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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 42-44

Open pathological dislocation of the hip secondary to trochanteric decubitus ulcer


1 Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2 Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria

Date of Web Publication7-Apr-2014

Correspondence Address:
Chima C Ihegihu
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra
Nigeria
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DOI: 10.4103/1119-0388.130183

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  Abstract 

This is a case report of a 30-year-old male hand digging manual borehole driller who became quadriplegic as a result of a complete cervical cord injury at the level of C5. He subsequently developed a trochanteric decubitus ulcer through which the head of the femur dislocated; a rare and unusual complication which has not been previously described in adult quadriplegics.

Keywords: Decubitus ulcer, dislocation, open, pathological, quadriplegic


How to cite this article:
Ihegihu CC, Ihegihu EY. Open pathological dislocation of the hip secondary to trochanteric decubitus ulcer. Trop J Med Res 2014;17:42-4

How to cite this URL:
Ihegihu CC, Ihegihu EY. Open pathological dislocation of the hip secondary to trochanteric decubitus ulcer. Trop J Med Res [serial online] 2014 [cited 2019 Mar 20];17:42-4. Available from: http://www.tjmrjournal.org/text.asp?2014/17/1/42/130183


  Introduction Top


Pathological dislocation of the hip can be congenital when there is malformation or deformity of the joint like in developmental dysplasia of the hip. [1] More often than not pathological dislocation of the hip joint is acquired. This can occur when there is disease of the hip joint in the form of infection, [2] metastasis, [3] when there is paralysis of the muscles of the hip joint in multiple sclerosis, [4] spinal cord injury, [5] and neurofibromatosis type 1. [6] Open pathological hip dislocation in which the joint is exposed and communicates with the environment through a decubitus ulcer is a rare and unusual complication which has not been previously reported in adult quadriplegics. Decubitus ulcers occur as a result of excessive pressure, primarily over the bony prominences of the buttock particularly the sacral, trochanteric and ischial regions. [7] Other areas of the body that can be affected are the ankles, heels, occiput, and over the scapulae. The incidence can be as high as 0.42-1.49% of orthopedic patients hospitalized each year. [8] Despite increased awareness and use of preventive measures, these ulcers remain a major concern in the hospitalized and immobile patient population.


  Case Report Top


A 30-year-old male, who was a hand digging manual borehole driller presented to Loveworld Specialist Hospital, a private orthopedic hospital located in Nnewi with a 10 months history of neck injury, inability to move or feel both upper and lower limbs. The bucket used for emptying sand from the borehole filled with sand, landed on the back of his neck when the rope used for lifting it out of the borehole snapped about 30 m from the bottom of the borehole. He felt a sharp pain at the site of impact on the neck, slumped, and noticed he could neither move nor feel both upper and lower limbs. There was no history of loss of consciousness and no other immediate associated symptoms. He was extricated and transported to a private hospital. At the hospital, investigations were carried out including plain radiograph of the cervical spine [Figure 1]. He was admitted, commenced on medication, and catheterized. His neck was immobilized in a rigid cervical collar. After about 6 weeks at the private hospital, the patient developed decubitus ulcers over both trochanters and the sacrum. The ulcers were dressed daily and at various times were debrided, but the ulcers progressively increased in size. The relatives demanded for discharge after 10 months in the hospital without any obvious improvement and referred to Loveworld Specialist Hospital.
Figure 1: Cervical spine

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On examination at presentation, the patient was cachetic, pale, severely dehydrated, febrile, and quadriplegic with the upper limbs completely immobile by the sides. There were multiple decubitus ulcers over the trochanters, sacrum, the chest wall, and both heels discharging foul smelling pus. The floor of the ulcers was covered with necrotic tissues and their edges were sloping. The ulcer over the right greater trochanter was extensive and deep exposing the dislocated head of the right femur [Figure 2]. There was severe generalized muscle wasting, spastic paralysis, and hypertonia of both upper and lower limb muscles. The deep tendon reflexes were exaggerated; there was clonus and extensor plantar reflex. Anal and bulbocavernosus reflexes were present, but there was loss of sensation below C5 bilaterally with respect to all modalities. There was reduced air entry in both lungs with bilateral basal crepitations. A Foleys catheter was in situ draining purulent urine. A diagnosis of complete cervical cord injury at the level of C5, complicated by multiple decubitus ulcers and severe sepsis was made. Plain radiograph of the pelvis and hip showed posterior dislocation of the right hip [Figure 3].
Figure 2: Dislocated head of the right femur

