Name: Nahurira Godwin

Age: 13 years

Sex: Male

Address: Rukunjiri, Bushenyi

Tribe: Munyankole

Religion: Catholic

Student: Primary 4

Next of Kin: Auntie (Kakunda Costes)

Informant: Auntie

Date of Admission: 20th 2010

In Patient No.: 09935

Date of Discharge: still awaiting surgery

PRESENTING COMPLAINTS

 Swollen right leg x 1 year

 Projecting bone x 4/12

HISTORY OF PRESENTING COMPLAINTS

Godwin was relatively well until a year ago when he developed pain on the right leg. This followed minor
injuries he had sustained during a soccer game which were not treated. The pain gradually increased in
intensity as the leg started to swell. The pain was worse on moving and relieved by rest. Later he
developed a high grade fever that was worse at night and not relieved by tepid sponging. A few weeks
later multiple sinuses developed around the right ankle and mid leg and were discharging foul smelling
green-yellow pus. They applied topical herbs and he also drunk some of the herbs with minimal relief.
The sinuses continued to discharge and this rendered him bed ridden most of the time due to severe
pain on moving the limb. A few months later a bone protruded anteriorly through a tear along the line
of the sinuses. This caused marked pain and thus was taken to Nyakibale hospital where he was
admitted. An X-ray of the leg was taken and the bone was drilled and was given several antibiotics
intravenously and pain killers. Another operation to remove the bone was to be done but the hospital
lacked blood transfusion facilities hence they were referred to KIUTH. There was no history of muscle
pains or swollen painful joints.

1
REVIEW OF SYSTEMS

RESPIRATORY SYSTEM: There was no history of cough, chest pain, or difficulty in breathing.

CENTRAL NERVOUS SYSTEM: There was no history of headache, blurred vision or loss of consciousness.

GASTROINTESTINAL SYSTEM: There was no history of abdominal pain, anorexia, nausea or vomiting, and
no diarrhea or constipation.

GENITOURINARY SYSTEM: no change in micturition habits, volume and the colour was clear or yellow
without any dysuria.

PAST MEDICAL HISTORY

This was his 2nd admission. He had been admitted in Nyakibale hospital with similar complaints prior to
admission in KIUTH. He was given antibiotics and pain killers and had mild improvement.

He had no known drug or food allergies.

HIV serostatus was not known.

There was no history of chronic illnesses such as sickle cell disease, diabetes or malignancies.

PAST SURGICAL HISTORY

Bone drilling had been done at Nyakibale hospital prior to admission at KIUTH.

He had no history of burns or blood transfusion.

FAMILY SOCIAL HISTORY

He is the 1st born with 3 siblings, 2 sisters aged 11 and 10 years and a younger brother aged 4 years old.
They are all alive and well. The children stay with their maternal grandmother.

The father died in 2010 of HIV/AIDS and the mother does minor jobs in town and visits the children
irregularly.

Since the onset of the condition he has not been going to school for the last 1 year.

They live in a 2 roomed semi- permanent house.

They fetch water from a protected spring and the drinking water is boiled.

They dispose their domestic waste in a pit.

They do not sleep under insecticide treated mosquito nets.

A 13 year old boy who presented with 1 year history of swollen right leg following untreated minor
trauma that was followed by severe pain, fever, multiple sinuses with foul smelling green-yellow pus,
that was not relieved by topical or oral herbs. Later a bone projected through the skin and bone drilling
was done at a hospital with administration of intravenous antibiotics and analgesics and was referred to
KIUTH for further management.

GENERAL EXAMINATION

He was an adolescent, fully conscious and alert. Well groomed and in a fair nutritional status. He was
afebrile with a temperature of 36.5 °C. He had no pallor, no dehydration, no jaundice, no central
cyanosis, and no oedema. There was mild lymphadenopathy in the right inguinal region, which were
small, soft and not fixed to the skin or underlying subcutaneous tissue.

LOCAL EXAMINATION

The right leg was dressed and the dressing was wet with a foul smell. The right leg was swollen from the
ankle joint to the knee joint with a bone (tibia) projecting anteriorly along the sheen. The right ankle
joint had mild varus. The leg measured 34 cm in length from the greater trochanter to the medial
malleolus which was equal to the left. However the diameter was 12.8 cm on the right and 10 cm on the
left. The skin on the right leg was hyperpigmetted with multiple sinuses and skin desquamation
especially around the projecting bone with pus oozing out the sinuses and besides the bone. The right
leg was warm to touch compared to the left. The muscles were firm on the right and soft on the left and
mild tenderness was elicited. There was more bone content on the right that was irregular and rough
unlike the smooth regular bone on the left. The knee joint was not swollen and was actively movable
and not tender. The ankle joint was swollen with mild varus but was freely movable and not tender. He
was able to walk with mild discomfort and had normal gait.

