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Cullen's sign: a new association with central dislocation of the hip joint
280
Injury: the British Journal of Accident Surgery (1988) Vol. lS/No. 4
this potentially very unstable injury it would be wise to reduce this dislocation and hold it temporarily with percutaneous Kirschner wires. This should be done as early as possible before oedema makes it too difficult. As always, a compromise must then be sought between adequate immobilization to allow soft tissue healing and early mobilization to prevent stiffness. A period of 4 weeks’ immobilization proved sufficient in this case and would seem reasonable.
REFERENCES
DeLee J. (1981) Transverse divergent dislocation of the elbow in a child. J. Bone Joint Surg. 63A, 322. Rockwood C. A. and Green D. P. (1984) Fractures. Philadelphia, J. B. Lippincott Co. Warmont A. (1854) Luxation simultanee du cubitus en dedans et du radius en dehors, compliquee de fracture de Requests for reprints should be addressed to: T. B. McAuliffe
Fig. 2. Lateral radiograph
of the same patient.
l’avant bras. Mon. Hop., J. prog. med. chir prat., p. 961. Wight J. S. (1893) Dislocation of the bones of the right forearm backward, the radius being outward and the ulna being inward, and the head of the radius being dislocated from the base of the ulna. Phys. and Surg. 15, 67. Paper accepted 7 January 1988.
MA FRCS,
Royal National Orthopaedic Hospital, Brockley Way, Stanmore,
Middx.
Cullen’s sign: a new association with central dislocation of the hip joint R. D. Sayers and K. M. Porter Birmingham
Accident
Hospital
INTRODUCTION discoloration caused by haemorrhage is known eponymously as Cullen’s sign and was initially reported in association with ruptured ectopic pregnancy (Cullen, 1918), and subsequently in association with acute pancreatitis (Fallis, 1937). A similar discoloration in the flanks has been described in acute pancreatitis (Turner, 1920) and is known as Grey Turner’s sign. Cullen’s sign has also been reported in a few other conditions including hepatocellular carcinoma (Mabin and Gelfand, 1974), and after percutaneous liver biopsy (Capron et al., 1977). Cullen’s sign has not previously been reported in association with musculoskeletal injury. We report a new association of Cullen’s sign with central dislocation of the hip joint. PERIUMBILICAL
normal. His abdominal pain settled on a conservative regimen of restricted oral fluids, and his bruising resolved. The central dislocation of the hip joint was reduced satisfactorily under general anaesthetic and a Denham pin was inserted through the femoral condyles to allow skeletal traction. He remained on traction for 6 weeks and was then mobilized non-weight-bearing for a further 6 weeks.
DISCUSSION The most likely cause of this patient’s umbilical bruising was blood from a retroperitoneal haematoma secondary to his pelvic fracture, tracking through the tissue planes of his abdominal wall to reach the umbilicus. Retroperitoneal haematoma is a common complication of pelvic fractures because of the associated soft
CASE REPORT Following a fall a 79-year-old man complained of pain in his left hip region and an inability to bear weight. He was clinically shocked and required resuscitation with intravenous plasma expanders and blood. Radiographs revealed a central dislocation of his left hip joint (Fig. 1). He was treated initially with skin traction. Two days after admission he developed left iliac fossa pain and vomiting. Examination revealed a pulse rate of 90/min (atrial fibrillation) and a blood pressure of 130/90 mmHg. He was afebrile. There was extensive bruising over his left hip joint and periumbilical bruising (Cullen’s sign) (Fig. 2). His left iliac fossa was tender without guarding and his bowel sounds were quiet. A rectal examination was normal. Chest and abdominal radiographs were normal. Investigations revealed a haemoglobin of 12.1 g/d1 and a white cell count of 8.0~10”/1. The serum urea, electrolytes and amylase were normal. Examination of the urine was 0 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/04028C42
$0340
Fig. 1. Radiograph of the pelvis showing central dislocation of the left hip joint.
Case reports
281
tissue injury to the highly vascular pelvic venous plexus. Hypovolaemic shock, abdominal pain and paralytic ileus are common sequelae. It is unlikely that this patient had any other important intra-abdominal pathology because his white cell count, amylase, urinalysis and radiographs were normal. To our knowledge Cullen’s sign has not previously been reported in association with musculoskeletal injury. However, it must be remembered that Cullen’s sign is classically associated with acute pancreatitis and ruptured ectopic pregnancy and is not a common feature of pelvic fractures.
Fig. 2. Photograph
of patient’s umbilicus
showing Cullen’s
sign. REFERENCES
Capron J. P., Chivvac D., Delamore J. et al. (1977) Cullen’s sign after percutaneous
liver biopsy (letter). Gastroenterol-
ogy 73, 1185.
Cullen T. S. (1918) A new sign in ruptured extra-uterine pregnancy. Am. J. Obstet. Dis. Worn. 78, 457. Fallis L. S. (1937) Cullen’s sign in acute pancreatitis. Ann. Surg. 106, 54.
