May 30, 2024

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.

History taking in chronic osteomyelitis
History taking

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

  1. What is the diagnosis?
  2. Why do you say so?
  3. What are other possibilities?
  4. 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)

Cierny -Madar classification

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.