|Year : 1989 | Volume
| Issue : 4 | Page : 232-4
An unusual case of hip disability--(a case report).
PB Bhosale, RS Dhir, NC Tejwani
P B Bhosale
An unusual case of postero-superior periarticular irritation of the hip joint of six months«SQ» duration due to an extension of a pre-sacral foreign body granuloma in an 18 year old unmarried girl is presented. Two wooden sticks which probably were inserted pervaginally by a village midwife to induce an abortion for an unwanted pregnancy had found its way to presacral region. The scanning of the vaginal fornix indicated a possible route through which the sticks might have been migrated.
|How to cite this article:|
Bhosale P B, Dhir R S, Tejwani N C. An unusual case of hip disability--(a case report). J Postgrad Med 1989;35:232-4
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Bhosale P B, Dhir R S, Tejwani N C. An unusual case of hip disability--(a case report). J Postgrad Med [serial online] 1989 [cited 2022 Jun 28 ];35:232-4
Available from: https://www.jpgmonline.com/text.asp?1989/35/4/232/5673
A case history of a female patient seeking advice for progressive disability of hip joint is presented in this article. The followup investigations and surgical findings, explaining the hip pathology are discussed.
An 18 year old unmarried female from countryside was admitted to S.D.B. Orthopaedic Centre and Research Institute, K.E.M. Hospital, Bombay, with increasing pain of the left hip causing progressive limp while walking and difficulty in squatting of six months' duration. There was no fever or any loss of weight and there was no history of injury. However four years ago, she was treated for pulmonary tuberculosis with chemotherapy for almost eighteen months, during which she had received a total of ninety intramuscular injections of streptomycin out of which some score were given in the left gluteal region. Subsequently, she had no disability until the present problem started. She did not volunteer any other in formation which could be correlated with the present illness.
On examination, she was a fairly built and nourished young girl with normally developed secondary sexual characteristics, and her vital parameters were within normal limits. Local examination of the left hip revealed a generalised fullness in the gluteal region with no sinuses, healed or active, or dimpling of the overlying skin. There was diffuse tenderness over the posterior aspect of the hip joint, but no increases in local warmth. The bony prominences around the hip bore their customary relationship to one another. An external rotation deformity of 20° in. the fully extended hip was the only fixed deformity present. Abduction and further external rotation were free and full, but any attempt at correcting the external rotation deformity and at adduction beyond 50° was restricted by spasm. Flexion of the hip in the neutral position was painfully restricted beyond 50° but with simultaneous abduction of the hip, the free and painless range of flexion improved to 100°. Any attempt at adduction and internal rotation of such flexed hip was quite painful and actively prevented by the patient. Squatting was uncomfortable and asymmetrical as the left hip flexed in abduction and external rotation, making the left knee protude out more than the right. Examination of the other hip and the spine showed no abnormality.
A roentgenogram of the pelvis with both hips did not reveal any abnormality. ESR was only 15 mm/1st hour by Westergren method, and blood counts were within normal limits. Based or, this data, a diagnosis of an extra-articular painful condition of the left hip was made, with a spectrum of possibilities including an antibioma, a fibromatosis, a haemangioma or an organising abscess involving the posterior superior capsule of the hip joint kept in mind.
The patient was taken up for surgical exploration; under general anaesthesia, she had a full range of passive movements of the left hip. The left gluteal region was exposed by Moore's posterior approach, which was proximally extended. The gluteus maximum was split in the direction of its fibres to reveal the short external rotators of the hip with its overlying fatty tissue, both of which were normal. The pyriformis was identified as it coursed out of the greater sciatic notch en route to its insertion at the greater trochanter, and upon retracting it inferiorly, a bluish red fleshy mass lying transversely over the posterior capsule and extending laterally upto the midcervical region came into view [Fig. 1]. The mass was easily separable from the capsule and the pyriformis muscle, and was found to extend into the pelvis through the greater sciatic foramen in a plane anterior to the sacrum and the pirifomis muscle. As the extrapelvis portion of the mass was excised, we discovered to our surprise, the pointed ends of a pair of wooden sticks peering out of the greater sciatic foramen. The sticks were lying transversely encased in the fleshy mass [Fig. 2]in the presacral region. Both the sticks could be easily delivered out [Fig. 2]and [Fig. 3] . These sticks were similar to the abortion sticks used by the midwives of the rural India to dilate the cervix in a bid to terminate an unwanted pregnancy. At this point, a per rectal examination was done to confirm that there were no more such sticks in the pelvis. The presacral cavity which contained the sticks was lavaged with dilute betadine solution and the wound was closed in layers without attempting removal of the intrapelvic extension of the fleshy mass. Post-operatively, the patient was kept on oral antibiotics for ten days, and was allowed out of bed in a couple of days. The wound healed primarily and sutures were removed after a fortnight. Her hip movements gradually improved and attained near normalcy in six weeks' time. Histopathological examination of the fleshy mass showed changes consistent with a foreign body granuloma.
Upon retrospective interrogation, the patient and her relatives admitted to having sought to terminate an unwanted pregnancy of four months' duration, one and a half years ago. The abortion was successfully induced by a. local village midwife, after which the patient was asymptomatic until the present problem started. They were ignorant of the procedure adopted for inducing the abortion and had no knowledge of any stick being left behind inside the uterus; and it was not possible to contact the midwife of her village to confirm the fact. Gynaecological examination of the patient prior to discharge showed no abnormality barring well healed scars of old tears of the cervix and left vaginal fornix.
Intrapelvic pathology is known to affect the hip function either by involving the acetabular floor directly or by extension of the lesion to the periarticular tissues along any of the existing tissue planes through various foramina. The foreign body granuloma of the presacral region in our case had extended through one of the greater sciatic foramen along the pyriformis muscle to affect the posterior periarticular tissues of the left hip joint.
On enquiring senior obstetricians and some of the midwives from the countryside, we learnt that the application of such sticks is a common mode of inducing an abortion in rural India. These sticks are prepared locally out of a thin bamboo stem. Two or three such sticks are used by pervaginal route to dilate the cervix to an adequate size and are left behind to be thrown out with the products of conception. The abortion often takes place within 48 hours of inserting of the sticks.
How did the sticks used to induce abortion in our case find their way through a vaginal tear to assume a presacral position, why did they not cause sepsis and what made them induce a hip pathology after a year long period of quiescence are questions to which answers are not readily forthcoming and require to be conjectured. This case is presented to record such a possibility which should be kept in mind.
We thank the Dean, Dr. G. B. Parulkar, K.E.M. Hospital, and Seth G.S. Medical College, Bombay for allowing us to publish this case.