We present a case of isolated intra-acetabular osteochondroma in a 21 year-old male who presented with history of right hip pain for 5 years and difficulty in walking. Patient was managed with excision of intra-articular exostoses through surgical hip dislocation. Intra-articular hip osteochondromas can be a rare cause of hip pain in patients with unexplained etiology, and their diagnosis and management can be challenging.
We report a rare case of a young man with hereditary multiple exostoses (HME) who presented with severe pain in the hips, requiring bilateral total hip arthroplasty (THA), along with excision of the exostoses. The reported incidence of exostoses around the hip has been reported from 30% in some series to 90% in other studies of HME. These patients may remain asymptomatic, but if not, their symptoms are usually related to the presence of the exostoses itself and the possibility of hip osteoarthrosis is frequently overlooked. This may account for a low incidence of THA for this condition. Surgical management often remains challenging as such lesions are not commonly encountered in the clinical practice and are often very difficult to treat.
SummaryThe authors present a case of splenic artery aneurysm rupture, which neatly illustrates some of the problems of modern medical practice and the potential detriment of blind adherence to protocol driven care, without adequate reflection on the whole clinical picture and possible alternative diagnoses. CASE PRESENTATIONA 25-year-old primigravida presented in labour at 38 weeks gestation after an uncomplicated pregnancy. Labour progressed uneventfully culminating in the birth of a healthy baby boy with minimal peripartum blood loss. Three hours postpartum (2300) she collapsed in the corridor and her observations revealed that she was hypotensive with a sinus tachycardia. The on-call obstetric resident prescribed 1 litre of crystalloid and a full blood count was requested. The haemoglobin (Hb) was 7.9 g/dl. Her predelivery Hb was 11.9 g/dl. This drop in Hb was thought to be due to haemodilution and possible broad ligament haematoma.At 0300, the obstetric resident was recontacted since the patient had severe upper abdominal pain, exacerbated by movement alongside right and left upper chest and shouldertip pain. She was dyspnoeic and her oxygen saturations were low and an arterial blood gas sample revealed a PaO2 of 7 kilo Pascal's (kPa). As per departmental protocol based on Royal College of Obstetricians and Gynaecologists (RCOG) guidelines, oxygen and Enoxaparin 1.5 mg/kg were administered to treat a suspected pulmonary embolism.At 0800 during labour ward rounds, the obstetric consultant performed a pelvic ultrasound scan which revealed only a 2 cm by 2 cm broad ligament haematoma. As she remained hypotensive and tachycardic with upper abdominal pain, an urgent departmental abdominal and a pelvic ultrasound was requested. The ultrasound scan showed free fluid in the pouch of Douglas with some right adnexal collection which measured 14×7×11 cm with low echo levels. A moderate amount of free fluid was seen within the peritoneal cavity and the spleen appeared slightly enlarged at 12.5 cm.Soon after the ultrasound the patient became haemodynamically unstable with a feeble pulse and unrecordable blood pressure. She was rushed to theatre and an emergency laparotomy performed. Two litres of fresh blood with copious clots were found in the abdominal cavity. No gynaecological cause was identified, however, an aneurysmal splenic artery was found to be actively bleeding at the splenic hilum with surrounding clots. The on-call surgical team was contacted and a splenectomy was performed after achieving haemostasis. She received a massive transfusion. In total, 26 units of blood, 4 pools of platelets and 1500 ml of fresh frozen plasma were required to resuscitate the patient and the patient was transferred to the intensive care unit (ITU).She developed disseminated intravascular coagulation postoperatively. She dropped her Hb during the early postoperative period from 14.7 to 8.7 g/dl within a few hours. A second look laparotomy revealed a large retroperitoneal haematoma which was evacuated, but no obvious fresh bleeding ...
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