Adult Orthopedic Conditions

1. Adult Orthopedic Conditions Block 5A January 6, 2010

2. Identifying data • JC • 21years old, male • Filipino, Roman Catholic • Right handed • From Albay • c/c R thigh pain

3. History of Present Illness 6 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 erythemaof the area and undocumented fever.  Patient took mefenamic acid which afforded pain relief.

4. 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 constraints

5. History of Present Illness 4 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 patient’s right thigh. Fever resolved and the pain decreased in intensity (VAS 2-3/10), however, the swelling and erythema persisted.

6. History of Present Illness 1 month PTC, patient consulted another physician, xray done revealed “impeksyonsabuto”, patient was then referred here to PGH, hence ,admission.

7. 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

8. Past Medical History • (+) occasional cough and colds • (-) bronchial asthma, recurrent fever • (-)HPN, DM, thyroid, kidney, liver disease • (-)STD • (-) food and drug allergy • (-) PTB

9. Family Medical History • (-) congenital anomaly • (+) BA- Brother, father side • (+)HPN, mother • (-) Pulmonary TB • (-)Allergy, DM, CA, Thyroid, Kidney, liver diseases

10. Personal Social History • HS graduate • 5th of 10 siblings • Non-smoker • Occasional alcoholic beverage drinker (1 liter a week) • Denies illegal drug abuse • Planned to work as a factory worker before the condition started

11. Physical Examination • Awake, 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 90 • RR 20 • Temp afebrile

12. PHYSICAL EXAMINATION • HEENT: 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 (-) rhonchi

13. PHYSICAL EXAMINATION • CVS: adynamicprecordium (-) 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 palpation

14. EXAMINATION OF THE EXTREMITIES • Lower extremity, right thigh: • Full and equal popliteal, anterior and posterior dorsalispedis pulses • No sensory deficits • Pink nail beds on all digits ,(-) clubbing, cyanosis • ROM, 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

15. Gross Picture

16. Radiographs

17. EXAMINATION OF THE EXTREMITIES

18. Assessment • Chronic Osteomyelitis, R femur

19. CHRONIC OSTEOMYELITIS Discussion

20. OSTEOMYELITIS • Osteomyelitis 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.

21. OSTEOMYELITIS: CLASSIFICATIONS • Traditional System (accdg. to time of onset) • Acute: 2 weeks • Subacute: weeks to months • Chronic: 3 months

22. OSTEOMYELITIS: CLASSIFICATIONS • Waldvogel System (accdg. to etiology and chronicity) • Hematogenous • Arising from contiguous infection (no vascular disease present) • Vascular disease present • Chronic

23. OSTEOMYELITIS: CLASSIFICATIONS • Cierney 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)

24. OSTEOMYELITIS: CLASSIFICATIONS

25. OSTEOMYELITIS: CLASSIFICATIONS • Cierney and Mader System (accdg. to anatomic extent of infection and physiologic status of host) • A: Healthy host • B: Compromised host • Bs: due to systemic factors • Bl: due to local factors • Bls: due to local and systemic factors • C: Treatment worse than disease

26. CHRONIC OSTEOMYELITIS • Difficult to eradicate completely • Though systemic symptoms may subside, foci in the bone may contain infected material, infected granulation tissue or a sequestrum • Intermittent acute exacerbations may occur and responds to rest and antibiotics • Hallmark: infected dead bone within a compromised soft-tissue envelope

27. CHRONIC OSTEOMYELITIS • The infected foci within the bone are surrounded by sclerotic, relatively avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissue • This avascular envelope of scar tissue leaves systemic antibiotics essentially ineffective

28. CHRONIC OSTEOMYELITIS • Secondary infections are common • Sinus tract cultures usually do not correlate with cultures obtained at bone biopsy • Multiple organisms may grow from cultures taken from sinus tracks and from open biopsy specimens of surrounding soft tissue and bone

29. CHRONIC OSTEOMYELITIS • Generally requires aggressive surgical excision combined with effective antibiotic treatment • Surgery is not always the best option, however, especially in compromised patients

30. CHRONIC OSTEOMYELITIS: DIAGNOSIS • The diagnosis of chronic osteomyelitis is based on clinical, laboratory, and imaging studies • Gold standard: biopsy specimen for histological and microbiological evaluation of the infected bone • Staphylococcal in most causes, especially posttraumatic • Anaerobes and gram-negative bacilli may also be seen

31. CHRONIC OSTEOMYELITIS: DIAGNOSIS • Physical examination: • Integrity of skin and soft tissue • Determine areas of tenderness • Assess bone stability • Evaluate neurovascular status of limb

32. CHRONIC OSTEOMYELITIS: DIAGNOSIS • Laboratory studies: • Generally nonspecific and give no indication of severity • Elevated ESR and CRP • Elevated WBC in 35%

33. CHRONIC OSTEOMYELITIS: DIAGNOSIS • Radiologic studies: • Plain radiographs • Soft 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)

34. SEQUESTRUM AND INVOLUCRUM • Cortical 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 case • Small sequestra may be resorbed or may be extruded through sinus tract

35. CHRONIC OSTEOMYELITIS: DIAGNOSIS • Radiologic studies: • Technetium-99m Scanning • Increased uptake in areas of increased blood flow and osteoblastic activity • Gallium Scanning • Increased uptake in areas of leukocyte and bacteria accumulation (can therefor be used to monitor response to surgery)

36. CHRONIC OSTEOMYELITIS: DIAGNOSIS • Radiologic studies: • CT Scan • Provides excellent definition of cortical bone and a fair evaluation of the surrounding soft tissues and is especially useful in identifying sequestra • MRI • Provides a fairly accurate determination of the extent of the pathological insult by showing the margins of bone and soft-tissue edema • May reveal a well-defined rim of high signal intensity surrounding the focus of active disease (rim sign)

37. TREATMENT • Generally cannot be eradicated without surgical treatment • Debridement • Curettage • Sequestrectomy • Goal: eradicate infection by achieving a viable and vascular environment • Reconstruction after adequate surgery and appropriate antibiotic therapy

38. TREATMENT • Limb is splinted until wound is healed • Will also prevent pathologic fractures • Antibiotic regimen is continued from prolonged period and should be monitored by IDS

39. TREATMENT • PolymethylmethacrylateAntibiotic Bead Chains • Delivers levels of antibiotics locally in concentrations that exceed the minimal inhibitory concentrations • Antibiotic is leached from the PMMA beads into the postoperative wound hematoma and secretion, which act as a transport medium • Aminoglycosides are the most commonly employed antibiotics for use with PMMA beads • Can be used in the treatment of osteomyelitis if soft-tissue coverage is impossible after initial débridement

40. TREATMENT • Biodegradable Antibiotic Delivery Systems • Asecond procedure is not required to remove the implant • Soft Tissue Transfer • Fills dead space left behind after extensive débridement • Ilizarov Technique • Allows radical resection of the infected bone • Hyperbaric Oxygen Therapy