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2 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 1 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. 2 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 3 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 4 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 5 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. 6 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.