Failure to timely diagnose Hip Dysplasia in infant resulting in need for surgical intervention.

The correct diagnostic test was ordered and the diagnostic information was missed, and therefore not relayed to the patient's parent in a timely manner. Incorrectly reading a diagnostic report from a test ordered is a fairly clear example of medical error.

A Pavlik harness can be used to treat developmental hip dysplasia in many cases avoiding the need for invasive surgery. This would have been able to be initiated earlier in the child's life had the condition been diagnosed before 6 months of age. While case reports do discuss that Pavlik harness treatment can be successful in late diagnosed cases, that is usually only in milder cases of DDH. We do not know the exact severity of this patient's DDH, because we do not have the specific measurements and full radiographic reports. The patient was only 3 months old at the time of ultrasound and this would have been amply time to attempt treatment with a harness. However, without the exact Tonnis measurements and radiographic reports, it is not possible to state with 100% certainty that the error caused injury. But it seems likely, given that surgery was later indicated by a reputable pediatric orthopedic surgeon, that it did.

The pediatrician demonstrated neglect by not carefully reviewing the report, which was flagged for hip dysplasia. The pediatrician did not review the report again, obtain follow up, or request a consultation despite the parent concerns regarding mobility. Finally, though the pediatrician apologized for the error, the statement that the timing of diagnosis did not matter is untrue.

Though impossible to predict the outcome of treatment for hip dysplasia with 100% accuracy, early treatment with the Pavlik method is highly successful. This method can only be used up to 6 months of age. Without details of the ultrasound, I cannot be sure how severe the dysplasia was initially and whether or not the hip was dislocated and reducible. Increased severity and an irreducible hip could confer a lower success rate of initial treatment with the Pavlik method. Of course, since the hip was left untreated, the need for surgical intervention, particularly at the age of around 14 months, is almost guaranteed. As such, it is extremely likely that not getting timely treatment could have led to the outcome of surgical intervention. Further details of the ultrasound would allow me to speak with more certainty.

There was medical error, though unclear if negligence. The radiology report demonstrated that there was hip dysplasia, hence a referral to pediatric orthopaedic surgery was needed earlier than later. However, it is possible that radiology reports sometimes have preliminary reads. It is difficult to ascertain why a physician reviewing a report would consider it normal when typically the reports are very binary (dysplastic, or non-dysplastic)

It is true that the earlier hip dysplasia is caught, the easier it is to treat with less invasive methods. However, these less invasive methods sometimes fail and require escalate to more aggressive (ie: hip spica cast or surgery) methods.

There are a few questions that need to be addressed to determine if a medical error was made. Based on information provided, there are a lot of details missing to know if error has been made. 1. Hip dysplasia is an umbrella term, a hip dislocation or subluxation is the most severe form of hip dysplasia. Mild forms of hip dysplasia can be identified on ultrasound, but if there was truly a hip dislocation, it is concerning that this was not obviously called out as a critical result by both the interpreting radiologist as well as the pediatrician. 2. If a hip dislocation was present on ultrasound, often a physical exam would also be abnormal. It would be helpful to know what was documented with respect to the physical exam and specifically Otolani, Barlow, and Geleazzi signs? 3. Was surgery by Dr. S done for a hip dislocation or residual hip dysplasia? It makes a big difference what surgery was done and specifically, what the radiograph showed when obtained in November. 4. Other braces can be used after 6 months of age. Unclear if patient had a hip dislocation that was clinically reducible or just shallow hip socket. 5. Gross motor delays are rarely, if ever (especially at the ages referenced here) related directly to hip dysplasia. Gross motor delays/syndromes can however be associated with hip dysplasia if child is not showing appropriate motor development, it is common for hips to be delayed in maturation. **If the term hip dysplasia is referencing a "hip dislocation" above, then the answer is closer to "extremely likely" or "definitely yes".

Based on somewhat limited information available and lack of imaging to review, it is difficult to know the answer. More data is necessary to discern this answer. There are no guarantees a brace would have worked for a dislocated hip, with effectiveness probably between 60-80%. Surgery may still have been necessary. If hip was located in the joint, but simply dysplastic, it would have a higher likelihood of success, but again depends on the child and reason for hip dysplasia. If this is a child with significant motor delays, it may not be successful, for example. Even hips treated with a brace can still have dysplasia down the road, so surgery may still have been needed. The question of if the error resulted in an injury - ie, harm, to the child is harder to answer at this time. They could have an excellent clinical outcome with surgery. Yes, it was delayed in terms of diagnosis, but outcome could be excellent and thus harm may be nonexistent. Again, need to know the details of the imaging to understand and determine whether causation is present, as some children have surgery for residual dysplasia at this age that may have been there regardless of the ultrasound result, especially in a breech infant, where this is known to occur with higher frequency.

Dr. M correctly identified that breech presentation is a major risk factor for hip dysplasia, and correctly ordered an ultrasound of the hips. It is important to identify whether this ultrasound was performed at an institution that routinely performs baby hip ultrasounds, as the technique is often provider dependent. Imaging utility may be limited due to quality of the imaging. Nevertheless, the American Academy of Orthopedic Surgeons guidelines for hip dysplasia recommends a follow up x-ray to screen for residual dysplasia at 6 months of age. X-rays are recommended even if the initial ultrasound is normal. From a surveillance standpoint for hip dysplasia, no follow up imaging appears to have been performed based on information provided. This likely delayed the diagnosis of hip dysplasia. . It is important to note that hip dysplasia has not been found to delay motor milestones, and even patients with dislocated hips or patients undergoing bracing for hip dysplasia often continue to develop appropriately if otherwise normal (nonsyndromic, full term, etc). Upon evaluation with Dr. S, the treatment protocol depends on the degree of dysplasia appreciated. If the hip were dislocated, for example, then the appropriate treatment after 6 months of age would be a closed vs. open reduction of the hip. This would require anesthesia and a spica cast, as bracing would likely not lead to reduction of the hip. As Dr. S mentioned, however, in retrospect full review of the ultrasound may have identified this issue earlier, depending on the quality of the imaging. Based on Dr. M admitting that this was missed on their part, this appears to be consistent with a delayed diagnosis of hip dysplasia. As a result, conservative management strategies would need to be bypassed, resulting in operative intervention.

Information provided suggests that the initial ultrasound report identified hip dysplasia, but treatment was delayed.