Chronic Osteomyelitis is a progressive long-term infection of the bone and bone marrow characterized by the presence of involucrum and sequestrum.
Details on Chronic Osteomyelitis can be explained in this link.
Proper sequential and relevant history taking is very important in any short case to begin.
Unnecessary and long negative history will take time and burden for the examiner and examinee.
When a case of chronic osteomyelitis came in OSCE, Important questions that the examiner wants the student to know are:
Questions on the short cases of Chronic osteomyelitis
- What is the diagnosis?
- Why do you say so?
- What are other possibilities?
- How do you manage the case?
Most of the time students will give an incomplete diagnosis.
Diagnosis: Chronic osteomyelitis of the right femur (INCOMPLETE DIAGNOSIS)
So, a Complete diagnosis should include the following points:
Likely Etiology
- Pyogenic
- Tubercular
- Fungal
Mode of development
- Compound fracture
- Post-surgical
- Chronic on acute osteomyelitis
- Spontaneous osteomyelitis
Accompanying sequalae/ Complications
- Sinus: Discharging or Apparently dry
- Stiffness and deformity of adjoining joint
- Limb length discrepancy
- Angular deformity particularly in the pediatric age group
Pathological fractures
So, COMPLETE DIAGNOSIS
Chronic pyogenic osteomyelitis of right femur, post-surgical with discharging sinus, 2 inches of shortening of femur, with 20 degrees of equinus deformity and knee flexion range from 10 degrees to 100 degrees
After explaining the diagnosis examiner ask further questions supporting your diagnosis:
Why so?
- History of spread over weeks to months
- Sinus which is discharging pus or serosanguinous discharge
- History of passing out bony pieces or spicules
On examination
Puckered sinus
Pigmentation on the skin (Indicates long-standing lesion)
Bony tenderness
Thickened and rough bone
Joint Stiffness
Why not tubercular osteomyelitis or what are the features of tubercular osteomyelitis?
Tubercular Osteomyelitis
History of preceding sinus within months
No History of acute infectious disease
Constitutional symptoms: Weight loss, evening rise in temperature
Sinus: Bluish margin, undermined/ Serous discharge (at least initially)
Washing of the limb (disproportionate than any other disease)
History of pulmonary TB
Positive family of tuberculosis
In fungal Osteomyelitis:
Colored discharge, mostly multiple sinuses (uncommon in long bone)
Definition of some important terms:
Sinus
Epithelial lining tract, connecting body cavity to the exterior
Fistula
Abnormal communication between two hollow spaces lined by epithelial surfaces
Significance of granulation tissue at sinus mouth (Pouching granulation tissue)
How do you manage the case?
I will first investigate the case
- X-ray of part adequate and in two planes
- Sinogram
- CBC with ESR
- Gram stain, ZN Stain
- Pus culture and sensitivity
- Pre-anesthetic work up
Treatment
- Extensive debridement of devitalized bony and soft tissue
- A suction drain may be applied
- Appropriate antibiotics for 4-6 weeks, 2 weeks intravenous
- Soft tissue coverage
- Reconstruction
Saucerization: Methods where deep cavities are made into shallow cavities so that walls are short and drainage can come out easily
Details on Chronic Osteomyelitis management are on this link.
