Pediatric Orthopedics

Adult Orthopedic ConditionsBlock 5AJanuary 6, 2010Identifying dataJC21 years old, maleFilipino, Roman CatholicRight handedFrom Albayc/c R thigh painHistory of Present Illness6 months PTA

(+) sharp, pin prick-like, continuous, VAS 10/10 pain at the Right distal thigh, radiating proximally to the R hip, associated with warmth and erythema of the area and undocumented fever.

Patient took mefenamic acid which afforded pain relief. History of Present Illness 5 months and 3 weeks PTA, patient noticed progressive swelling of the painful area. Patient consulted an albularyo who applied unknown blessed oils over the affected area which afforded no relief of the swelling and erythema. Patient cant stand up properly and started to use crutches to ambulate.

He then sought consult at a local hospital where he was confined for 10 days and given unrecalled antibiotics. Xray done during the 4th day of admission revealed no abnormal findings. Patient then opted to go home with minimal relief of the symptoms due to financial constraintsHistory of Present Illness4 months PTA, with the persistence of pain, swelling, erythema and fever, patient noticed yellowish discharge coming out of a sinus found at the lateral aspect of his right mid thigh

He then consulted another albularyo who drained the pus out of the patients right thigh. Fever resolved and the pain decreased in intensity (VAS 2-3/10), however, the swelling and erythema persisted.History of Present Illness1 month PTC, patient consulted another physician, xray done revealed impeksyon sa buto, patient was then referred here to PGH, hence ,admission.Review of systems(-)HA, dizziness(-) DOB(-) chest pain(-) palpitation(-) cough, colds(-) fever, malaise, anorexia, (-) edema(-) abdominal pain(-) urinary changes(-) bowel changes(-)weight loss(+) R thigh Pain

Past Medical History(+) occasional cough and colds(-) bronchial asthma, recurrent fever(-)HPN, DM, thyroid, kidney, liver disease(-)STD(-) food and drug allergy(-) PTBFamily Medical History(-) congenital anomaly(+) BA- Brother, father side(+)HPN, mother (-) Pulmonary TB(-)Allergy, DM, CA, Thyroid, Kidney, liver diseasesPersonal Social HistoryHS graduate5th of 10 siblingsNon-smokerOccasional alcoholic beverage drinker (1 liter a week)Denies illegal drug abusePlanned to work as a factory worker before the condition startedPhysical ExaminationAwake, alert, cooperative, ambulatory NICRD, comfortably sitted in bed with slightly erythematous and swollen R thigh of the Distal third of the R leg

BP 110/80 HR 90RR 20Temp afebrile

PHYSICAL EXAMINATIONHEENT: no gross deformities, structural congenital anomalies on the head, face and neck, anicteric sclerae, pink palpabral conjunctivae, (-) tonsilopharyngeal congestion (-) cervical lymphadenopathies

CHEST & LUNGS: (-) gross deformities, symmetric chest expansion, clear breath sounds (-) wheezes (-) crackles (-) rhonchiPHYSICAL EXAMINATIONCVS: adynamic precordium (-) heaves (-) thrills distinct heart sounds, normal rate, regular rhythm (-) murmurs

Abdomen: flat abdomen, normoactive bowel sounds, soft to palpation (-) organomegaly (-) tenderness on deep and light palpationEXAMINATION OF THE EXTREMITIESLower extremity, right thigh:Full and equal popliteal, anterior and posterior dorsalis pedis pulsesNo sensory deficitsPink nail beds on all digits ,(-) clubbing, cyanosisROM, full on active and passive motion Skin: soft, moist, good turgor, (+) 2x2 cm hyperpigmented scar, lateral middle 3rd of thigh(+)15x20cm erythematous and swollen area at the anterior side of distal third of thigh

Gross PictureRadiographsEXAMINATION OF THE EXTREMITIESLEG LENGTH MEASUREMENTRIGHTLEFTTLL8787ALL9191CircumferenceRIGHTLEFT10 cm above patella44.440.325 cm above patella4646.5AssessmentChronic Osteomyelitis, R femurCHRONIC OSTEOMYELITISDiscussionOSTEOMYELITISOsteomyelitis is defined as an inflammation of the bone caused by an infecting organism The infection may be limited to a single portion of the bone or may involve numerous regions, such as the marrow, cortex, periosteum, and the surrounding soft tissue. The infection generally is due to a single organism, but polymicrobial infections can occur, especially in the diabetic foot.OSTEOMYELITIS: CLASSIFICATIONSTraditional System (accdg. to time of onset)Acute: 2 weeksSubacute: weeks to monthsChronic: 3 months

OSTEOMYELITIS: CLASSIFICATIONSWaldvogel System (accdg. to etiology and chronicity)HematogenousArising from contiguous infection (no vascular disease present)Vascular disease presentChronic

