- Email: [email protected]
Temporomandibular joint destruction after a burn
2 14
Burns,10,2
14-2 16
Printedin Great Britain
Temporomandibular burn
joint destruction
after a
L. Hilbert, W. J. Peters and P. S. Tepperman Toronto General Hospitaland
Mount Sinai Hospital, Toronto, Ontario, Canada
Summary
A case is presented of temporomandibular joint destruction diagnosed 6 months after a 24 per cent third-degree bum. The aetiology appears to have been a septic arthritis.
INTRODUCTION JOINT involvement after a bum injury occurs with an incidence of about l-2 per cent (Evans, 1973). Musculoskeletal involvement may, however, be overlooked, because it often fails to produce symptoms that would warrant radiological investigation (Evans, 1973; Jackson, 1980). The present report describes an unusual case of temporomandibular (TM) joint destruction, diagnosed
6 months
after a major bum.
CASE REPORT A 37-year-old East Indian man, with a long history of paranoid schizophrenia, was admitted with a selfinflicted 24 per cent third-degree flame bum to his neck, arms, chest and abdomen. Following fluid resuscitation and stabilization, excision of the eschar was performed on the fourth day postbum. Two days later, the patient became febrile, tachypnoeic, more confused and hypotensive (requiring vasopressor support) with an elevated cardiac output and markedly decreased peripheral vascular resistance. A diagnosis of sepsis was made. The patient was given a full course of cloxacillin and tobramvcin. Multinle blood cultures were negative. Three weeks postbum, all burned areas were skin grafted. Periodically the patient continued to spike temperatures of 39.0-39.5 “C. All blood cultures continued to be negative. Searches for other sources of infection also proved to be negative. Seven weeks postbum, the patient was noted to have a left otitis extema. A culture showed Proteus mirabilis, Staphylococcus
aweus and Enterococci. A IO-day course of ampicillin was initiated and he subsequently remained afebrile. He was then transferred to an active rehabilitation medicine unit for extensive physical and psychiatric rehabilitation. Approximately 3 months postbum, the patient developed restricted movement in his elbows and shoulders. Radiographs of these joints showed evidence of early heterotopic bone formation. A bone scan demonstrated increased uptake in both elbows and shoulders (Fig. la). In addition, the bone scan surprisingly indicated increased uptake in the region of the left TM joint (Fig. 1 a-c). A Gallium scan was negative. Tomograms of the left TM joint (Fig. 2) revealed erosion and sclerotic changes of the condylar head, with destructive changes of the temporal aspect. A CT scan showed no evidence of intracranial extension of this process. Further examination of the patient-who remained symptomatically schizophrenic-showed pain and restricted motion of the left TM joint. ESR was 16, WBC 5. I, and a differential count was negative. A joint aspirate failed to show any bacterial growth. Repeat tomograms and bone scan I year postbum were unchanged. The patient’s pain had settled, but his ankylosis persisted, with maximum mouth opening reduced to 2.2 cm. He continues with his psychiatric rehabilitation.
DISCUSSION
The commonest destructive joint changes following bums are: septic arthritic, heterotopic ossification and dislocation (Evans, 1973). The early clinical case of the present patient (septicaemia with a 7-week history of periodic unexplained temperature spikes) appears to suggest an aetiology of septic arthritis of haematogenous
origin.
The previous
antibiotic
therapy
b
a
Fig. I. a-c, Bone scan 3 months postbum showing increased uptake in both elbows and shoulders, and in the region of the left TM joint.
C
Fig. 2. Comparable tomograms of the left (a) and right (b) TM joints 3 months postbum.
probably explains the negative growth of the joint aspirate. Septic arthritis following burns is most common in exposed joints (Evans, 1973; Jackson, 1976). Excluding these penetrating injuries, septic arthritis most frequently occurs in hips, knees, ankles and wrists (Evans, 1973). A literature search revealed only one other ease of TM joint involvement after a burn (Schwartz et al., 1976). In that case, a diagnosis was not made until 5 years after the bum injury. Interestingly, that patient and the present case showed coexistent extensive heterotopic ossification involving other joints. Correspondence
REFERENCES Evans E. B. (1973) Bone and joint changes secondary to bums. In: Lynch J. B. and Lewis S. R. (ed.): Symposium on the Treatment of Burns. St Louis, Mosby, p. 76. Jackson D. M. (1976) Bums into joints. Burns 2, 90. Jackson D. M. (1980) Destructive bums: some orthopaedic complications. Burns 7, 105. Schwartz E. E., Weiss w. and Plotkin R. (1976) Ankylosis of the temporomandibular joint following bum. JAMA 235, 1477.
Paper accepted 5 August 1983.
should be addressed to: L. Hilbert, Toronto General Hospital, Toronto, Ontario,
BRITISH
BURN
Canada.
ASSOCIATION
1984 Meeting
Date: 26-27 April 1984. Venue: Writtle Agricultural
College, Near Chelmsford,
Essex.
Host and meeting organiser: Dr. M. D. Eve, Burn Unit, St. Andrew’s Hospital, Essex.
Billericay,
Abstracts and papers.for the meeting to. Dr J. C. Lawrence, M. R. C. Bums Research Group, Accident Hospital, Birmingham 15.
