key: cord-0740687-16tqgi6w
authors: Pandya, Chiraag; Sangoi, Dhrumin; Badhe, Sachin
title: Low trauma posterior native hip dislocation with acute longitudinal transverse myelitis due to SARS-CoV-2 - A case-report
date: 2021-06-16
journal: Trauma Case Rep
DOI: 10.1016/j.tcr.2021.100501
sha: 45855cae00962b457caf1a670505cd333f409c04
doc_id: 740687
cord_uid: 16tqgi6w

BACKGROUND: Native hip dislocations are most commonly seen after high energy trauma. While there are documented cases of hip dislocation with associated stroke, we present a case of posterior hip dislocation in the context of acute longitudinal transverse myelitis due to a rare presentation of SARS-CoV-2. CASE REPORT: A 60-year-old male presented with bilateral lower limb weakness with a shortened internally rotated left leg. Plain radiographs revealed a posteriorly dislocated native left hip and MRI of the spine showed acute longitudinal transverse myelitis of the cervical and thoracic regions. His nasopharyngeal swab was positive for SARS-CoV-2. His hip was reduced, and he was treated with intravenous steroids. His neurological symptoms improved with follow-up MRI showing resolution of the transverse myelitis. CONCLUSION: This case illustrates a classic orthopaedic emergency in the context of a rare presentation of SARS-CoV-2, and the vigilance that orthopaedic doctors must have when examining patients with lower limb neurological deficit.

The majority of native hip dislocations occur after motor vehicle collisions [1] . Although hip subluxation and dislocation occur commonly in neuromuscular diseases such as cerebral palsy, spinal muscular atrophy and myelomeningocele, they are not known to affect patients with transverse myelitis. There have been case reports on anterior native hip J o u r n a l P r e -p r o o f dislocation secondary to stroke [2] and many studies show increased incidence of Total Hip Replacement dislocation in patients with neurological condition like Parkinson's disease. We present an unusual case of posterior hip dislocation from a trivial fall from standing height in a patient that, after investigations, was found to have acute longitudinal transverse myelitis and SARS-CoV-2.

A 60-year-old gentleman was admitted under our care presenting with weakness of both legs. He had presented to the emergency department 2 days prior complaining only of lower abdominal pain. He was found to be in urinary retention and was catheterised, treated as a urinary tract infection with antibiotics, and discharged. In the following 2 days he complained of an increasingly unsteady gait with tingling in both his hands and feet. This culminated in a simple fall whilst trying to get out of bed on the morning before the day of admission. He was unable to mobilise after this point.

Examination revealed an internally rotated and shortened left leg however, he was able to perform straight leg raise to some extent. Hypotonia was noted in both lower limbs. Results of Cerebrospinal Fluid analysis and further laboratory test can be seen in table 1.

He was taken to theatre to successfully reduce his hip ( Figure 4) and was commenced on intravenous methylprednisolone for which he received a total of 4.5g followed by high dose prednisolone. His folate and vitamin B12 were also replaced and was kept on bed rest for 2 weeks prior to being mobilised by the physiotherapists. Three weeks after admission, a new leg length discrepancy was noted, and x-rays confirmed a re-dislocation of the Left hip. The patient did not complain of any pain which is most likely due to sensory loss caused by J o u r n a l P r e -p r o o f transverse myelitis. This was again successfully reduced in theatre. Computer tomography ruled out any fracture or bony injury.

The patient was kept on bed rest with a de-rotation boot. Daily leg length measurement was caried out with comparison to the normal side. Repeat T2 Weighted Magnetic Resonance Imaging 6-weeks after admission reported complete resolution of previously seen cord signal change ( Figure 5 ). The patient's sharp and soft touch sensory loss and motor weakness had completely resolved. The patient underwent inpatient physiotherapy during his 12-week hospital admission before being discharged to continue rehabilitation in the community. Unfortunately, the patient re-dislocated his hip shortly after being discharged, so has required further manipulation under anaesthesia. His further plan will be to refer him to tertiary level specialist centre managing such hip conditions.

As far as authors are aware, this is the first case of posterior hip dislocation secondary to transverse myelitis which probably occurred secondary to Covid 19 infection. There have been 4 case reports of acute transverse myelitis presenting with Covid 19 infection since the start of this pandemic [3] [4] [5] [6] .

The hypotonia and weakness due to this neurological condition and mechanism of fall might have led to posterior dislocation of the hip.

There was a delay in hip reduction due to the delay in diagnosis. This was complicated by the neurology in lower limbs and the fact that patient was able to SLR to some extent without significant pain. There was a need of diagnosing underlying neurological cause with MRI prior to taking the patient to theatres. Most authors recommend a reduction time of J o u r n a l P r e -p r o o f fewer than 6 hours, while there is some evidence that fewer than 12 hours may be a critical time; regardless, the rate of secondary complications increases dramatically with increased time-to-reduction [7] .

There have been case reports on anterior native hip dislocation secondary to stroke [2] , hip dislocation in spinal muscular atrophy [8] We stress here the importance of measuring daily leg-length in such cases where pain is masked by underlying neurological problem and absent pain sensation/joint proprioception.

There should be a multi-disciplinary approach to manage such conditions with input from neurology, physiotherapists, occupational therapists and orthopaedic surgeons. 

Traumatic hip dislocation--a review

Anterior hip dislocation in conjunction with a stroke: a diagnosis not to miss

Acute myelitis after SARS-CoV-2 infection: a case report

Acute transverse myelitis in COVID-19 infection

Acute transverse myelitis associated with SARS-CoV-2: A Case-Report. Brain Behav Immun Health

COVID-19-associated acute transverse myelitis: a rare entity

Posterior Hip Dislocation. StatPearls. StatPearls Publishing Copyright © 2020

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