Narrow Results

Introduction: We report the presentation, management, and outcome in five children with osteoarticular tuberculosis of distal radius.

Patients: Patients were recruited in a prospective study. All patients underwent an open biopsy, curettage and diagnosis confirmed by histopathological/microbiological examination. In cavitary lytic lesions, bone grafting was also undertaken. The multidrug anti-tubercular chemotherapy was given for one year.

Observations: Five patients were included in the study. The average follow-up post-completion chemotherapy was 34.8 months. Bony lesions presented as a poorly defined radiolucent lytic area in metaphysis, cavitary lytic lesions with or without sequestrum or spanned the physeal plate. At final follow-up, except for one case, a full pain free range of movements was achieved in all cases. Fibular graft was used in two cases with cavitary lesions and incorporated well in both cases.

Conclusions: Tuberculosis can involve the adjacent physis and can be multifocal. The presentation is usually lytic with minimal sclerosis. For smaller ill defined lesions, curettage and multidrug anti-tubercular chemotherapy results in excellent outcome. Cavitary lytic lesions should be bone grafted as there is a risk of pathological fractures.

The number of domestic animal bites is on an uptrend, but the numbers are underestimated as not all patients visit hospitals to seek treatment [Lee KJ et al. Domestic dog and cat bites: Epidemiology and analysis of 823 cases over the last 5 years. J Wound Manag Res 15 (2): 68-77, 2019]. Among all bites, bites to the extremities such as hands and fingers have a higher rate of infection than elsewhere in the body due to superficial structures and high vascularity, which can aid the rapid spread of the infection [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43 (6): 590–594, 2016]. The general perception of the public about pet animal bite is that wounds that are larger and have extensive tissue involvement are dangerous, while meager puncture wounds or scratches are harmless [Kim JWK, Kim JY, Kim UG, Kang DH, Kim DS, Kim JD. Treatment of phalangeal osteomyelitis caused by a cat bite. Clin Case Reports 9 (10): 1–10, 2021]. In contrast, a small penetrating puncture injury by a pet is often considered harmless and is not treated properly, which eventually requires surgical procedure and results in permanent functional impairment for the patient [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43(6): 590–594, 2016]. Animal bites to the extremities, particularly the hands and fingers are commonly encountered as they are the most exposed parts of the body. Such bites can result in inflammation of the tendon sheath, septic arthritis, and in some cases, osteomyelitis, depending on the depth of the bite [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43 (6): 590–594, 2016]. Dog bites usually do not reach up to bone-deep, while cat bites tend to cause deep, penetrating wounds due to their sharp needle-like teeth, which can pierce joint capsules and inoculate oral flora deeper into joint capsule and periosteum [Lee KJ et al. Domestic dog and cat bites: Epidemiology and analysis of 823 cases over the last 5 years. J Wound Manag Res 15(2): 68–77, 2019; Kim JWK, Kim JY, Kim UG, Kang DH, Kim DS, Kim JD. Treatment of phalangeal osteomyelitis caused by a cat bite. Clin Case Reports9(10): 1–10, 2021; Elcock KL, Reid J, Moncayo-Nieto OL, Rust PA. Biting the hand that feeds you: Management of human and animal bites. Injury 53(2): 227–236, 2022, https://doi.org/10.1016/j.injury.2021.11.045]. Conversely, dog bites are more destructive causing large wounds that drain freely [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43(6): 590–594, 2016]. This is one of the most important reasons why cat bites are more harmful than dog bites. Pasteurella multocida, a small Gram-negative coccobacillus, is an oral commensal in many domestic animals, particularly dogs (isolated in 50–60% of cultures) and cats (isolated in 70–90% of cultures) harbor a higher proportionate of this organism in their oral cavity [Chodakewitz J, Bia FJ. Septic arthritis and osteomyelitis from a cat bite. Yale J Biol Med 61(6): 513–518, 1988]. Human infections with P. multocida are commonly encountered following animal bites or scratches [Kim JWK, Kim JY, Kim UG, Kang DH, Kim DS, Kim JD. Treatment of phalangeal osteomyelitis caused by a cat bite. Clin Case Reports 9(10): 1–10, 2021]. However, these can also occur in the absence of trauma in cases where the animal’s secretions come in contact with a wound or mucous membrane of an individual [Elcock KL, Reid J, Moncayo-Nieto OL, Rust PA. Biting the hand that feeds you: Management of human and animal bites. Injury 53(2): 227–236, 2022, https://doi.org/10.1016/j.injury.2021.11.045; Chodakewitz J, Bia FJ. Septic arthritis and osteomyelitis from a cat bite. Yale J Biol Med 61(6): 513–518, 1988]. We present a case report of a child with a pet cat bite to the right hand, leading to osteomyelitis of the trapezoid bone due to negligence.

