2006, 09:06

Hmm, one wonders whether the GPs down the Old Kent Road would have known to send the kid off for an X-ray either. My recollection of that lot was a recorded message saying "The Surgery is closed, if you are sick call 999, if you are not then make your way to Guy's casualty", Some great pubs down there though, and once they knew you were from The Hospital extremely hospitable. The patient population were all salt of the earth. When you see the top heart surgeon in the country get called out of bed at 2am to fix an old docker's ticker at no cost to the patient, you realise how good the NHS can be. I think Thatcher later decided to shut his department down for a few months, he was doing too many operations and spending too much money.

Those who say specialists shouldn't have extensive medical training should sit in an outpatients clinic in an area where the GPs aren't too good. The referrel letter says "Dr Doctor, Please advise", and if the specialist didn't know a lot about medicine outside his speciality, the patient would never get a diagnosis.

That lot will have retired by now, and I am sure it's all changed for the better. I am sure Mac was a good one :)

Had a good friend die of osteosarcoma, surgeon too and he never caught it in time, thought his knee was sore from playing sport. Nasty thing to get, kills quickly and ibuprofen doesn't fix that sort of thing.

Mac the Knife

18th Aug 2006, 11:08

A noble reply TFP.

Peace

:ok:

rhovsquared

20th Aug 2006, 20:37

[QUOTE=Curious Pax]As Belfast Child mentions it could be Perthes - although 3 is young that is the age when my son was diagnosed with it. If it is that then young is good as they seem more likely to recover without intervention.
Perthes is where the ball at the top of the thigh bone that fits into the hip bone crumbles - sounds frightening at first, but the bone slowly grows back, and the child is monitored with x-rays to ensure that the new bone is developing with the correct shape. Diagnosis is also easy because an x-ray of the hip shows it clearly.

Legg Perth's on a plain film usually shows stippled epiphyses and has similar plain film findings to MED multiple epiphyseal dysplasia[sometime presents with mild retardation, but the phenotype is morbidly affected, also in the same Diff Diag category is Hurler's syndrome. ref. Harrold Rosenbaum's, 100 pearls in clinical diagnostic Radiology
sorry, no time now to read through, but from the first post I feel that your GP needs to look more carefully, and definitey enlist the assistance of both Pediatric ortho and neuro as a start. THIS MUST BE THOUROUGHLY INVESTIGATED FIRST!! b4 talking of factitious disorders

I'm not gonna add more[ I don't have enough info] and because this is a sensitive topic and I don't wish to speculate.

my heart goes out to the little miss, may all be well.

rhov :)

Re-entry

22nd Aug 2006, 10:25

Great thread. Why such erudite types as mac waste time posting on an aviation website defeats me.
But CC,a digression; did you know that cheetahs whistle? They sound like songbirds. Had some as 'passengers' once.
Hope the girl gets better.

DX Wombat

22nd Aug 2006, 10:36

Why such erudite types as mac waste time posting on an aviation website defeats me. Probably because, like myself, they want people to have the CORRECT facts and good advice, not some of the theories put forward by people who have absolutely no medical or nursing qualifications and whose advice may be, at its mildest, suspect and at its worst downright dangerous.:mad:
I hope the little girl is doing well and her problem has been properly diagnosed and treated by now.

cavortingcheetah

22nd Aug 2006, 11:58

:hmm:

A timely reminder that I have been remiss at posting an update on this thread. I have been quite astounded at the number of replies it has generated, at the depth of knowledge made available and at the concern of many of those who have posted, many thanks to all of you.
I understand that the little girl has now almost ceased to limp but that no one is any the wiser as to why she started doing so in the first place. As far as I can determine, at second hand; the GP has decided to adopt a watch and wait policy and that no X ray has been taken. I am not qualified to pronounce on the wisdom of this but the 'panic' would seem to be over, at least for the time being.
I should be seeing the prime grandparent sometime in the next few days and will post any appropriate update as it may come to my attention.
Again, many thanks to one and all. The input was most appreciated and I rather suspect that the poor old GP in question was somewhat rocked and shocked at the idea that there are people on the internet who actually do know what they are talking about. Perhaps as a consequence of this enlightenment; he will view my opinions with greater respect the next time I attempt to discuss some of the finer points of Septo-Hippocampal Dysfunction with him!;) :)