Bilateral gluteus maximus contracture due to intra muscular injections

Report

A 21-year-old male presented with inability to squat and sit cross-legged since the age of five years. He had a history of multiple injections in both buttocks for a febrile illness in childhood. Limitation of his hip movements was mild initially but eventually progressed to such an extent that he could not squat and sit cross-legged (Figure 1(a)). Physiotherapy produced no improvement. There was atrophy of both glutei and dimpling of the overlying skin. Hip flexion was 0–40° on the left side and 0–70° on the right side. Further flexion was associated with external rotation and abduction of the ipsilateral hip. This has been described as reverse Ober’s sign (Figure 1(b)). At full flexion, the knee was directed towards ipsilateral axilla on both sides. Adduction and internal rotation were not possible even with the full extension of the hip joint. There was no abnormality noted on plain radiographs. OPEN IN VIEWER

A diagnosis of bilateral gluteus maximus contracture (GMC) was made, and open release of contracture was carried out. In lateral position, a posterolateral approach to the hip was used. The gluteus maximus muscle was identified as fibrotic and atrophied. The tight fascia covering it was divided in line with the skin incision from the greater trochanter to a point 4 cm inferolateral to posterior superior iliac spine. There were no red-coloured muscle fibres under the fascia. The tensor facia lata was also found to be tight and displaced posteriorly. The incision was extended distally over the lateral femur. The gluteus maximus attachment on the gluteal tubercle on the posterior femur was identified and divided (Figure 1(c)). The posterior half of the gluteal fascia and the fibrotic gluteus maximus muscle were tight in hip flexion and were divided transversely up to the sciatic nerve. This allowed hip flexion to 100° in adduction. After placing the hip in this position, the two halves of the posterior gluteal facia were sutured to the anterior gluteal flap. A triangular-shaped defect was created in the posterior gluteal fascia (Figure 2(a)). Active and passive range of motion exercise were started two to three days after surgery. The same procedure was performed in the opposite hip after four weeks. At the end of 12 months, the patient could squat with the knee facing anteriorly (Figure 2(b)). OPEN IN VIEWER

Discussion

Common causes of GMC are repeated intramuscular injections into the gluteal region, poliomyelitis and abscesses in buttocks.^1–3 This may be caused by the direct trauma of the needle or chemicals in the injection fluid. GMC is a clinical diagnosis. The limb has limited adduction and internal rotation. On flexing the hip, the knee moves towards the ipsilateral axilla. Passive stretching is helpful in early mild cases. Surgical release is required in chronic cases.^4,5