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Pseudomonas aeruginosa osteomyelitis of the distal phalanx of the great toe following blunt injury: a case report
Foot and Ankle Surgery 2001
7: 45±48
Case report
Pseudomonas aeruginosa osteomyelitis of the distal phalanx of the great toe following blunt injury: a case report K . R . S H A R P E , C . E . BR U C E A N D H . P . J . W A L S H Department of Orthopaedic and Trauma Surgery, Royal Liverpool Children's NHS Trust, Liverpool, UK
Summary
This is a case report of a young patient who sustained a blunt injury to the great toe distal phalanx when he had been wearing training shoes and subsequently developed Pseudomonas osteomyelitis. He had no puncture wound but did sustain a breach of the continuity between skin and the base of the nail. This case is highlighted to stress the importance of blunt injuries occurring to a foot in a training shoe when the deep structures are exposed and the possible consequences of such an event. Keywords: Pseudomonas aeruginosa osteomyelitis; distal phalanx; great toe; blunt injury
Case report A 12-year-old child presented to the Accident and Emergency Department with pain in the right great toe after kicking the kerb when wearing training shoes. The patient had a painful, swollen great toe with slight bleeding arising from the nail bed, around the margins of the nail. There was no deformity or bruising and radiographs were thought not to demonstrate any evidence of a fracture. Antibiotic treatment was not considered necessary, a dry dressing and neighbour strapping was applied and the patient was discharged. Later radiological review of the ®lms, however, revealed there to be an undisplaced fracture through the growth plate of the base of the distal phalanx of the right great toe. The boy was recalled and referred to the fracture clinic. Correspondence: K. R. Sharpe, c/o Secretary to Mr C. Bruce, Department of Trauma and Orthopaedics, Royal Liverpool Children's NHS Trust, Eaton Road, Liverpool, UK (e-mail: [email protected]). Ó 2001 Blackwell Science Ltd
Nine days after the original injury, the child was seen by the orthopaedic team. The patient complained of increasing pain and swelling in the big toe since the Accident and Emergency attendance and on examination the right great toe was swollen, red and tender with reduced movements of the interphalangeal joint. New radiographs were taken and these showed a lytic lesion in the base of the distal phalanx of the great toe. The patient was admitted for debridement and lavage of the presumed infection. Under general anaesthetic, a transverse incision was made over the dorsum of the distal phalanx distal to the extensor tendon insertion. Beneath the skin, a mass of granulation tissue was visible. Further dissection revealed a lytic defect of the underlying phalanx. The lesion extended to the growth plate and contained frank pus. Culture and sensitivity swabs were taken from within the lesion, and the defect was debrided, curetted and washed with 1 l of saline. The patient was empirically treated with intravenous Cefuroxime, pending the culture results. 45
46
(a)
K.R. SHARPE ET AL.
(b)
Figure 1 Radiograph of right foot great toe on day of injury.
(a)
(b)
Figure 2 Radiograph of right foot 9 days after injury at time of orthopaedic referral. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 45±48
PSEUDOMONAS AERUGINOSA OSTEOMYELITIS
(a)
47
(b)
Figure 3 Radiograph of right foot great toe 18 days after injury.
Further operative debridement proved to be necessary 3 days later when pus began to discharge from the wound, despite the initial treatment. Intravenous Cefuroxime was continued following the second procedure and the patient's clinical picture began to improve. Two days later, the patient was discharged on oral Cephradine. A further 2 days after discharge from hospital the child presented to the Accident and Emergency department again with recurrent symptoms of pain, swelling and discharge. Repeat radiographs demonstrated an increase in the size of the lytic area of the distal phalanx. The child was readmitted. By this time, culture and sensitivity results were available. Pseudomonas aeruginosa sensitive to Cipro¯oxacin had been cultured, and intravenous therapy was commenced. The distal phalanx was explored once more and was found to contain a modest amount of pus. The lesion was debrided again and the wound
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 45±48
kept open with a wick dressing. The dressing was changed regularly on the ward. Microbiological advice recommended a combination of parenteral Gentamycin and Ceftazidime by intravenous infusion in combination with topical 2% Tauroline dressings. Inpatient treatment was continued and over a 9-day period the appearance of the wound continued to improve. Systemic antibiotic treatment was subsequently discontinued at the recommendation of the microbiologists and topical 2% Tobamycin dressings were commenced. The patient was discharged and dressings were continued as an outpatient. The patient was reviewed at regular intervals in the outpatient clinic where the wound was observed to heal without further signs of infection. Follow up culture swabs, taken from the healing wound, eventually showed no growth for P. aeruginosa on several consecutive occasions.