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Figure 3: Posterior dislocation of the right hip

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  Discussion Top


Despite increased awareness, decubitus ulcers remain a major orthopedic complication in the hospitalized immobile patient population. Preventive care includes use of assessment tools to identify high risk patients, frequent repositioning, water, air or foam mattresses that reduce pressure over bony prominences, special beds that can be manipulated without moving the patient to reduce pressure over bony prominences as well as careful attention to optimize the overall patient condition. Complications associated with pressure ulcers can be life-threatening and include infection, necrotizing fasciitis, Marjolin's ulcer, and even death. Open dislocation of the hip joint associated with trochanteric decubitus ulcer is a rare occurrence which we did not come across in our search through the literature, hence the need to report it. In trochanteric decubitus ulcers exposing the hip joint not amenable to nonsurgical treatment, the major orthopedic procedures that can be carried out include; proximal femoral resection (Girdlestone arthroplasty), [9] hip disarticulation, and hemipelvectomy. [10]

 
  References Top

1.Morin C, Wicart P. French Society of Pediatric Orthopaedics. Congenital dislocation of the hip, with late diagnosis after 1 year of age: Update and management. Orthop Traumatol Surg Res 2012;98:S154-8.  Back to cited text no. 1
    
2.Tahasildar N, Sudesh P, Tripathy SK, Shashidhar BK. Bilateral pathological dislocation of the hip secondary to tuberculous arthritis following disseminated tuberculosis: A case report and review of the literature. J Pediatr Orthop B 2012;21:567-73.  Back to cited text no. 2
    
3.Hoshi M, Taguchi S, Takada J, Oebisu N, Nakamura H, Takami M. Palliative surgery for acetabular metastasis with pathological central dislocation of the hip joint after radiation therapy: A case report. Jpn J Clin Oncol 2012;42:757-60.  Back to cited text no. 3
    
4.Schneider M, Krug AJ. Dislocation of the hip secondary to trochanteric decubitus ulcer, a complication of multiple sclerosis. J Bone Joint Surg 1960;42:1165-9.  Back to cited text no. 4
    
5.Graham GP, Dent CM, Evans PD, McKibbin B. Recurrent dislocation of the hip in adult paraplegics. Paraplegia 1992;30:587-91.  Back to cited text no. 5
    
6.Lampasi M, Greggi T, Sudanese A. Pathological dislocation of the hip in neurofibromatosis: A case report. Chir Organi Mov 2008;91:163-6.  Back to cited text no. 6
    
7.Iyun AO, Malomo AO, Oluwatosin OM, Ademola SA, Shokunbi MT. Pattern of presentation of pressure ulcers in traumatic spinal cord injured patients in University College Hospital, Ibadan. Int Wound J 2012;9:206-13.  Back to cited text no. 7
    
8.Gajda T, Kuk E, GaŸdzik TS. An integrated system for the management of decubitus ulcers. Ortop Traumatol Rehabil 2005;7:72-8.  Back to cited text no. 8
    
9.Rubayi S, Pompan D, Garland D. Proximal femoral resection and myocutaneous flap for treatment of pressure ulcers in spinal injury patients. Ann Plast Surg 1991;27:132-8.  Back to cited text no. 9
    
10.Chan JW, Virgo KS, Johnson FE. Hemipelvectomy for severe decubitus ulcers in patients with previous spinal cord injury. Am J Surg 2003;185:69-73.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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