dr nirmal kumar sinha & dr rajaram pai [manipal campus] melaka-manipal medical college, malaysia
TRANSCRIPT
- Slide 1
- Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia
- Slide 2
- 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.
- Slide 3
- Clinical picture of the case
- Slide 4
- In May05, patient developed high fever with acute pain in the lower part of thigh.
- Slide 5
- 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
- Slide 6
- 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.
- Slide 7
- Pain, fever and swelling decreased considerably after the drainage of pus
- Slide 8
- 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
- Slide 9
- The patient was getting the dressing changed at a nearby health post. No h/o passing bone chips through the wound
- Slide 10
- 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
- Slide 11
- There was moderate rise of temp locally, the femur was tender, broader and irregular all along the length.
- Slide 12
- Fixed flexion deformity
- Slide 13
- There was a discharging sinus on the medial aspect of lower third of thigh The sinus was fixed to the underlying bone
- Slide 14
- There was puckering of skin around the sinus There was seropurulent discharge through the sinus
- Slide 15
- There was true shortening of 1 cm in the infra-trochanteric thigh segment, There was no distal neurovascular deficit
- Slide 16
- 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
- Slide 17
- 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
- Slide 18
- Blood - Hb - 11.0 g/dl - ESR 86 mm/hr - Neutrophils- 80
- Slide 19
- Heavy growth of Staph. Aureus, and scanty growth of gram negative bacilli
- Slide 20
- X-ray showed involvement of entire diaphysis and lower metaphysis
- Slide 21
- There was large sequestrum lying medially & extending almost to entire diaphysis of femur
- Slide 22
- There was formation of mature involucrum around the sequestrum predominantly on anterolateral aspect of sequestrum
- Slide 23
- Sequestrum Involucrum
- Slide 24
- We planned to remove the entire sequestrum and all infected tissue with it.
- Slide 25
- Large diaphysial sequestrum Medially lying sequestrum Proximity to femoral vessels Intra operative bleeding from hyperemic infected tissue and bone
- Slide 26
- We decided to approach the femur antero-medially. Superficial plane was developed between rectus femoris and vastus medius
- Slide 27
- 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
- Slide 28
- Sequestrum being exposed
- Slide 29
- Sequestrum was exposed to its entire length and then extracted out
- Slide 30
- Sequestrum out from the wound
- Slide 31
- Sequestrum
- Slide 32
- Surrounding infected granulation is also removed giving a good clearance of infected tissue Rectus femoris v.intermedius v. medius Sequestrum was lying here
- Slide 33
- Local tissue looked healthy after debridement The sinus tract was also debrided After through irrigation wound was closed over a suction drain
- Slide 34
- Wound is now looking clean after sequestrectomy & debridement
- Slide 35
- Drain was removed after 48 hrs - First dressing There was only minimal bleeding through the sinus - Subsequent dressing were dry
- Slide 36
- 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.
- Slide 37
- Skin traction & physiotherapy was used to correct the flexion deformity And other measures were taken to improve the general condition of the patient
- Slide 38
- Pre operative Post operative
- Slide 39
- Happy patient !
- Slide 40