Mabin T. A. and Gelfand M. (1974) Cullen’s sign, a feature in liver disease. Br. Med. J. 1, 493. Turner G. G. (1920) Local discolouration of the abdominal wall as a sign of acute pancreatitis. Br. J. Surg. 7. 394. Paper accepted 7 January 1988.
Reyue.stsfor reprints should he addressed to: Dr R. D. Sayers, Birmingham Accident Hospital, Bath Row, Birmingham BIS 1NA
Vertical intercondylar
dislocation of ‘the patella
P. D. Rollinson Royal Surrey County
Hospital,
Guildford
CASE REPORT An l&year-old male was tackled and knocked to the ground whilst playing soccer. He felt something displace in his right knee and was unable to stand or walk. The patella had dislocated laterally in the same knee 1 year before, and this had been easily reduced in the accident and emergency department. This time, examination revealed a prominent swelling of the right knee, which was confirmed by palpation to be the patella lying vertically in the intercondylar groove (Fig. 1). It was initially difficult to ascertain in which direction the patella had rotated on its vertical axis, but careful palpation showed that the articular surface was facing laterally. A V-shaped split was felt in the lateral retinacular fibres adjacent to the superolateral quadrant of the patella. The knee was held in extension and no flexion was possible. Radiographs confirmed the clinical findings (Fig. 2). Attempts at closed reduction, firstly under 1Omg of intravenous diazepam (Diazemuls) and then under a general anaesthetic in theatre. were unsuccessful. An open reduction was performed through an anterolateral approach. The Vshaped split in the lateral retinacular fibres was enlarged, the synovium incised, and a bone spike was positioned under the medial edge of the patella. The patella was successfully reduced by hyperextending the knee and using the bone spike to rotate the patella. The incision was closed in layers and a well padded plaster cylinder applied. Quadriceps exercises were started postoperatively days later. The cast was
physiotherapy @ 1988 Butterworth & Co (Publishers) Ltd $0340
and the
DISCUSSION Whilst lateral dislocation of the patella is common, other types of patella dislocations are unusual. Intraarticular dislocation occurs when the patella lies horizontally between the femoral and tibia1 condyles (Brady and Russell, 1965). The patella is superiorly dislocated when it is displaced upwards and maintained
and the patient was discharged 2
removed at 4 weeks and with the knee had a full range of movement at 8
0020-1383/88/040281-02
weeks. After 3 months, the knee was asymptomatic. patient had returned to playing soccer.
Fig. 1. Patella rotated through 90” and lying vertically in the intercondylar groove.
Injury: the British Journal of Accident Surgery (1988) Vol. lS/No. 4
this potentially very unstable injury it would be wise to reduce this dislocation and hold it temporarily with percutaneous Kirschner wires. This should be done as early as possible before oedema makes it too difficult. As always, a compromise must then be sought between adequate immobilization to allow soft tissue healing and early mobilization to prevent stiffness. A period of 4 weeks’ immobilization proved sufficient in this case and would seem reasonable.
REFERENCES
DeLee J. (1981) Transverse divergent dislocation of the elbow in a child. J. Bone Joint Surg. 63A, 322. Rockwood C. A. and Green D. P. (1984) Fractures. Philadelphia, J. B. Lippincott Co. Warmont A. (1854) Luxation simultanee du cubitus en dedans et du radius en dehors, compliquee de fracture de Requests for reprints should be addressed to: T. B. McAuliffe
Fig. 2. Lateral radiograph
of the same patient.
l’avant bras. Mon. Hop., J. prog. med. chir prat., p. 961. Wight J. S. (1893) Dislocation of the bones of the right forearm backward, the radius being outward and the ulna being inward, and the head of the radius being dislocated from the base of the ulna. Phys. and Surg. 15, 67. Paper accepted 7 January 1988.
MA FRCS,
Royal National Orthopaedic Hospital, Brockley Way, Stanmore,
Middx.
Cullen’s sign: a new association with central dislocation of the hip joint R. D. Sayers and K. M. Porter Birmingham
Accident
Hospital
INTRODUCTION discoloration caused by haemorrhage is known eponymously as Cullen’s sign and was initially reported in association with ruptured ectopic pregnancy (Cullen, 1918), and subsequently in association with acute pancreatitis (Fallis, 1937). A similar discoloration in the flanks has been described in acute pancreatitis (Turner, 1920) and is known as Grey Turner’s sign. Cullen’s sign has also been reported in a few other conditions including hepatocellular carcinoma (Mabin and Gelfand, 1974), and after percutaneous liver biopsy (Capron et al., 1977). Cullen’s sign has not previously been reported in association with musculoskeletal injury. We report a new association of Cullen’s sign with central dislocation of the hip joint. PERIUMBILICAL
normal. His abdominal pain settled on a conservative regimen of restricted oral fluids, and his bruising resolved. The central dislocation of the hip joint was reduced satisfactorily under general anaesthetic and a Denham pin was inserted through the femoral condyles to allow skeletal traction. He remained on traction for 6 weeks and was then mobilized non-weight-bearing for a further 6 weeks.
