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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 15  |  Issue : 2  |  Page : 100-102

Simultaneous bilateral femoral neck fracture following tetanus in a healthy adult


1 College of Medical Sciences, University of Maiduguri and University of Maiduguri Teaching Hospital, Borno State, Nigeria
2 University of Maiduguri Teaching Hospital, Maiduguri Borno State, Nigeria

Date of Web Publication13-Jan-2017

Correspondence Address:
Theophilus M Dabkana
College of Medical Sciences, University of Maiduguri, Borno
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2384-5589.198315

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  Abstract 

A 45-year-old trader presented to us with 4 weeks history of difficulty in opening his mouth, inability to walk and tonic–clonic seizures with bilateral femoral neck fractures. Three weeks before the onset of problems, the patient had been knocked down by a tricycle and had sustained an open wound over the right medial malleolus; the wound was sutured at a general hospital and the patient discharged home. One week later, the wound started discharging a foul-smelling pus and was dressed at a primary health centre; however, by the second week, the patient started having difficulty in opening his mouth. By the third week, he was bed ridden, developed tonic–clonic seizures and felt a crunching sound associated with severe pain in both hips. He was taken to a traditional bone setter who gave him some herbs, but his symptoms got worse. He was then brought to the Accident and Emergency Department of the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria where a diagnosis of tetanus was made. Further evaluation revealed Gardener-type IV bilateral femoral neck fractures. He was managed for the tetanus, underwent bilateral bipolar hemiarthroplasty and was discharged home. He spent 10 weeks in the hospital.

Keywords: Healthy adult, simultaneous bilateral femoral neck fractures, sutured dirty wound, tetanus


How to cite this article:
Dabkana TM, Nyaku FT, Bunu B, Timta A. Simultaneous bilateral femoral neck fracture following tetanus in a healthy adult. Afr J Med Health Sci 2016;15:100-2

How to cite this URL:
Dabkana TM, Nyaku FT, Bunu B, Timta A. Simultaneous bilateral femoral neck fracture following tetanus in a healthy adult. Afr J Med Health Sci [serial online] 2016 [cited 2019 Jun 19];15:100-2. Available from: http://www.ajmhs.org/text.asp?2016/15/2/100/198315


  Introduction Top


Tetanus is a clinical condition that presents with locked jaws and tonic–clonic seizures that may lead to death; it is caused by a respiratory complication following an infection by a bacillus, Clostridium tetani, that produces an exotoxin that is neurotoxic. The organism thrives is an anaerobic environment, such as a dirty and infected wound.[1],[2] This infection is common in wounds of the lower limbs because of the proximity of this part of the body to the ground that harbours these organisms. The spores of these organisms germinate and produce the exotoxin that causes generalised rigidity of the musculo-skeletal system and is associated with tonic–clonic seizures. Seizures are triggered off by minimal stimuli, such as noise, light or touch and can last from few seconds to several minutes. These spasms are dangerous and painful and can cause laryngeal spasms, apnoea, rhabdomyolysis or fractures.[3]

Though fractures of the vertebral column, as well as parts of the scapular, and spinal deformities in neonates, juveniles and adolescents have been reported by different authors in Nigeria and elsewhere in the world,[3],[4] ’simultaneous bilateral femoral neck’ fractures following tetanus are yet to be reported. We therefore present the findings in a case wherein we treated the patient at the University of Maiduguri Teaching Hospital Maiduguri, Borno State in Nigeria.


  Case Report Top


A 45-year-old businessman presented with 4 weeks history of difficulty in walking, tonic–clonic seizures and fever. Three weeks before onset of symptoms, he had injury over the right medial malleolus after falling off a tricycle. The wound was sutured at a general hospital and the patient sent home. He continued his business trips, and 1 week later, he noticed a foul-smelling discharge from the wound and had it dressed at another General Hospital. However, 1 week later, he developed fever and noticed that he could not open his mouth properly. He was then taken to a traditional bone setter, who applied herbs to the wound. However, the patient developed tonic–clonic seizures, and a day later, he felt a crunching noise associated with severe pain in both hips. At this point, he could no longer walk and was brought to the Accident and Emergency department of the University of Maiduguri Teaching Hospital.

On examination, we found him to be a middle-aged man who was not pale but febrile to touch with difficulty in opening his mouth, general body rigidity with pain and having tonic–clonic seizures following any sound around him or on touching him. The pulse rate was 120/min, and blood pressure was 160/100 mmHg. Both lower limbs were externally rotated, and both hips were very tender to touch and during movement, triggering off generalised body spasm.

The right ankle was bandaged with a dirty strip of clothing, and the wound discharged a foul-smelling pus. Removal of the dressing revealed a vertical wound over the medial malleolus, which still had nylon sutures in situ.

A diagnosis of tetanus was made, and the patient’s wound dressed; he was sedated with IV diazepam and IV metronidazole, and ceftriaxone was started. He was then sent for X-ray of the pelvis, which revealed bilateral Gardener-type IV fractures [Figure 1].
Figure 1 X-ray of the pelvis showing bilateral Gardener-type IV fractures

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He also had an undisplaced medial malleolar fracture. He was then admitted to the ward where bilateral skin traction with 5 kg weight was applied, and he was kept in a secluded area. The wound was dressed daily until it healed. A nasogastric tube was passed for feeding, and IV drugs continued along with sedation. 5000 iu of tetanus immune globulin (TIG) was also given STAT.

