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A 34-year-old man is involved in a motor vehicle accident and sustains an open tibia fracture and is treated with intramedullary nailing. For the next 4 years, he continues to have pain and persistent discharge from a sinus over his shin. He ambulates with crutches and refrains from putting weight on the extremity. The clinical appearance and radiographs are seen in Figures A and B. Wound culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What is the next step in treatment?
Retention of tibial nail, lifelong intravenous antibiotic suppression
Debridement and lavage, exchange nailing using a larger diameter nail, intravenous antibiotics for 6 weeks.
Debridement and lavage, excision of sinus tract, implant removal, intravenous antibiotics for 6 weeks.
Debridement and lavage, addition of ring fixator, intravenous antibiotics for 6 weeks.
Debridement and lavage, excision of sinus tract, exchange nailing using antibiotic impregnated-cement nail, intravenous antibiotics for 6 weeks.
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A 45-year-old homeless hemophiliac male presents with chronic tibial osteomyelitis. Which of the following factors has been shown to predict a better prognosis?
Use of external fixation
Infection with Methicillin-resistant Staphylococcus aureus
Contralateral lower extremity amputation
A 33-year-old motorcyclist is involved in a motor vehicle accident and sustains a Grade III open fracture of his tibia that is treated surgically. Over the next 35 years, he undergoes multiple debridements for a persistently draining wound. Over the last year, he has noticed "tissue growing out of the wound" and a malodorous smell. A photograph of the wound and a recent radiograph are seen in Figure A. A biopsy of the mass is shown in Figures B, and C. What is the most likely pathologic process?
Squamous cell carcinoma
Basal cell carcinoma
A 34-year-old man sustained a gunshot wound to the knee 18 months ago and was treated with bullet removal and a 10 day course of oral antibiotics. He now complains of 12 months duration of pain in the thigh and recent ulceration and drainage of the skin near the site of his gunshot wound. Physical exam is notable for a draining sinus tract, erythema and tenderness of the mid-thigh. He is afebrile. An MRI image of this patient is shown in Figure A. Which of the following is the most appropriate management?
Two week course of oral cephalosporin
Core needle bone culture followed by intravenous antibiotics
Surgical debridement, culture, and intravenous antibiotics
Core needle biopsy, chest CT scan, and bone scan
Neoadjuvant chemotherapy and wide resection followed by adjuvant chemotherapy
HPI - Swelling and pain right thigh - Spontaneous onset, gradually progressive over 03 months. Pain thigh is mild, activity related. No fever/ night pain/ recent trauma / puncture injury. Able to walk full weight bearing.
Likely diagnosis on clincal presentation and plain radiographs
HPI - 55 yo male farmer 14 months s/p ORIF ankle with subsequent infection at 3 months. Outside surgeon removed hardware and patient underwent 8 surgical debridements through old direct medial and lateral incisions. IV abx treatment has continued for last 11 months at time of presentation. He has drainage from medial wound. 1 month prior previous surgeon performed biopsy to confirm osteomyelitis. Previous cultures reveal MRSA osteomyelitis. Patient wishes to keep leg.
MRI/Bone Scan: Reveal focal edema/increased signal within 2 cm of tibiotalar joint.
CT: Reveals nonunion fibula
What management strategy would you offer?
HPI - Continuos secretion through a medial fistula on his tibia for the last 2 years
What is the best approach?