48
K.R. SHARPE ET AL.
Discussion It is recognized that puncture wounds to the foot, sustained whilst the foot is within an athletic training type shoe, are strongly associated with the development of infection, particularly P. aeruginosa [1, 2]. These infections can be considerably destructive in their pathological course, leading to much tissue damage and bone loss if they progress to osteomyelitis [3]. The aggressive management of such wounds is therefore fully justi®ed. If an infection of this nature can be prevented or cut short by timely and appropriate intervention, then there is much to be gained. It would also be justi®able therefore that any breach of the skin sustained by blunt injury in an environment known to harbour Pseudomonas bacteria, should be regarded with equal caution. Our patient had an unrecognized Salter Harris fracture of the distal phalangeal base, which only served to complicate the clinical signi®cance of the blunt injury that had caused a breach in the integrity of the super®cial soft tissues. To facilitate as speedy a recovery as possible from such a situation, it is
paramount that the true severity of the injury should be appreciated as soon as possible. It is hoped that in highlighting this case, the signi®cance of blunt injury to a foot contained in a training shoe, where a breach of the skin is seen, might better be appreciated especially in the presence of a bony injury. We believe that early appropriate debridement and washout of a puncture wound to the foot is an essential part of management of these injuries if infection, especially P. aeruginosa, is to be prevented [4]. We would also countenance therefore a similar attitude to blunt injury to the foot±particularly at the toes±where deep structures have been exposed.
References 1 Jacobs RF, McCarthy RE, Elser JM. Pseudomonas osteochondritis complicating puncture wounds of the foot in children: a 10-year evaluation. J Infect Dis 1989; 160: 657±661. 2 Riley D. Pseudomonas osteomyelitis can occur in the foot after puncture wounds. Practitioner 1988; 22: 296±298. 3 Jarvis JH, Skipper J. Pseudomonas osteochondritis complicating puncture wounds in children. J Pediatr Orthop 1994; 14: 755±759. 4 Fitzgerald RH Jr, Cowan JD. Puncture wounds of the foot. Orthop Clin North Am October, 1975; 6: 965±972.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 45±48
7: 45±48
Case report
Pseudomonas aeruginosa osteomyelitis of the distal phalanx of the great toe following blunt injury: a case report K . R . S H A R P E , C . E . BR U C E A N D H . P . J . W A L S H Department of Orthopaedic and Trauma Surgery, Royal Liverpool Children's NHS Trust, Liverpool, UK
Summary
This is a case report of a young patient who sustained a blunt injury to the great toe distal phalanx when he had been wearing training shoes and subsequently developed Pseudomonas osteomyelitis. He had no puncture wound but did sustain a breach of the continuity between skin and the base of the nail. This case is highlighted to stress the importance of blunt injuries occurring to a foot in a training shoe when the deep structures are exposed and the possible consequences of such an event. Keywords: Pseudomonas aeruginosa osteomyelitis; distal phalanx; great toe; blunt injury
Case report A 12-year-old child presented to the Accident and Emergency Department with pain in the right great toe after kicking the kerb when wearing training shoes. The patient had a painful, swollen great toe with slight bleeding arising from the nail bed, around the margins of the nail. There was no deformity or bruising and radiographs were thought not to demonstrate any evidence of a fracture. Antibiotic treatment was not considered necessary, a dry dressing and neighbour strapping was applied and the patient was discharged. Later radiological review of the ®lms, however, revealed there to be an undisplaced fracture through the growth plate of the base of the distal phalanx of the right great toe. The boy was recalled and referred to the fracture clinic. Correspondence: K. R. Sharpe, c/o Secretary to Mr C. Bruce, Department of Trauma and Orthopaedics, Royal Liverpool Children's NHS Trust, Eaton Road, Liverpool, UK (e-mail: [email protected]). Ó 2001 Blackwell Science Ltd
Nine days after the original injury, the child was seen by the orthopaedic team. The patient complained of increasing pain and swelling in the big toe since the Accident and Emergency attendance and on examination the right great toe was swollen, red and tender with reduced movements of the interphalangeal joint. New radiographs were taken and these showed a lytic lesion in the base of the distal phalanx of the great toe. The patient was admitted for debridement and lavage of the presumed infection. Under general anaesthetic, a transverse incision was made over the dorsum of the distal phalanx distal to the extensor tendon insertion. Beneath the skin, a mass of granulation tissue was visible. Further dissection revealed a lytic defect of the underlying phalanx. The lesion extended to the growth plate and contained frank pus. Culture and sensitivity swabs were taken from within the lesion, and the defect was debrided, curetted and washed with 1 l of saline. The patient was empirically treated with intravenous Cefuroxime, pending the culture results. 45
46
(a)
K.R. SHARPE ET AL.
