HIP JOINT ARTHRITIS PRESENTING 20 YEARS AFTER AN EXTENSIVE CHILDHOOD BURN

By KENNETH TAYLOR, F.R.C.S.l Department of Surgery, Western Injirmary, Glasgow

WHEN the nightgown of an S-year-old schoolgirl caught fire in December 1951 she received extensive burns of her trunk, chest and neck. The total area involved was between 60 and 70 per cent of which the whole of the upper thighs, groins, abdominal wall and lower anterior chest was full-thickness skin loss.

She survived the initial period of shock and was later transferred to the care of Mr Tom Gibson for skin grafting. She had a number of skin-grafting procedures including the application of homografts from her father. Almost 4 months elapsed from the time of injury until the burned area was healed sufliciently well to allow her up. During this period Mr Gibson recalls this distressed child lying in a foetal position with hips and knees acutely flexed. No amount of cajoling would persuade her to extend them and in the end light extension traction had to be applied to the unburned lower legs. Even when she began to walk there was still a slight flexion contracture in the right groin (Fig. I) which was subsequently fully released by inserting a split skin graft.

FIG. I. Virtually healed 5 months after burning. The contracture of the right hip was fully corrected by inserting a skin graft and was therefore due entirely to skin shortage.

Over the years she had many plastic surgical procedures to her groins, vulva, breasts and neck. In 1971,zo years after her injury and now aged 28, she was referred to a general surgical clinic complaining of right groin pain of sudden onset, associated with the appearance of a lump just below the right groin crease. Because of the dis- comfort, she had begun to limp. Examination revealed the presence of a hard, smooth, tender lump, 19 inches in diameter, lying in the right groin just lateral to the femoral vessels. There was considerable limitation in right hip movements because of pain.

Under general anaesthesia the lump was explored and was found to be a bony

1 Present address: Department of Cardiothoracic Surgery, Royal Infirmary, Glasgow.

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HIP JOINT ARTHRITIS AFTER EXTENSIVE CHILDHOOD BURN 331

outgrowth from the femoral neck. Histology confirmed the presence of normal bone tissue and a post-operative X-ray revealed gross changes in both hip joints, with marked new bone formation and osteoarthritis (Fig. 2). Though the initial tenderness subsided, follow-up examination has shown persistent limitation in all movements of the right hip joint, and to a lesser extent the left, with a marked antalgic gait whenever the patient walks. It is likely that some form of joint replacement will be required in the future, as the degree of arthritic change is virtually certain to lead to progressive immobility and pain. At the present time, however, she remains satisfactorily mobile as far as work is concerned.

FIG. 2. A and B, Osteoarthritic changes in and new bone formation around the hip joints.

DISCUSSION

The sequence of events in this patient’s case seems to have been initial prolonged immobility, leading to soft tissue flexion contractures which, though released, have progressed to advanced osteoarthritic change in the affected joints. Calcification has been seen in the soft tissues after serious burning (Moncrief, 1970), particularly around the elbow joint, but so far as we are aware this is the first report of intra-articular damage.

The prolonged immobility in this patient’s case is undoubtedly significant, and it must therefore be stressed that though young people in particular exhibit an extra- ordinary ability to restore full function in an immobilised limb, this ability has its limitations.

REFERENCE

MONCRIEF, J. A. (1970). Burns, in “The Principles of Surgery”, edited by Schwartz, S. I., pp. 205-226. McGraw Hill Book Company.