OSTEOMYELITIS: CLASSIFICATIONSCierney and Mader System (accdg. to anatomic extent of infection and physiologic status of host)1: Medullary only (acute hematogenous)2: Superficial cortex (contigous spread or soft tissue trauma)3: Localized (cortical and medullary, mechanically stable)4: Diffuse (cortical and medullary, mechanically unstable)

OSTEOMYELITIS: CLASSIFICATIONS

OSTEOMYELITIS: CLASSIFICATIONSCierney and Mader System (accdg. to anatomic extent of infection and physiologic status of host)A: Healthy hostB: Compromised hostBs: due to systemic factorsBl: due to local factorsBls: due to local and systemic factorsC: Treatment worse than disease

CHRONIC OSTEOMYELITISDifficult to eradicate completelyThough systemic symptoms may subside, foci in the bone may contain infected material, infected granulation tissue or a sequestrumIntermittent acute exacerbations may occur and responds to rest and antibioticsHallmark: infected dead bone within a compromised soft-tissue envelopeCHRONIC OSTEOMYELITISThe infected foci within the bone are surrounded by sclerotic, relatively avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissueThis avascular envelope of scar tissue leaves systemic antibiotics essentially ineffectiveCHRONIC OSTEOMYELITISSecondary infections are commonSinus tract cultures usually do not correlate with cultures obtained at bone biopsyMultiple organisms may grow from cultures taken from sinus tracks and from open biopsy specimens of surrounding soft tissue and bone

CHRONIC OSTEOMYELITISGenerally requires aggressive surgical excision combined with effective antibiotic treatmentSurgery is not always the best option, however, especially in compromised patients

CHRONIC OSTEOMYELITIS: DIAGNOSISThe diagnosis of chronic osteomyelitis is based on clinical, laboratory, and imaging studiesGold standard: biopsy specimen for histological and microbiological evaluation of the infected boneStaphylococcal in most causes, especially posttraumaticAnaerobes and gram-negative bacilli may also be seenCHRONIC OSTEOMYELITIS: DIAGNOSISPhysical examination:Integrity of skin and soft tissueDetermine areas of tendernessAssess bone stabilityEvaluate neurovascular status of limbCHRONIC OSTEOMYELITIS: DIAGNOSISLaboratory studies:Generally nonspecific and give no indication of severityElevated ESR and CRPElevated WBC in 35%CHRONIC OSTEOMYELITIS: DIAGNOSISRadiologic studies:Plain radiographsSoft tissue edema and loss of fascial planes (earliest signs of bone infection)Cortical destruction (7 to 10 days)Periosteal reaction (2 to 6 weeks)Sequestrum: dead bone (6 to 8 weeks)Involucrum: sheath of periosteal new bone (6 to 8 weeks)SEQUESTRUM AND INVOLUCRUMCortical penetration and accumulation of inflammatory exudates periosteal stripping inner layer stimulated to form bone later infected barrier is formed cortex and spongiosa deprived of blood supply necrosis sinus tract formation in some caseSmall sequestra may be resorbed or may be extruded through sinus tractCHRONIC OSTEOMYELITIS: DIAGNOSISRadiologic studies:Technetium-99m ScanningIncreased uptake in areas of increased blood flow and osteoblastic activityGallium ScanningIncreased uptake in areas of leukocyte and bacteria accumulation (can therefor be used to monitor response to surgery)CHRONIC OSTEOMYELITIS: DIAGNOSISRadiologic studies:CT ScanProvides excellent definition of cortical bone and a fair evaluation of the surrounding soft tissues and is especially useful in identifying sequestraMRIProvides a fairly accurate determination of the extent of the pathological insult by showing the margins of bone and soft-tissue edemaMay reveal a well-defined rim of high signal intensity surrounding the focus of active disease (rim sign)TREATMENTGenerally cannot be eradicated without surgical treatmentDebridementCurettageSequestrectomyGoal: eradicate infection by achieving a viable and vascular environmentReconstruction after adequate surgery and appropriate antibiotic therapyTREATMENTLimb is splinted until wound is healedWill also prevent pathologic fracturesAntibiotic regimen is continued from prolonged period and should be monitored by IDS

TREATMENTPolymethylmethacrylate Antibiotic Bead Chains Delivers levels of antibiotics locally in concentrations that exceed the minimal inhibitory concentrationsAntibiotic is leached from the PMMA beads into the postoperative wound hematoma and secretion, which act as a transport mediumAminoglycosides are the most commonly employed antibiotics for use with PMMA beadsCan be used in the treatment of osteomyelitis if soft-tissue coverage is impossible after initial dbridementTREATMENTBiodegradable Antibiotic Delivery SystemsA second procedure is not required to remove the implantSoft Tissue TransferFills dead space left behind after extensive dbridementIlizarov TechniqueAllows radical resection of the infected boneHyperbaric Oxygen Therapy