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Cellulitis without concomittant osteomyelitis

Coseo MC - MedPix (2007)

View Article: MedPix Image - MedPix Case

Affiliation: Uniformed Services University

ABSTRACT

Diagnosis: Cellulitis without concomittant osteomyelitis

History: This patient is a 33-year-old African American with multiple injuries from an improvised explosive device in Iraq. The patient sustained a traumatic below knee amputation (BKA) of the right lower extremity and a comminuted, open mid-diaphyseal left tibial and fibular fractures with a significant soft tissue defect. Taylor Spatial Frame was used to provide reduction and external fixation to his left tibia-fibula fractures, with a rectus flap and split thickness skin graft for the soft tissue injury. The patient was readmitted a month later with purulent drainage from the rectus flap that grew out methicillin-sensitive Staphylococcus aureus. The taylor spatial frame was removed and patient underwent multiple irrigation and debridement procedures. A tagged white blood cell scan was needed to determine if he had osteomyelitis associated with his cellulitis. If the soft tissue infection extended to bone, it would delay scheduling of the replacement of his Taylor Spatial Frame.

Findings: Radiographs: Anteroposterior and lateral radiographs left tibia and fibula show Gustillo-anderson classification Grade IIIB Tibia fracture with external fixation, and wound vacuum dressing covering covering soft tissue. Grade III B tibial fractures are characterized by a wound greater than 10 cm with a displaced fracture and diaphyseal segmental loss. The diagnosis is supported by the radiographic findings of an open, comminuted fracture of the tibia with limb shortening. Bone scans: 99m Technetium-Duration 900 sec: Anterior and Posterior views of the lower extremities 111 Indium-Duration 900 sec: Anterior and Posterior views of the lower extremities show a moderately intense accumulation of leukocytes at the metaphyseal region of the right tibia proximal to the amputation margin. Not associated with abnormal bone uptake, likely representing soft tissue inflammation. A mild to moderate increased leukocyte uptake about the medial aspect of the distal left lower leg and hindfoot, spanning multiple bones, seemingly superficially. A distribution suggestive of soft tissue inflammation. A mild increased leukocyte concentration at the proximal metaphyseal region of the left femur in the region of multiple penetrating fixation pins with a vertical orientation, mostly superficial to bone. Likely representing fracture callus and unlikely to represent infection tracking along fixation pins or the marrow cavity. Focally increased blood flow, blood pool and bone phase uptake of radiotracer at the mid left tibial fracture is not associated with abnormal leukocyte concentration. Other foci of mildly increased bone radiotracer concentrations and mild diffuse leukocyte concentrations are compatible with blast trauma and operative interventions. No suggestion of specific post-operative complications.

Ddx: 1. Osteomyelitis 2. Cellulitis 3. Fracture with callus formation

Dxhow: The results of the imaging studies provide evidence that there is a pathologic process occurring in the patient’s left lower extremity. However, the imaging studies show that leukocyte uptake crosses multiple bones and is superficial with a distribution that is more indicative of a cellulitis without concomitant osteomyelitis. Increased leukocyte uptake around fixation pin sites were concluded to be normal fracture callus formation. The imaging studies provide evidence to support a diagnosis of cellulitis but could not exclude osteomyelitis.

Exam: Deferred

No MeSH data available.


Anteroposterior and lateral radiographs left tibia and fibula show Gustillo-anderson classification Grade IIIB Tibia fracture with external fixation
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MPX1914_synpic33045: Anteroposterior and lateral radiographs left tibia and fibula show Gustillo-anderson classification Grade IIIB Tibia fracture with external fixation


Cellulitis without concomittant osteomyelitis

Coseo MC - MedPix (2007)

Anteroposterior and lateral radiographs left tibia and fibula show Gustillo-anderson classification Grade IIIB Tibia fracture with external fixation
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=MPX1914&req=5

MPX1914_synpic33045: Anteroposterior and lateral radiographs left tibia and fibula show Gustillo-anderson classification Grade IIIB Tibia fracture with external fixation

View Article: MedPix Image - MedPix Case

Affiliation: Uniformed Services University

ABSTRACT

Diagnosis: Cellulitis without concomittant osteomyelitis

History: This patient is a 33-year-old African American with multiple injuries from an improvised explosive device in Iraq. The patient sustained a traumatic below knee amputation (BKA) of the right lower extremity and a comminuted, open mid-diaphyseal left tibial and fibular fractures with a significant soft tissue defect. Taylor Spatial Frame was used to provide reduction and external fixation to his left tibia-fibula fractures, with a rectus flap and split thickness skin graft for the soft tissue injury. The patient was readmitted a month later with purulent drainage from the rectus flap that grew out methicillin-sensitive Staphylococcus aureus. The taylor spatial frame was removed and patient underwent multiple irrigation and debridement procedures. A tagged white blood cell scan was needed to determine if he had osteomyelitis associated with his cellulitis. If the soft tissue infection extended to bone, it would delay scheduling of the replacement of his Taylor Spatial Frame.

Findings: Radiographs: Anteroposterior and lateral radiographs left tibia and fibula show Gustillo-anderson classification Grade IIIB Tibia fracture with external fixation, and wound vacuum dressing covering covering soft tissue. Grade III B tibial fractures are characterized by a wound greater than 10 cm with a displaced fracture and diaphyseal segmental loss. The diagnosis is supported by the radiographic findings of an open, comminuted fracture of the tibia with limb shortening. Bone scans: 99m Technetium-Duration 900 sec: Anterior and Posterior views of the lower extremities 111 Indium-Duration 900 sec: Anterior and Posterior views of the lower extremities show a moderately intense accumulation of leukocytes at the metaphyseal region of the right tibia proximal to the amputation margin. Not associated with abnormal bone uptake, likely representing soft tissue inflammation. A mild to moderate increased leukocyte uptake about the medial aspect of the distal left lower leg and hindfoot, spanning multiple bones, seemingly superficially. A distribution suggestive of soft tissue inflammation. A mild increased leukocyte concentration at the proximal metaphyseal region of the left femur in the region of multiple penetrating fixation pins with a vertical orientation, mostly superficial to bone. Likely representing fracture callus and unlikely to represent infection tracking along fixation pins or the marrow cavity. Focally increased blood flow, blood pool and bone phase uptake of radiotracer at the mid left tibial fracture is not associated with abnormal leukocyte concentration. Other foci of mildly increased bone radiotracer concentrations and mild diffuse leukocyte concentrations are compatible with blast trauma and operative interventions. No suggestion of specific post-operative complications.

Ddx: 1. Osteomyelitis 2. Cellulitis 3. Fracture with callus formation

Dxhow: The results of the imaging studies provide evidence that there is a pathologic process occurring in the patient’s left lower extremity. However, the imaging studies show that leukocyte uptake crosses multiple bones and is superficial with a distribution that is more indicative of a cellulitis without concomitant osteomyelitis. Increased leukocyte uptake around fixation pin sites were concluded to be normal fracture callus formation. The imaging studies provide evidence to support a diagnosis of cellulitis but could not exclude osteomyelitis.

Exam: Deferred

No MeSH data available.