OTHER SYSTEMS: were unremarkable.

PROBLEM LIST

1. Minor untreated trauma.

2. Severe leg pain with fever

3. Swollen right leg

4. Multiple discharging sinuses of foul smelling green-yellow pus

5. Protruding bone through the skin

6. Use of topical herbs

7. Poor social-economic status

Chronic osteomyelitis

DIFFERENTIAL DIAGNOSIS

1. Bone tumour

INVESTIGATIONS

1. X-ray of the leg: to see the extent of involucrum and the sequestrum

2. Computerised tomography scans; assses the cortex of bone for erosion and detect small
sequestra.

3. Magnetic resonance imaging; to demonstrate soft-tissue collections and sinus tracts.

4. Microbiology: to know the causative bacteria and its sensitivity to antibiotics to allow for specific
antimicrobial therapy.

5. Blood: haemoglobin estimation, grouping and, WBC count and differential.

6. Histology to identify dead bone.

RESULTS

1. The X-ray showed the sequestrum penetrating the soft tissues up to the skin, involucrum well
demarcated and multiple sinus tracts.

2. Other tests were not done due to lack of resources and limiting costs.

MANAGEMENT

The patient was admitted and the following was done prior to operation:

 IV metronidazole 500 mg 8 hourly x 5/7

 Caps Cloxacillin 500 mg 8 hourly x 5/7

The patient was still awaiting a sequestrectomy to be done.

4
DISCUSSION

Osteomyelitis is defined as a pyogenic infection of the bone. Classification:

1. According to severity: Acute; Subacute; and chronic osteomyelitis.

2. According to route of entry:

a) Haematogenous: spread of infection from a distant focus or infection of devitalized

b) Exogenous: direct trauma and inoculation of infectious material in compound fractures,

Etiology: common agents are:

1. In infants younger than 1 year of age: coliform organisms, Pseudomonas, Haemophilus influenza
and Salmonella.

2. Older than 6 years: Staphylococcus aureus acoounts for more than 80% of the cases. Others
include Streptococcus pneumonia and group A streptococci. Patients with sickle cell disease are
predisposed to Salmonella osteomyelitis.

Acute pyogenic infections are characterized by the formation of pus - a concentrate of defunct
leucocytes, dead and dying bacteria and tissue debris - which is often localized in an abscess. Pressure
builds up within the abscess and infection may then extend directly along the tissue planes. It may also
spread further afield via lymphatics (causing lymphangitis and lymphadenopathy) or via the bloodstream
(bacteraemia and septicaemia). The accompanying systemic reaction varies from a vague feeling of
lassitude with mild pyrexia to severe illness, fever, toxaemia and shock. The generalized effects are due
to the release of bacterial enzymes and endotoxins as well as cellular breakdown products from the host
tissues.

Chronic infection may follow on acute or, depending on the type of organism and the host reaction, it
may be 'chronic' from the start. It usually involves the formation of granulation tissue (a combination of
fibroblastic and vascular proliferation) leading to fibrosis. Some organisms provoke a ntin-pyogenic
reaction involving the formation of cellular granulomas which consist largely of lymphocytes, modified
macrophages and multinucleated giant cells; this is seen most typically in tuberculosis. Systemic effects
are less acute but may ultimately be very debilitating, with lymphadenopathy, splenomegaly and tissue
wasting.

The host response is crucial in determining the course of the disease. Resistance is likely to be depressed
in the very young and the very old, in states of malnutrition or immuno-suppression, and in certain
diseases such as diabetes.

Acute osteomyelitis is almost invariably a disease of children. When adults are affected it may be
because their resistance is lowered by debility, disease or drugs. Trauma may determine the site of
5
infection, possibly by causing a small haematoma or fluid collection in a bone. The blood stream is
invaded, perhaps from a minor skin abrasion, a boil, a septic tooth or - in the newborn - from an infected
umbilical cord. In adults the source of infection may be a urethral catheter, an indwelling arterial line or
a dirty needle and syringe. Organisms usually settle in the metaphysis, most often in the proximal tibia
or in the distal and proximal ends of the femur. This predilection for the metaphysis has been attributed
to the peculiar arrangement of the blood vessels in that area: the non-anastomosing terminal branches
of the nutrient artery twist back in hairpin loops before entering the large network of sinusoidal veins;
the relative vascular stasis favours bacterial colonization. In young infants, in whom there is still a free
anastomosis between metaphyseal and epiphyseal blood vessels, infection can just as easily lodge in the
epiphysis. In adults, haematogenous infection is more common in the vertebrae than in the long bones.
For Godwin he was 13 years old and sustained minor trauma to the leg and the infection affected the
tibia.
The pathological picture varies considerably, depending on the patient's age, the site of infection, the
virulence of the organism and the host response. However, underlying the variations there is a
characteristic pattern marked by inflammation, suppuration, necrosis, reactive new bone formation and,
ultimately, resolution and healing.
Clinical features of acute osteomyelitis are pain, fever, inflammation and acute tenderness unless
modified by antibiotics. X-ray is normal during the first 10 days.
Cellulitis is often mistaken for acute osteomyelitis. Other differentials include Streptococcal necrotizizing
myositis, acute suppurative arthritis, acute rheumatism, sickle cell crisis, and Gaucher’s disease.