Burns,10,2
14-2 16
Printedin Great Britain
Temporomandibular burn
joint destruction
after a
L. Hilbert, W. J. Peters and P. S. Tepperman Toronto General Hospitaland
Mount Sinai Hospital, Toronto, Ontario, Canada
Summary
A case is presented of temporomandibular joint destruction diagnosed 6 months after a 24 per cent third-degree bum. The aetiology appears to have been a septic arthritis.
INTRODUCTION JOINT involvement after a bum injury occurs with an incidence of about l-2 per cent (Evans, 1973). Musculoskeletal involvement may, however, be overlooked, because it often fails to produce symptoms that would warrant radiological investigation (Evans, 1973; Jackson, 1980). The present report describes an unusual case of temporomandibular (TM) joint destruction, diagnosed
6 months
after a major bum.
CASE REPORT A 37-year-old East Indian man, with a long history of paranoid schizophrenia, was admitted with a selfinflicted 24 per cent third-degree flame bum to his neck, arms, chest and abdomen. Following fluid resuscitation and stabilization, excision of the eschar was performed on the fourth day postbum. Two days later, the patient became febrile, tachypnoeic, more confused and hypotensive (requiring vasopressor support) with an elevated cardiac output and markedly decreased peripheral vascular resistance. A diagnosis of sepsis was made. The patient was given a full course of cloxacillin and tobramvcin. Multinle blood cultures were negative. Three weeks postbum, all burned areas were skin grafted. Periodically the patient continued to spike temperatures of 39.0-39.5 “C. All blood cultures continued to be negative. Searches for other sources of infection also proved to be negative. Seven weeks postbum, the patient was noted to have a left otitis extema. A culture showed Proteus mirabilis, Staphylococcus
aweus and Enterococci. A IO-day course of ampicillin was initiated and he subsequently remained afebrile. He was then transferred to an active rehabilitation medicine unit for extensive physical and psychiatric rehabilitation. Approximately 3 months postbum, the patient developed restricted movement in his elbows and shoulders. Radiographs of these joints showed evidence of early heterotopic bone formation. A bone scan demonstrated increased uptake in both elbows and shoulders (Fig. la). In addition, the bone scan surprisingly indicated increased uptake in the region of the left TM joint (Fig. 1 a-c). A Gallium scan was negative. Tomograms of the left TM joint (Fig. 2) revealed erosion and sclerotic changes of the condylar head, with destructive changes of the temporal aspect. A CT scan showed no evidence of intracranial extension of this process. Further examination of the patient-who remained symptomatically schizophrenic-showed pain and restricted motion of the left TM joint. ESR was 16, WBC 5. I, and a differential count was negative. A joint aspirate failed to show any bacterial growth. Repeat tomograms and bone scan I year postbum were unchanged. The patient’s pain had settled, but his ankylosis persisted, with maximum mouth opening reduced to 2.2 cm. He continues with his psychiatric rehabilitation.
DISCUSSION
The commonest destructive joint changes following bums are: septic arthritic, heterotopic ossification and dislocation (Evans, 1973). The early clinical case of the present patient (septicaemia with a 7-week history of periodic unexplained temperature spikes) appears to suggest an aetiology of septic arthritis of haematogenous
origin.
The previous
antibiotic
therapy
b
a
Fig. I. a-c, Bone scan 3 months postbum showing increased uptake in both elbows and shoulders, and in the region of the left TM joint.
C
Fig. 2. Comparable tomograms of the left (a) and right (b) TM joints 3 months postbum.
probably explains the negative growth of the joint aspirate. Septic arthritis following burns is most common in exposed joints (Evans, 1973; Jackson, 1976). Excluding these penetrating injuries, septic arthritis most frequently occurs in hips, knees, ankles and wrists (Evans, 1973). A literature search revealed only one other ease of TM joint involvement after a burn (Schwartz et al., 1976). In that case, a diagnosis was not made until 5 years after the bum injury. Interestingly, that patient and the present case showed coexistent extensive heterotopic ossification involving other joints. Correspondence
REFERENCES Evans E. B. (1973) Bone and joint changes secondary to bums. In: Lynch J. B. and Lewis S. R. (ed.): Symposium on the Treatment of Burns. St Louis, Mosby, p. 76. Jackson D. M. (1976) Bums into joints. Burns 2, 90. Jackson D. M. (1980) Destructive bums: some orthopaedic complications. Burns 7, 105. Schwartz E. E., Weiss w. and Plotkin R. (1976) Ankylosis of the temporomandibular joint following bum. JAMA 235, 1477.
Paper accepted 5 August 1983.
should be addressed to: L. Hilbert, Toronto General Hospital, Toronto, Ontario,
BRITISH
BURN
Canada.
ASSOCIATION
1984 Meeting
Date: 26-27 April 1984. Venue: Writtle Agricultural
College, Near Chelmsford,
Essex.
Host and meeting organiser: Dr. M. D. Eve, Burn Unit, St. Andrew’s Hospital, Essex.
Billericay,
Abstracts and papers.for the meeting to. Dr J. C. Lawrence, M. R. C. Bums Research Group, Accident Hospital, Birmingham 15.