After 2 weeks, spasms stopped, and the patient started talking. Nasogastric tube was removed, oral feeding started and antibiotics (amoxiclav 1 g bd and metronidazole 400 g tds) were continued for 2 weeks.

After 1 month on admission, he had a right hip bipolar hemiarthroplasty followed by left hip bipolar hemiarthroplasty 3 weeks later [Figure 2].
Figure 2 Postoperative X-ray of bilateral hemiarthroplasty

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Both surgeries were uneventful. The patient did mobilise well on axillary crutches and had since been discharged home after receiving another 300 iu of TIG. Tetanus toxoid 0.5 ml was then given, and a booster dose would be given during follow-up.


  Discussion Top


Pathophysiology of tetanus

Tetanus is a clinical condition that is caused when the obligate anaerobic motile gram-positive bacillus Clostridium tetani contaminates dead and devitalised tissue that is usually low in oxygen. The bacillus has spores that germinate in anaerobic conditions, producing the following two toxins: (1) tetanolysin and (2) tetanospasmin.[3]

The following are the features of the toxins:

  1. Tetanolysin has no known pathologic activity.
  2. Tetanospasmin is responsible for the clinical conditions; it is a very potent toxin with a minimal lethal dose of 2.5 ng/kg body weight. It consists of a heavy chain of 150 kDa and a light chain of 50 kDa. It travels by retrograde axonal transport from the contaminated site to the spinal cord in 2–14 days and enters the central inhibitory neurons.


The light chain then cleaves to the protein synaptobrevin, which facilitates the binding of neurotransmitter-containing vesicles to the cell membrane. The heavy chain mediates the binding of the whole toxin (tetanospasmin) to the pre-synaptic motor neuron and also creates a pore for the entry of the light chain into the cytosol. Once this happens, gamma-aminobutyric acid and glycine-containing vesicles are not released, leading to the loss of inhibitory actions on the motor and autonomic neurons.[4] This causes sustained uninhibited violent contractions of skeletal muscles leading to muscle avulsion from their origin or insertion. Various parts of the skeleton have been known to be fractured following generalised tetanus, with the vertebral column being more involved.[5],[6],[7],[8] In addition, the patients have laryngeal spasms leading to respiratory problems. However, long bones are not known to fracture. Femoral neck fractures following grand mal seizures and sustained myoclonus unrelated to tetanus have been reported.[9],[10] However, Taylor and Grant reported bilateral femoral neck fracture following a hypoglycemic convulsion.[11]

The femoral neck, a strong part of the femur that is meant to withstand a lot of stress and loading, hardly fractures following skeletal muscle contractions.


  Conclusion Top


Though not reported before now, bilateral femoral neck fractures can occur in healthy adults following tonic-clinic seizures in tetanus. This can be prevented by proper wound management. However, when it occurs, proper treatment of the condition with wound care, sedation, attention to nutrition, antibiotics and airway care should supersede the treatment of the fracture. Where facilities are available, partial or total bilateral hip arthroplasty should be performed as soon as the patient’s clinical condition warrants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Roberg OT Jr. Spinal deformity following tetanus and its relation to juvenile kyphosis. J Bone Jt Surg 1937;19:603-29.  Back to cited text no. 1
    
2.
Bandele EO, Akinyanju OO, Bojuwoye BJ. An analysis of tetanus deaths in Lagos. J Natl Med Assoc 1991;83:55-8.  Back to cited text no. 2
    
3.
World Health Organization. WHO Technical Note: Current Recommendation for Treatment of Tetanus During Humanitarian Emergencies; January 2010.  Back to cited text no. 3
    
4.
Yeh FL, Dong M, Yao J, Tepp WH, Lin G, Johnson EA et al. SV2 mediates entry of tetanus neurotoxin into central neurons. PLoS Pathog 2010;6:e1001207. doi: 10.1371/journal.ppat.1001207  Back to cited text no. 4
    
5.
Alfery DD, Rauscher A. Tetanus: A review. Crit Care Med 1979;7:176-81.  Back to cited text no. 5
    
6.
Hegenbarth R, Ebel KD. Roentgen findings in fractures of the vertebral column in childhood examination of 35 patients and its results. Pediatr Radiol 1976;5:34-9. [Online].  Back to cited text no. 6
    
7.
Kalideen JM, Satyapal KS. Fractures of the acromion in tetanus neonatorum. Clin Radiol 1994;49:563-5.  Back to cited text no. 7
    
8.
Colangelo C. Compression fractures of the thoracic vertebral in a patient with tetanus. J Am Med Assoc 1959;170:455-7.  Back to cited text no. 8
    
9.
Ribacoba-Montero R, Salas-Puig J. Simultaneous bilateral fractures of the hip following a grand mal seizure. An unusual complication. Seizure 1997;6:403-4. [Last accessed on 2016 Mar 27].  Back to cited text no. 9
    
10.
Van Heest A, Vorlicky L, Thompson RC Jr. Bilateral central acetabular fracture dislocations secondary to sustained myoclonus. Clin Orthop Relat Res 1996;210-3. [Last accessed 2016 Mar 27].  Back to cited text no. 10
    
11.
Taylor LJ, Grant SC. Bilateral fracture of the femoral neck during a hypoglycemic convulsion. A case report. J Bone Jt Surg Br 1985;67:536-7.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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