Download Osteomyelitis

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TOPIC
PAGE(S)
Introduction and Brief Patient History………………………………………………… 1
What is Osteomyelitis and it’s Symptoms? ...................................................................... 1
Standard X-Ray Projections…………………………………………………………… 2
Diagnosis and Procedures……………………………………………………………… 2-3
Treatments……………………………………………………………………………… 3-4
Conclusion/Summary…………………………………………………………………... 5
References……………………………………………………………………………… 6
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Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through
the bloodstream or spreading from nearby tissue. Osteomyelitis can also begin in the bone itself
if an injury exposes the bone to germs. People who have diabetes may develop Osteomyelitis in
their feet if they have foot ulcers which lead to a major amputation. Early recognition, proper
assessment, and prompt intervention are vital. In the following pages, you will find a detailed
report describing the condition, the methods used to reach the conclusions, some comparisons, as
well as a brief description of the prognosis of the disease and how it can be treated.
The case that caught my attention was a 49 year old male who entered the emergency
department in Lutheran Medical Center at approximately 9 o’clock in the morning. The patient
was on a stretcher. His doctor requested 3 different views of x-ray to be done on his right foot.
The clinical history and reason for the exam was to rule out Osteomyelitis. Also, there was a
surgical amputation of the fifth toe and metatarsal of the right foot.
The symptoms of Osteomyelitis often develop more gradually. Patients who develop
Osteomyelitis tend to have symptoms and signs which include pain, fever, chills, irritability,
swelling or redness over the affected bone. The symptoms and signs may vary. For example, in
people with diabetes, peripheral neuropathy, or peripheral vascular disease, there may be no pain
or fever. The only symptom may be an area of skin breakdown that is worsening or not healing.
In this case, the patient was brought to the hospital due to pain and tenderness of his right foot. In
the same time, there was a surgical amputation done to his fifth toe and the metatarsal of the
right foot. The procedure was performed under the previous diagnosis of soft tissue swelling of
the fifth toe with the pockets of air in the soft tissue. Moreover, evidence of destruction of the
fifth toe and the findings was compatible with Osteomyelitis.
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The standard projection of the foot includes the anterior-posterior (AP), internal oblique, and
lateral view. In this case, the patient was on a stretcher and all views were taken as a table top
using a DR cassette. The technique used for radiographing the foot is usually between 2-4 mAS
and 53-60kV. These particular radiographs were taken at 2 mAS and 62 kV. The technique had
to be increased due to the cast the patient had. The patient was shielded in all the views to protect
him from unnecessary radiation and the collimation was only to the point of interest. In all of the
views, the source-to-image receptor distance (SID) was 40 inch to table top. My right marker
was placed on the cassette and exposed with the patient in all the views. In the AP view, the
patient was supine and the right leg was flexed enough to place the entire plantar surface of the
foot firmly flat on the IR. The tube was angled 10 degree cephalic (toward the heel) entering the
base of the third metatarsal. In the internal oblique view, the patient was also supine and the right
leg was flexed, but the patient’s leg was rotated medially until the plantar surface of the foot
formed a 30 degree angle with the IR. The center ray was perpendicular to the base of the third
metatarsal. In the lateral view, the patient was turned toward the affected side (right side) until
the foot and ankle were in lateral view. The opposite leg was behind the affected leg and the
center ray was perpendicular through the base of the third metatarsal. Due to the cast, palpation
and perfect alignment were limited.