DISCUSSION The most likely cause of this patient’s umbilical bruising was blood from a retroperitoneal haematoma secondary to his pelvic fracture, tracking through the tissue planes of his abdominal wall to reach the umbilicus. Retroperitoneal haematoma is a common complication of pelvic fractures because of the associated soft
CASE REPORT Following a fall a 79-year-old man complained of pain in his left hip region and an inability to bear weight. He was clinically shocked and required resuscitation with intravenous plasma expanders and blood. Radiographs revealed a central dislocation of his left hip joint (Fig. 1). He was treated initially with skin traction. Two days after admission he developed left iliac fossa pain and vomiting. Examination revealed a pulse rate of 90/min (atrial fibrillation) and a blood pressure of 130/90 mmHg. He was afebrile. There was extensive bruising over his left hip joint and periumbilical bruising (Cullen’s sign) (Fig. 2). His left iliac fossa was tender without guarding and his bowel sounds were quiet. A rectal examination was normal. Chest and abdominal radiographs were normal. Investigations revealed a haemoglobin of 12.1 g/d1 and a white cell count of 8.0~10”/1. The serum urea, electrolytes and amylase were normal. Examination of the urine was 0 1988 Butterworth & Co (Publishers) Ltd 0020-1383/88/04028C42
$0340
Fig. 1. Radiograph of the pelvis showing central dislocation of the left hip joint.
Case reports
281
tissue injury to the highly vascular pelvic venous plexus. Hypovolaemic shock, abdominal pain and paralytic ileus are common sequelae. It is unlikely that this patient had any other important intra-abdominal pathology because his white cell count, amylase, urinalysis and radiographs were normal. To our knowledge Cullen’s sign has not previously been reported in association with musculoskeletal injury. However, it must be remembered that Cullen’s sign is classically associated with acute pancreatitis and ruptured ectopic pregnancy and is not a common feature of pelvic fractures.
Fig. 2. Photograph
of patient’s umbilicus
showing Cullen’s
sign. REFERENCES
Capron J. P., Chivvac D., Delamore J. et al. (1977) Cullen’s sign after percutaneous
liver biopsy (letter). Gastroenterol-
ogy 73, 1185.
Cullen T. S. (1918) A new sign in ruptured extra-uterine pregnancy. Am. J. Obstet. Dis. Worn. 78, 457. Fallis L. S. (1937) Cullen’s sign in acute pancreatitis. Ann. Surg. 106, 54.
Mabin T. A. and Gelfand M. (1974) Cullen’s sign, a feature in liver disease. Br. Med. J. 1, 493. Turner G. G. (1920) Local discolouration of the abdominal wall as a sign of acute pancreatitis. Br. J. Surg. 7. 394. Paper accepted 7 January 1988.
Reyue.stsfor reprints should he addressed to: Dr R. D. Sayers, Birmingham Accident Hospital, Bath Row, Birmingham BIS 1NA
Vertical intercondylar
dislocation of ‘the patella
P. D. Rollinson Royal Surrey County
Hospital,
Guildford
CASE REPORT An l&year-old male was tackled and knocked to the ground whilst playing soccer. He felt something displace in his right knee and was unable to stand or walk. The patella had dislocated laterally in the same knee 1 year before, and this had been easily reduced in the accident and emergency department. This time, examination revealed a prominent swelling of the right knee, which was confirmed by palpation to be the patella lying vertically in the intercondylar groove (Fig. 1). It was initially difficult to ascertain in which direction the patella had rotated on its vertical axis, but careful palpation showed that the articular surface was facing laterally. A V-shaped split was felt in the lateral retinacular fibres adjacent to the superolateral quadrant of the patella. The knee was held in extension and no flexion was possible. Radiographs confirmed the clinical findings (Fig. 2). Attempts at closed reduction, firstly under 1Omg of intravenous diazepam (Diazemuls) and then under a general anaesthetic in theatre. were unsuccessful. An open reduction was performed through an anterolateral approach. The Vshaped split in the lateral retinacular fibres was enlarged, the synovium incised, and a bone spike was positioned under the medial edge of the patella. The patella was successfully reduced by hyperextending the knee and using the bone spike to rotate the patella. The incision was closed in layers and a well padded plaster cylinder applied. Quadriceps exercises were started postoperatively days later. The cast was
physiotherapy @ 1988 Butterworth & Co (Publishers) Ltd $0340
and the
DISCUSSION Whilst lateral dislocation of the patella is common, other types of patella dislocations are unusual. Intraarticular dislocation occurs when the patella lies horizontally between the femoral and tibia1 condyles (Brady and Russell, 1965). The patella is superiorly dislocated when it is displaced upwards and maintained
and the patient was discharged 2
removed at 4 weeks and with the knee had a full range of movement at 8
0020-1383/88/040281-02
weeks. After 3 months, the knee was asymptomatic. patient had returned to playing soccer.
Fig. 1. Patella rotated through 90” and lying vertically in the intercondylar groove.