Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia
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- Slide 1
- Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus]
Melaka-Manipal Medical College, Malaysia
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- An eight year old boy presented to us in June06 with a H/O
discharging sinus since last 1 year in lower and medial aspect of
right thigh.
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- Clinical picture of the case
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- In May05, patient developed high fever with acute pain in the
lower part of thigh.
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- About two days later,a diffuse swelling appeared in the lower
part of thigh. It was hot & very painful, and progressed
rapidly to involve entire thigh
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- Pt. was t/ted with some oral drugs & IM inj. Pain, fever
and swelling persisted for a month until pus was drained from the
thigh swelling at a local hospital.
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- Pain, fever and swelling decreased considerably after the
drainage of pus
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- Since then pus continued to flow intermittently from the site
of drainage, the quantity was variable, sometimes serous, sometimes
frank purulent pus was coming out from the sinus
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- The patient was getting the dressing changed at a nearby health
post. No h/o passing bone chips through the wound
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- The patient was afebrile and pale Right knee was in FFD The
limb was shorter Right thigh was wasted, minimal swelling was
present in the mid third of thigh
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- There was moderate rise of temp locally, the femur was tender,
broader and irregular all along the length.
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- Fixed flexion deformity
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- There was a discharging sinus on the medial aspect of lower
third of thigh The sinus was fixed to the underlying bone
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- There was puckering of skin around the sinus There was
seropurulent discharge through the sinus
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- There was true shortening of 1 cm in the infra-trochanteric
thigh segment, There was no distal neurovascular deficit
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- Right knee was in twenty degree fixed flexion deformity,
further painless movement up to 90 degree was also present. Right
hip movements were painless and full range
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- Chronic osteomyelitis of lower right femur with a discharging
sinus on medial aspect of lower thigh with 1 cm shortening and 20
degree of fixed flexion deformity of right knee in a 8 yr. old
boy
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- Blood - Hb - 11.0 g/dl - ESR 86 mm/hr - Neutrophils- 80
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- Heavy growth of Staph. Aureus, and scanty growth of gram
negative bacilli
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- X-ray showed involvement of entire diaphysis and lower
metaphysis
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- There was large sequestrum lying medially & extending
almost to entire diaphysis of femur
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- There was formation of mature involucrum around the sequestrum
predominantly on anterolateral aspect of sequestrum
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- Sequestrum Involucrum
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- We planned to remove the entire sequestrum and all infected
tissue with it.
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- Large diaphysial sequestrum Medially lying sequestrum Proximity
to femoral vessels Intra operative bleeding from hyperemic infected
tissue and bone
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- We decided to approach the femur antero-medially. Superficial
plane was developed between rectus femoris and vastus medius
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- Vastus intermedius was now into view It was split in midline to
expose the femoral diaphysis The femoral vessels are protected by
medial part of the muscle
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- Sequestrum being exposed
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- Sequestrum was exposed to its entire length and then extracted
out
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- Sequestrum out from the wound
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- Sequestrum
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- Surrounding infected granulation is also removed giving a good
clearance of infected tissue Rectus femoris v.intermedius v. medius
Sequestrum was lying here
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- Local tissue looked healthy after debridement The sinus tract
was also debrided After through irrigation wound was closed over a
suction drain
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- Wound is now looking clean after sequestrectomy &
debridement
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- Drain was removed after 48 hrs - First dressing There was only
minimal bleeding through the sinus - Subsequent dressing were
dry
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- There was fever on first two post op days which was probably
due to handling of infected tissue, Appropriate antibiotics were
given IV for 6 weeks post operatively.
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- Skin traction & physiotherapy was used to correct the
flexion deformity And other measures were taken to improve the
general condition of the patient
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- Pre operative Post operative
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- Happy patient !
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