Chronic osteomyelitis usually results from a delay in diagnosis or inadequate treatment. It is seen more
often in undeveloped countries. Bone is destroyed or devitalized in a discrete area at the focus of
infection or more diffusely along the surface of a foreign implant. Cavities containing pus and pieces of
dead bone (sequestra) are surrounded by vascular tissue, and beyond that by areas of sclerosis - the
result of chronic reactive new bone formation. The sequestra act as substrates for bacterial adhesion in
much the same way as foreign implants, ensuring the persistence of infection until they are removed or
discharged through draining sinuses. Sinuses may seal off for weeks or even months, giving the
appearance of healing, only to reopen (or appear somewhere else) when the tissue tension rises. Bone
destruction, and the increasingly brittle sclerosis, may occasionally result in a pathological fracture. The
histological picture is one of chronic inflammatory cell infiltration around areas of a cellular bone or
microscopic sequestra. The patient presents because pain, pyrexia, redness and tenderness have
recurred (a 'flare'), or with a discharging sinus. In long-standing cases the tissues are thickened and often
puckered or folded in where a scar or sinus is attached to the underlying bone. There may be a
seropurulent discharge and excoriation of the surrounding skin. In post-traumatic osteomyelitis the
bone may be deformed or non-united. Godwin presented with suppurative discharge and with an
already fractured bone that was penetrating through the skin.
X-ray examination will usually show bone resorption - either as a patchy loss of density or as frank
excavation around an implant - with thickening and sclerosis of the surrounding bone. However, there
are marked variations: there may be no more than localized loss of trabeculation, or an area of
osteoporosis, or periosteal thickening; sequestra show up as unnaturally dense fragments, in contrast to
the surrounding vascularized bone; sometimes the bone is crudely thickened and misshapen, resembling
a bone tumour.

The principles of treatment are: (1) to provide analgesia and general supportive measures; (2) rest the
affected part; (3) effective antibiotic or chemotherapy; and (4) surgical eradication of infected and
necrotic tissue. Special laboratory investigations may be needed to identify the infecting microbe and
6
test for the most effective microbicide. For acute infections, the timing of surgery is all-important: in the
early stages, antibiotics should be given a chance and the clinical condition carefully monitored to detect
signs of improvement or deterioration; if there is pus, it must be let out and the sooner the better. For
chronic infection, the choice between conservative and surgical treatment is much more difficult and
each case must be decided on its merits. The indication for surgical treatment in chronic osteomyelitis is
the presence of local pain and swelling, with or without drainage, in a bone with an area of lysis or a
sequestrum, or both. Godwin had swelling, bone lysis and a sequestrum. Removal of the sequestrum
and granulation tissue is the goal of the surgical exploration.

Complications:
1. Early:
 Bacteremia and septicemia which may lead to septic lesions in other locations e.g. lung
abscess, liver abscess;
 Skin sinus formation;
 Damage to the growth plate causing tethering, physeal bar, and subsequent growth
deformity;
 Septic arthritis.
2. Late:
 Limb shortening;
 Malignancy changes at the sinus site;
 Pathological fractures;
 Vascular necrosis of femoral head.
Godwin had early complications such as skin sinus formation, and a varus due to tethering of tendons.
He was also at a high risk for malignant change.

7
REFERENCES

1. R.C.G Russell, Norman S. Williams, & Christopher J.K. Bulstrode, BAILEY & LOVE’S SHORT
PRACTICE OF SURGERY, 24th Edition,© 2004 Edward Arnold (Publishers) Ltd.

2. Norman L. Browse, John Black, Kevin G. Burnand, William E.G. Thomas, BROWSE’S
INTRODUCTION TO THE SYMPTOMS AND SIGNS OF SURGICAL DISEASE, 4th Edition, ©2005
BookPower / ELST .

3. Louis Solomon, David Warwick, Selvadurai Nayagam, APLEY’S SYSTEM OF ORTHOPAEDICS AND
FRACTURES, 8th Edition, ©2001 Arnold A member of the Hodder Headline Group LONDON.

4. Lecture notes.