Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia
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Chronic osteomyilitis of femur with a large diaphysial sequestrum in an eight year old boy Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia
Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia
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
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