Background: There are many options to treat post osteomyelitic gaps in forearm bones. We report a pediatric series with postosteomyelitic forearm segmental defects reconstructed with fibular only graft: the non vascular fibular intramedullary bridging bone and additional grafting (FIBBAG) and the results thereof.

Methods: Outcomes in 8 patients treated with fibular strut and overlay matchstick grafts were retrospectively assessed. The clinical results were expressed as forearm shortening, range of motion at elbow and wrist joint. The radiological evaluation included time to union, presence of fractures and recurrence of infection, if any.

Results: The average patient age was 6 years (range, 3–12 years). The radius was involved in 6 and ulna in 2. Union occurred in all patients. The average intraoperative gap to be spanned was 5.86 cm (range, 3–14 cm). The average time for union was 6.63 months (range, 2–14 months). Two patients required additional bone grafting procedures. No graft fatigues/fractures were noted in available follow up. There was no recurrence of infection in any case. A positive ulnar variance was seen in 3 patients at follow up. Forearm shortening was a major cosmetic limitation following the procedure.

Conclusions: Fibular strut and additional bone grafting (FIBBAG) is one of the viable options for reconstruction of post osteomyelitic forearm defects in children with low procedural complication rate.

Background: The induced membrane technique is now commonly used for large diaphyseal bone defects. Recently, several papers reported using the induced membrane technique for hand surgery. We applied this technique with some modifications to treat osteomyelitis of the phalanges.

Methods: This study included six men and one woman with a mean age of 56 years. The causes of osteomyelitis included animal bite (n = 3), trauma (n = 3), and an indwelling needle (n = 1). Two-staged surgeries were performed, including an initial stage with radical debridement of the infected tissue and placement of a cement spacer into the bone defect. Four weeks after the first stage, a bone graft was performed. A bone block with cortex was harvested from the iliac crest or radius, and costal cartilage was used for proximal interphalangeal (PIP) joint arthroplasty in two cases. Grafted bones were fixed with a mini screw or an external fixator.

Results: In all cases, the infection subsided, and bone union was obtained within two to three months. No absorption of the grafted bone was observed. In the two cases with PIP joint defect, joint motion without pain was preserved at 56° and 26°.

Conclusions: A short interval between the two surgical stages of the induced membrane technique could be advantageous for patients in terms of time and financial burden and early rehabilitation of movement. Cortico-cancellous bone grafts were able to maintain bone length and stability with screw fixation. In the cases with PIP joint defects, instead of arthrodesis, we performed PIP arthroplasty using costal cartilage, eventually obtained some motion without pain. The induced membrane technique was useful and technically feasible for treating osteomyelitis in the hand, and secondary joint reconstruction was possible to obtain some motion.

The best treatment for mallet fingers is still a matter of debate. Numerous splints with different designs to keep the distal interphalangeal (DIP) joint in extension have been described in literature. The outcomes of splint treatment are generally good with occasional reports of minor skin complications. Percutaneous Kirschner-wire pinning of the DIP joint for closed tendinous mallet finger represents a alternative treatment modality that reliably immobilises the joint and does not need much patient compliance or use of an external splint. We report a rare but devastating complication of percutaneous pinning of the DIP joint for closed tendinous mallet finger.

Level of Evidence: Level V (Therapeutic)

Metacarpal tuberculosis is rare even in endemic areas. This is a report of a 12-year-old girl with gradual, painless swelling of the dorsal aspect of the right hand over a 2-year period. She developed a discharging sinus over the mass after a traumatic incident. The radiographs showed a well-defined, expansile osteolytic lesion. Blood test, fine needle aspiration biopsy and smears were not diagnostic. A second histologic examination with phenotypic test was required for diagnosis and to begin appropriate chemotherapy. Establishing the diagnosis was not straightforward, even though we suspected tuberculosis.

Level of Evidence: Level V (Therapeutic)

Porous hydroxyapatite block(HAB) could be used as a sustainer of antibiotics or anticancer drugs because of its interlinked pore structure. HAB was mixed with an antibiotic solution and decompressed in vacuum container under from 5 to 10 in. (127 mm-254 mm) Hg/20 min. to load antibiotics into HAB-pores. Twenty-one patients with osteomyelitis including one with tuberculosis and 5 patients with infected joint replacement had been treated in combination with intravenous injection. On follow up study(from 8 to 85 months; averaged 41.5 months), all of the foci had completely healed primarily by the end of the follow-up period except a case which was used on the open tibial fracture with a plate fixation. These new methods are simple, can be performed safely to treat osteomyelitis as a one stage operation.