Limping Grand daughter.

[Flyin'Dutch']

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]

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]

Originally Posted by Flyin'Dutch'

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!

[gingernut]

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]

"..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]

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.

[Mac the Knife]

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]

!

[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 !"

[/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]

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]

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]

"...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]

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]

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]

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]

"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]

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]

Originally Posted by gingernut

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]

Originally Posted by gingernut

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]

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 ). 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]

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!