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Dr Nirmal Kumar Sinha & Dr Rajaram Pai [Manipal campus] Melaka-Manipal Medical College, Malaysia
An eight year old boy presented to us in June’06 with a H/O discharging sinus since last 1 year in lower and medial aspect of right thigh.
Clinical picture of the case
In May’05, patient developed high fever with acute pain in the lower part of thigh.
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
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.
Pain, fever and swelling decreased considerably after the drainage of pus
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
The patient was getting the dressing changed at a nearby health post. No h/o passing bone chips through the wound
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
There was moderate rise of temp locally, the femur was tender, broader and irregular all along the length.
Fixed flexion deformity
There was a discharging sinus on the medial aspect of lower third of thigh The sinus was fixed to the underlying bone
There was puckering of skin around the sinus There was seropurulent discharge through the sinus
There was true shortening of 1 cm in the infra-trochanteric thigh segment, There was no distal neurovascular deficit
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
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
Blood - Hb g/dl - ESR – 86 mm/hr - Neutrophils- 80
Heavy growth of Staph. Aureus, and scanty growth of gram negative bacilli
X-ray showed involvement of entire diaphysis and lower metaphysis
There was large sequestrum lying medially & extending almost to entire diaphysis of femur
There was formation of mature involucrum around the sequestrum predominantly on anterolateral aspect of sequestrum
We planned to remove the entire sequestrum and all infected tissue with it.
Large diaphysial sequestrum Medially lying sequestrum Proximity to femoral vessels Intra operative bleeding from hyperemic infected tissue and bone
We decided to approach the femur antero-medially. Superficial plane was developed between rectus femoris and vastus medius
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
Sequestrum being exposed
Sequestrum was exposed to its entire length and then extracted out
Sequestrum out from the wound
Surrounding infected granulation is also removed giving a good clearance of infected tissue Rectus femoris v.intermedius v. medius Sequestrum was lying here
Local tissue looked healthy after debridement The sinus tract was also debrided After through irrigation wound was closed over a suction drain
Wound is now looking clean after sequestrectomy & debridement
Drain was removed after 48 hrs - First dressing There was only minimal bleeding through the sinus - Subsequent dressing were dry
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.
Skin traction & physiotherapy was used to correct the flexion deformity And other measures were taken to improve the general condition of the patient
Pre operative Post operative
Happy patient !
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