Surgery and Healing in the Developing World - Dartmouth-Hitchcock
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Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Surgery and Healing in the Developing World - Dartmouth-Hitchcock Surgery and Healing in the Developing World - Dartmouth-Hitchcock

dartmouth.hitchcock.org
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21.06.2013 Views

Abscesses and Other Infections Treated by Surgery Figure 6. Sardonic smile of tetanus. 365 Gas Gangrene This deadly infection, caused by the obligate anaerobe Clostridium perfringens, causes a rapidly progressive necrosis of muscle tissue and release of toxins. The only hope for cure is immediate complete excision of all involved muscles, often requiring amputation of limbs. Pyomyositis Pyomyositis is bacterial infection with abscess-formation in one or more muscles, especially the larger muscles. It is uncommon in wealthy communities and relatively common in poor tropical countries. Signs include swelling, pain, tenderness and redness over the muscle(s) with fever and loss of function. Usually the bacteria are sensitive to penicillin. Treatment involves intra-venous penicillin or cloxacillin followed by wide incision and drainage, packing the wound open or inserting large drains. If the patient does not recover following this treatment and becomes more septic, examine for undrained abscesses and change to clindamycin plus gentamicin, if available, or chloramphenicol. Osteomyelitis Osteomyelitis is far more common in poorer than in affluent communities. Early diagnosis and immediate treatment are the ideal but this is seldom achieved in most parts of the world. Thus, many patients present with chronic osteomyelitis manifested by sequestra and sinuses and they face long-term or permanent disability. 35 Therefore early diagnosis and treatment are imperative. Diagnosis of osteomyelitis usually starts with a sick child who is limping or unable to use the affected limb. There may not be redness in the earliest and most treatable stage. However, there is tenderness and usually swelling over the affected part of the bone. Any child with a fever and a painful limb should be suspected of suffering from osteomyelitis and urgent diagnostic drilling of the bone should be done. Treatment of early osteomyelitis is early exposure and drilling of the cortex in several sites with a 2mm drill bit (Fig. 7). Only this will reveal the early infection by pus extruding from one or more drill sites. Children under age one often have an associated septic arthritis which must also be drained. At any age, osteomyelitis of the upper end of the femur tends to be associated with pus in the hip joint which needs to be drained. If osteomyelitis is confirmed, the wound is packed open and antibiotics started. As soon as a culture is obtained, start cloxacillin or oral chloramphenicol and, if necessary, change to a more appropriate antibiotic based on the culture sensitivities. Antibiotics should be

35 366 Surgery and Healing in the Developing World Figure 7. Drilling cortex of bone to diagnose and drain acute osteomyelitis. continued for 3 weeks or longer if pus continues to drain. Management of later stages of osteomyelitis requires experience in exploring and unroofing the sequestrum within the encasing involucrum (Figs. 8A, B). Breast Acute Breast Abscess Breast abscesses appear in two typical manners: acute abscesses, which usually occur during lactation, and more chronic or recurrent abscesses. During lactation, a cracked nipple may lead to breast infection usually due to Staphylococcus. If detected within a day or two, antibiotics and breast pumping may clear the infection. Figure 8A. Chronic osteomyelitis with involucrum encasing dead sequestrum. Figure 8B. Chronic sinus and swelling in the same little girl.

35<br />

366 <strong>Surgery</strong> <strong>and</strong> <strong>Heal<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> Develop<strong>in</strong>g <strong>World</strong><br />

Figure 7. Drill<strong>in</strong>g cortex of bone to diagnose <strong>and</strong> dra<strong>in</strong> acute osteomyelitis.<br />

cont<strong>in</strong>ued for 3 weeks or longer if pus cont<strong>in</strong>ues to dra<strong>in</strong>. Management of later<br />

stages of osteomyelitis requires experience <strong>in</strong> explor<strong>in</strong>g <strong>and</strong> unroof<strong>in</strong>g <strong>the</strong> sequestrum<br />

with<strong>in</strong> <strong>the</strong> encas<strong>in</strong>g <strong>in</strong>volucrum (Figs. 8A, B).<br />

Breast<br />

Acute Breast Abscess<br />

Breast abscesses appear <strong>in</strong> two typical manners: acute abscesses, which usually<br />

occur dur<strong>in</strong>g lactation, <strong>and</strong> more chronic or recurrent abscesses. Dur<strong>in</strong>g lactation, a<br />

cracked nipple may lead to breast <strong>in</strong>fection usually due to Staphylococcus. If detected<br />

with<strong>in</strong> a day or two, antibiotics <strong>and</strong> breast pump<strong>in</strong>g may clear <strong>the</strong> <strong>in</strong>fection.<br />

Figure 8A. Chronic osteomyelitis<br />

with <strong>in</strong>volucrum encas<strong>in</strong>g dead<br />

sequestrum.<br />

Figure 8B. Chronic s<strong>in</strong>us <strong>and</strong><br />

swell<strong>in</strong>g <strong>in</strong> <strong>the</strong> same little girl.

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