How do doctors diagnose Osteomyelitis? In general, doctors may order a combination of
tests and procedures to determine which germ is causing the infection. Blood tests may reveal
elevated levels of white blood cells and other factors that may indicate that a patient’s blood is
fighting an infection. If Osteomyelitis was caused by an infection in the blood, tests may reveal
what germs are to blame. No blood test exists that tells a doctor whether the patients do or do not
have Osteomyelitis. However, blood tests do give clues that the doctors use to decide what
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further tests and procedures the patient may need. The x-rays are to determine any damages in
the bone. However, damage may not be visible until Osteomyelitis has been present for several
weeks. The problem is that many times they are initially inconclusive. Bone has to lose upwards
of fifty percent of its density before changes will be seen on x-ray. By the time it takes the bone
to lose this much density (2 to 6 weeks) and show up on an x-ray the bacteria has fairly well
infiltrated the bone. In that case, doctors explain to their patients that amputation of the affected
area is a must to prevent the spread of the infection. Furthermore, detailed imaging tests may be
necessary if your Osteomyelitis has developed more recently. Computerized tomography (CT)
and Magnetic resonance imaging (MRI) are examples of detailed images. A CT scan combines
x- ray images taken from many different angles, creating detailed cross- sectional views of
person’s internal structures. An MRI use radio waves and a strong magnetic field. MRI’s can
produce exceptionally detailed images of bones and the soft tissues that surround them. Finally, a
bone biopsy is the gold standard for diagnosing Osteomyelitis, because it can also reveal what
particular type of germ has infected your bone. Knowing the type of germ allows doctors to
choose an antibiotic that works particularly well for that type of infection. An open biopsy
requires anesthesia and surgery to access the bone. In some situations, a surgeon inserts a long
needle through your skin and into your bone to take a biopsy. This procedure requires local
anesthetics to numb the area where the needle is inserted. An x-ray or other imaging scans may
be used for guidance.
It is easy to compare a normal foot x-ray images with abnormal images if the patient has
acute Osteomyelitis and the part that effected must be amputate. A regular x-ray of a foot would
show the entire foot in profile with no bone of foot missing and no swelling of any part of that
foot. A foot with Osteomyelitis would have a slightly grayness around the foot, which means
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infection or accumulation of fluids around a particular area of the foot. Also, the phalange or the
part of the bone that has the infection would show as having slightly less dense than the other
bone of the foot. In this case, the fifth phalange and the metatarsal of the patient’s right foot were
missing.
In many cases, Osteomyelitis can be effectively treated with antibiotics and pain
medications. If a biopsy is obtained, this can help guide the choice of the best antibiotic. The
duration of treatment of Osteomyelitis with antibiotics is usually four to eight weeks, but varies
with the type of infection and the response to the treatments. In some cases, the affected area will
be immobilized with a brace to reduce the pain and speed the treatment. In this case, amputation
was a must to prevent the spread of the infection.
With early diagnosis and appropriate treatment, the prognosis for Osteomyelitis is good.
Antibiotics regimes are used for four to eight weeks and sometimes longer in the treatment of
Osteomyelitis depending on the bacteria that caused it and the response of the patient.
Commonly, patients can make a full recovery without longstanding complications. However, if
there is a long delay in diagnosis or treatment, there can be severe damage to the bone or
surrounding soft tissues that can lead to permanent deficits or make the patient more prone to
reoccurrence. If surgery or bone grafting is needed, this will prolong the time it takes to recover.
In this particular case and after the successful surgery, a cast is used to ensure that the bones heal
properly. Luckily the amputation in this case was for the fifth toe and the metatarsal bone only;
therefore, there is no need for special shoes for this patient. This patient will probably visit the
doctor more often in the future to make a complete examination of his lower extremities. This
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will help in detecting any new destruction in the bones and the patient will stand a better chance
of resolving the infection with antibiotics.
Toe amputation due to bone infection is a common procedure by a wide variety of health care
providers. The method of toe amputation and the level of amputation are determined by the
extent of the infection. Osteomyelitis is a type of bone infection that can lead to the amputation
of the effected part in most cases. Therefore, early recognition and proper treatment are
mandatory to avoid poor outcomes.
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 Eugene D. Frank, Bruce W. Long, Barbara J. Smith. Merrill’s Atlas of
Radiographic Positioning and Procedures: Volume 1, 12e. March 2, 2011. Print.
 Davis BL. Kuznicki J. Praveen SS. Sferra JJ. Lower-extremity amputations in
patients with diabetes: pre-and post- surgical decisions related to successful
rehabilitation. Diabetes Metab Res Rev 2004: Web 2 October 2013.
 Kofler, Johann. Feist Melanie. Starke, Alexander. Nuss,Karl. Berliner Munchener
Tieraztliche Wochenschift Volume:120. P56-164.published:Mar-Apr 2007. Web.
2 October 2013.

Malizos, Konstantions N.; Gougoulias, Nikolaos E.; DAILIANA, Zoe H.;
Varitimidis, Sokrati; Bargiotas, Konstantinos A.; Paridis, Dionysios. Injury. Mar
2010, Vol. 41 Issue 3, p285-293. Web. 2 October 2013.