(b)
Figure 1 Radiograph of right foot great toe on day of injury.
(a)
(b)
Figure 2 Radiograph of right foot 9 days after injury at time of orthopaedic referral. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 45±48
PSEUDOMONAS AERUGINOSA OSTEOMYELITIS
(a)
47
(b)
Figure 3 Radiograph of right foot great toe 18 days after injury.
Further operative debridement proved to be necessary 3 days later when pus began to discharge from the wound, despite the initial treatment. Intravenous Cefuroxime was continued following the second procedure and the patient's clinical picture began to improve. Two days later, the patient was discharged on oral Cephradine. A further 2 days after discharge from hospital the child presented to the Accident and Emergency department again with recurrent symptoms of pain, swelling and discharge. Repeat radiographs demonstrated an increase in the size of the lytic area of the distal phalanx. The child was readmitted. By this time, culture and sensitivity results were available. Pseudomonas aeruginosa sensitive to Cipro¯oxacin had been cultured, and intravenous therapy was commenced. The distal phalanx was explored once more and was found to contain a modest amount of pus. The lesion was debrided again and the wound
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 45±48
kept open with a wick dressing. The dressing was changed regularly on the ward. Microbiological advice recommended a combination of parenteral Gentamycin and Ceftazidime by intravenous infusion in combination with topical 2% Tauroline dressings. Inpatient treatment was continued and over a 9-day period the appearance of the wound continued to improve. Systemic antibiotic treatment was subsequently discontinued at the recommendation of the microbiologists and topical 2% Tobamycin dressings were commenced. The patient was discharged and dressings were continued as an outpatient. The patient was reviewed at regular intervals in the outpatient clinic where the wound was observed to heal without further signs of infection. Follow up culture swabs, taken from the healing wound, eventually showed no growth for P. aeruginosa on several consecutive occasions.
48
K.R. SHARPE ET AL.
Discussion It is recognized that puncture wounds to the foot, sustained whilst the foot is within an athletic training type shoe, are strongly associated with the development of infection, particularly P. aeruginosa [1, 2]. These infections can be considerably destructive in their pathological course, leading to much tissue damage and bone loss if they progress to osteomyelitis [3]. The aggressive management of such wounds is therefore fully justi®ed. If an infection of this nature can be prevented or cut short by timely and appropriate intervention, then there is much to be gained. It would also be justi®able therefore that any breach of the skin sustained by blunt injury in an environment known to harbour Pseudomonas bacteria, should be regarded with equal caution. Our patient had an unrecognized Salter Harris fracture of the distal phalangeal base, which only served to complicate the clinical signi®cance of the blunt injury that had caused a breach in the integrity of the super®cial soft tissues. To facilitate as speedy a recovery as possible from such a situation, it is
paramount that the true severity of the injury should be appreciated as soon as possible. It is hoped that in highlighting this case, the signi®cance of blunt injury to a foot contained in a training shoe, where a breach of the skin is seen, might better be appreciated especially in the presence of a bony injury. We believe that early appropriate debridement and washout of a puncture wound to the foot is an essential part of management of these injuries if infection, especially P. aeruginosa, is to be prevented [4]. We would also countenance therefore a similar attitude to blunt injury to the foot±particularly at the toes±where deep structures have been exposed.
References 1 Jacobs RF, McCarthy RE, Elser JM. Pseudomonas osteochondritis complicating puncture wounds of the foot in children: a 10-year evaluation. J Infect Dis 1989; 160: 657±661. 2 Riley D. Pseudomonas osteomyelitis can occur in the foot after puncture wounds. Practitioner 1988; 22: 296±298. 3 Jarvis JH, Skipper J. Pseudomonas osteochondritis complicating puncture wounds in children. J Pediatr Orthop 1994; 14: 755±759. 4 Fitzgerald RH Jr, Cowan JD. Puncture wounds of the foot. Orthop Clin North Am October, 1975; 6: 965±972.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 45±48