Transcutaneous Skin Perforation by a Protruding Xiphoid Process in a Bedbound Patient With Post-Traumatic Cervical Myelopathy: A Case Report and Review of the Literature
This case report describes a rare instance of complete transcutaneous skin perforation by a protruding xiphoid process in a bedbound patient with cervical myelopathy and diabetes, which was successfully treated with xiphoidectomy and targeted antimicrobial therapy while highlighting the importance of distinguishing reactive pseudoepitheliomatous hyperplasia from malignancy.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
The human body is a complex structure of bones and soft tissues that usually works in harmony, but sometimes, a small anatomical variation can lead to unexpected problems. At the very bottom of the breastbone, or sternum, lies a tiny, pointed piece of bone called the xiphoid process. For most people, this small bone is flat against the chest or curves slightly inward, hidden beneath layers of skin and muscle. However, in some individuals, it grows outward, pointing sharply toward the front of the body. While this variation is common, it rarely causes trouble beyond occasional pain. The real danger arises when a person loses the ability to move, causing their body to rest constantly against this bony point. Without the cushion of muscle and fat, and without the ability to shift position, that small bone can begin to press against the skin with relentless force, much like a rock pressing into soft earth. This pressure can eventually break the skin, leading to a wound that refuses to heal and invites infection.
This story comes from a medical report detailing a rare and severe complication in a 71-year-old man who had been bedbound for months due to a spinal cord injury. The patient, who also had diabetes and high blood pressure, had suffered a fall that damaged his neck and left him unable to move his legs or control his lower body. Over time, a small bump on his lower chest began to grow more prominent. What started as a noticeable protrusion slowly eroded through the skin, creating a chronic, open sore that discharged fluid and became infected. The medical team realized that the sharp tip of his xiphoid process had pushed all the way through his chest wall, piercing the skin from the inside out. This was not a simple infection or a standard bed sore; it was a case where a bone had physically perforated the body's outer barrier.
To understand what was happening, the doctors examined the patient's chest. They saw a cone-shaped swelling at the bottom of his sternum, with a raw, ulcerated center where the skin had broken down. The tip of the bone was visible through the wound, surrounded by inflamed tissue. An X-ray confirmed their suspicion, showing that the xiphoid process was bent sharply forward, sticking out well beyond the normal curve of the chest wall. The doctors knew that simply cleaning the wound would not be enough because the bone itself was the cause of the injury. They decided to perform surgery to remove the offending bone and the damaged skin around it.
During the operation, the surgeons carefully cut away the protruding xiphoid process along with the ulcerated skin and the dead tissue surrounding it. They worked with precision to avoid damaging the heart and the diaphragm, which sit just behind this area. Once the bone was removed, they cleaned the area thoroughly and closed the wound in layers. The removed tissue was sent to a laboratory to be analyzed. The tests revealed that the wound was infected with a specific type of bacteria called Escherichia coli, which had developed resistance to many common antibiotics. Because of this resistance, the medical team treated the patient with a stronger antibiotic called a carbapenem, which the bacteria were still sensitive to.
The analysis of the removed tissue provided further clarity. Under a microscope, the doctors saw that the skin around the wound had reacted to the chronic irritation by growing thick and inflamed, a change that can sometimes look like cancer but was actually a benign response to the pressure. The bone itself showed no signs of cancer or deep infection within the marrow, confirming that the problem was limited to the surface where the skin had been breached. The patient recovered well from the surgery and was able to leave the hospital after about three weeks. At a follow-up visit a few weeks later, the wound had healed completely, with no sign of the sore returning.
This case highlights how a combination of factors can turn a harmless anatomical quirk into a serious medical emergency. The patient's inability to move meant he could not relieve the pressure on his chest. His diabetes likely slowed his body's ability to heal, and the loss of fat and muscle over his chest wall removed the natural padding that usually protects the skin from the bone beneath. The result was a pressure injury that formed over an unusual bony prominence, leading to a complete break in the skin. The report suggests that while this specific outcome is extremely rare, doctors should be aware that a protruding xiphoid process can act like any other bony point in a bedbound patient, causing skin breakdown and infection if left unaddressed. The successful treatment involved removing the bone and the infected tissue, followed by targeted antibiotic therapy, proving that surgical intervention can resolve even the most severe cases of this condition.
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