’Twas the night before Grand Round …

Richard J B Ellis, Barnaby N Hirons, Alexandra E May, David J McCreary, Nicholas D Peterson, Leonard M Quinn, Besa Ziso, Michael Bonello, Brython Hywel, Benedict D Michael, Sean D Brown, Benjamin D Murray, Duncan M Rogers, Matt Barrett and Mark Doran
Med J Aust 2015; 203 (11): 457. || doi: 10.5694/mja15.00803
Published online: 14 December 2015

’Twas the night before Grand Round, when all through the Walton
not a creature was stirring, not even the matron.
The nurses were waiting on the ward in despair
with hopes that the registrar soon would be there.

This educated, thirty-three-year-old chap
had just been admitted after a minor mishap.
The gent had fallen whilst out for a jog
and awoke the next morning, his left leg like a log.

Before his admission he had been so well
With no past history on which we can dwell.
No family history for us to try to link
but had eleven pack-years and took the occasional drink.

A pain in his groin he was suffering
He described as dull and not like a sting
“What a miserable way to spend my Christmas vacation.”
The man remarked using “double air quotation”.

He talked of his issue with sensory supply
noting the numbness of his anterior thigh.
Spreading over his knee and down to his calf
I asked “Which side?”, he said “The medial half.”

Then out on the ward there arose such a clatter
I sprang from my exam to see what was t’matter.
Away to the door it’s our neuro main man
pulling back the curtain, to reveal Dr Doran.

His eyes — how they twinkled! His dimples, how merry!
His cheeks were like roses, his nose like a cherry!
Around his neck was a tie drawn up like a bow
and the ’tache on his lip was as white as the snow.

“We must examine” Dr Doran ordained
“or else this man’s symptoms go unexplained.”
So on thorough neurological examination
it confirmed the described loss of pinprick sensation.

Tone grossly normal, his reflexes intact
except the left knee jerk, it appeared that he lacked.
No wasting or fascic’ to find on inspection
there was clear weakness of left hip into flexion.

3 out of 5 knee extension was detected
but internal rotation was left unaffected.
And finally of note in an exam that’s so formal
was to say that his left A-D-ductors are normal.

I laid down my tendon hammer, the exam at its close,
I thought to myself, “What will we diagnose?”
“Your exam’s out of order”, Doran did chime.
“Well you try to do it whilst keeping in rhyme.”

I gathered my thoughts with flare and cohesion
To let us know where and what is the lesion?
I straightened my tie and said it with verve
“This fits with a lesion of the femoral nerve.”

“Now wait just a minute, don’t be so hurried.
What are causes that we should be worried?”
More rapid than Broca, the differential came
and I whistled and shouted and called them by name:

“Direct injury! A tumour! And radiation to the pelvis!
Pelvic fracture! Vasculitis!” Keep going Dr Ellis!
My mind went blank, my confidence misplaced!
But then I remembered, “Haemorrhage, retrofascial space!”

An MRI arrived of his abdo and pelvis
revealing to us all his lesional diagnosis.
Isointense on T1 and hyper- on T2
a subacute haematoma appeared in our view.

Left iliopsoas muscle its location reported
Clearly the femoral nerve would be distorted.
Second to fourth branches of t’lumbar plexus
This neurological correlate will ne’er again vex us.

And anymore results for us to see?
His APTT’s elevated by a factor of three.
“Should we now check this man’s clotting line?”
“It appears that he’s deficient in factor nine.”

It would seem the odd cause of his admission
Arose from an inherited bleeding predisposition.
And if you know your haemophilia A’s from your haemophilia B’s
You’ll know that the diagnosis is … Christmas Disease!

So Doran packed up his bag, to his team gave a whistle
and off he flew like the down of a thistle.
But I heard him exclaim, as he head out of sight
“Happy Christmas to all, and to all a good night!”

  • Richard J B Ellis1
  • Barnaby N Hirons2
  • Alexandra E May3
  • David J McCreary4
  • Nicholas D Peterson5
  • Leonard M Quinn6
  • Besa Ziso1
  • Michael Bonello1
  • Brython Hywel1
  • Benedict D Michael1
  • Sean D Brown7
  • Benjamin D Murray8
  • Duncan M Rogers9
  • Matt Barrett10
  • Mark Doran1

  • 1 The Walton Centre NHS Foundation Trust, Liverpool, UK
  • 2 Holy Spirit Northside, Brisbane, QLD
  • 3 The Ash Surgery, Liverpool, UK
  • 4 University Hospital Aintree, Liverpool, UK
  • 5 Whiston Hospital, Prescot, UK
  • 6 Southport Hospital, Southport, UK
  • 7 Clatterbridge Hospital, Wirral, UK
  • 8 Liverpool Heart and Chest Hospital, Liverpool, UK
  • 9 Market Street Surgery, Newton Le Willows, UK
  • 10 The Old Post Office Clinic, Ingleton, UK

  • 1. Silverstein A. Neuropathy in hemophilia. JAMA 1964; 190: 544-545.
  • 2. Kettlekamp DB, Powers SR. Femoral compression neuropathy in hemorrhagic disorders. Arch Surg 1969; 98: 367-368.
  • 3. Moore CC. A visit from St Nicholas. Sentinel 1823.


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