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CASE REPORTCHRONIC OSTEOMYELITIS OF THE RIGHT
FOOT
Presented by:Annisa Trie Anna [C11108280]
Advisor:dr. Erick
dr. Harianto
Supervisor:dr. Henry Yurianto, M. Phil., Ph.D,SpOT.
Orthopaedic and Traumatology DepartmentMedical Faculty of Hasanuddin University
Makassar, 2012
Patient Identity
Name : R Age / Sex : 49 years old/ male Admission : July 23th, 2012 Registration :555 978 Status : JAMKESMAS
HISTORY TAKING
Chief complain : Swelling and pain at the right foot
Anamnesis : Suffered since 4 years ago and become heavy 4 months before admitted to the hospital. Intermittent pain, especially felt pain on exertion and reduced at rest. On the right foot also contained small lumps that if injured out the pus and blood. Initially, in 2008 approximately 2 weeks after tumor surgery on the right foot, swelling and redness. Patients admitted often do not wear footwear when working in the fields. History of intermittent fever (-), history of family with the same disease (-), history of prior treatment (-).
General status
Moderate illness/ concious BP : 120/80 mmHg Pulse : 80x/m, regular RR : 20x /m, regular T : 36.50 C (axillar)
Local statusRight Foot RegionI : wound and scar at dorsal aspect,
Swelling (+), deformity (-), sinus(+).P : Tenderness (+), warm compared to
surrounding.ROM : Active and passive motion ankle
joint within normal limits. Active extend of big toe (+) and extend other toes (-)
NVD :Good sensitivity, Dorsalis pedis and tibialis posterior artery palpable, CRT < 2“.
CLINICAL PICTURE
Radiology findings
Laboratorium Findings (20th July 2012 )
WBC : 13,66 x 103 /uL RBC : 4,29 x 106 /uL HGB : 11,6 g/dL HCT : 373,3% PLT : 312x 103 /uL CT : 7’ 30” BT : 2’ 00” GDS : 91 mg/dl ESR : 40/78 mm HBSAg : negatif
Culture and sensitivity test – Samples : Blood – Result : no growth of
bacteria Evaluation of cytology (FNA)
– Results: Chronic granulomatous inflammation causa specific process could not be ascertained - suppurative inflammation
– Suggestion: FNA repeated after treatment
Resume
A male 49 years old with pain and swelling on the right foot. Suffered since 4 years ago and become heavy 4 months before admitted to the hospital. On the right foot also contained small lumps that if injured out the pus and blood. Initially, swelling and redness.. History of tumor surgery before 4 years ago (+). History of intermittent fever (-), history of family with the same disease (-), history of prior treatment (-).
On physical examination of the left leg : wound and scar at dorsal aspect, Swelling (+), sinus (+), tenderness (+), warm compared to surrounding. ROM, active and passive motion ankle joint within normal limits. Active extend of big toe (+) and extend other toes (-). NVD are within normal limit.
Laboratory finding : increased of ESR. Radiography : characterized by thick, irregular, sclerotic bone interspersed with radiolucencies, an elevated periosteum, and chronic draining sinuses, periosteal new bone, and soft tissue swelling.
Evaluation of cytology (FNA) :Chronic granulomatous inflammation causa specific process could not be ascertained - suppurative inflammation
Diagnosis
CHRONIC OSTEOMYELITIS OF THE RIGHT FOOT
Management
Medicamentosa: Analgetic Antibiotic
Surgery : Debridement and Guttering
DISCUSSION
Definition
Osteomyelitis 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
Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed.
Port D’ entry
Contagenous
Hematogenous Direct
infection
CLASSIFICATION Based on onset
Acute SubacuteChronic
Mechanism of infectionExogenous
Direct infection Contagenous
Hematogenous
Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed
Chronic Osteomyelitis
This used to be dreade sequel to acute hematogenous osteomyelitis
Now days, it more frequently follows an open fracture or operation.
Usual organisms are staphylococcus aureus, Escherichia coli, Streptococcus pyogens, Proteus and Pseudomonas.
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
Pathology Bone is destroyed or devitalized in a discrete
area at the focus of infection.
Cavities containing pus and pieces of dead bone (sequestra) are surrounded by vascular tissue, and beyond that by areas of sclerosis the result of chronic reactive new bone formation.
Sequestra, foreign implants act as substrates for bacterial adhesion, ensuring the persistence of infection and sinus drainage.
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
Cierny and Mader staging system of chronic osteomyelitis based on
anatomical
I Medullary Endosteal disease
II Superficial Cortical surface infected because of coverage defect
III Localized Cortical sequestrum that can be excised without compromising stability
IV Diffuse Features of I, II, and III plus mechanical instability before or after débridement
Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed
Staging System based on phisiological class
A host Normal Immunocompetent with good local vascularity
B host Compromised Local (L) or systemic (S) factors that compromise immunity or healing
C host Prohibitive Minimal disability, prohibitive morbidity anticipated, or poor prognosis for cure
Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed
DIAGNOSIS
BIOPSY “Gold
Standart”
IMAGING
LABORATORY
CLINICAL
Sign & symtomps The patient presents because pain, pyrexia,
redness and tenderness have recurred (a 'flare'), or with a discharging sinus.
In long-standing cases the tissues are thickened and often puckered or folded in where a scar or sinus is attached to the underlying bone.
There may be a sero-purulent discharge and excoriation of the surrounding skin.
In post-traumatic osteomyelitis the bone may be deformed or non-united.
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
Laboratory ESR and white blood cell count may be
increased
Organisms cultured from discharging sinuses should be tested repeatedly for antibiotic sensitivity.
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
Imaging
X-ray examinationBone resorption with
thickening and sclerosis of surrounding bone,
loss of trabeculation, area osteoporosis,
periosteal thickening, sequestra, or the bone crudely thickened and misshapen.
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION
Radioisotope scintigraphySensitive but not specific. Using 99m Tc-HDP for showing increased activity of perfusion and bone phase and 67 Ga-Citrate or In-labelled leucocytes for showing hidden foci of infection
CT and MRIShow the extent of bone destruction and reactive edema, hidden abscess and sequestra.
Management Antibiotics Operation :
Thorough debridement of necrotic tissue and bone
Stabilization of boneDead space managementSoft tissue coverageLimb reconstruction
CHAPTER 19, chronic osteomyelitis Bruce D. Browner, M.D., F.A.C.S.Ed Pesanti, M.D., F.A.C.P.
Complication
A pathologic fracture may develop if the bone is excessively loaded before healing and remodeling.
Joint stiffness Malignent changes in epidermis
(epidermioid carcinoma)
Robert B. Salter, Textbook of disorders and injuries of the musculoskeletal system. Third edition
THANK YOU