Axe injury xxxx(surgery) 464568541 .pptx

Axe injury o6u

1. AXE INJURY (SURGERY) SUB GROUB 2 ​

2. Table of Contents 01 management of traumatic wounds 02 03 04 microbiology features of chronic osteomylitis 05 antibiotics 06 Osteomylitis pathology Pathways to Diagnosis and Antibiotic Principles in Infection Managemen clinical signs and radiological findings

3. CASE OVERVIEW Amgad, a 35-year-old farmer, suffered a deep leg wound from an axe. After a relative cleaned and bandaged the injury, he resumed work but experienced increasing pain, redness, and swelling. He developed a fever, prompting his brother to take him to the hospital. The surgeon assessed the wound as infected and not suitable for immediate suturing. Amgad received wound care and antibiotics (Amoxicillin) but showed no improvement after two weeks. His symptoms worsened, leading the doctor to suspect a bone infection. Despite ongoing treatment, Amgad's condition deteriorated, resulting in chronic osteomyelitis. Further testing was conducted for appropriate antibiotic therapy. Months later, he developed soft pitting edema in both legs, and his serum albumin level was low at 1.6 gm/dL .

4. objective (1) 1) Effectiveness of Initial First Aid:   - Positive Aspects:     Wound Cleaning: Using clean water to remove debris and bacteria.    Bandaging: Protecting the wound from contamination. - Negative Aspects:   .  Improper Bandaging: The entire limb was bandaged instead of just the wound, potentially trapping bacteria and leading to infection.      . Delayed Medical Attention: The deep wound required professional care sooner, which could have prevented complications.        . Physical Activity: Irrigating land the next day may have exacerbated the injury.    Conclusion: The initial management was insufficient, particularly in seeking timely medical help and limiting activity.

5. 2 ) Standard Management for Wounds: - Initial Assessment and First Aid:   Stop bleeding, clean the wound with saline, disinfect as necessary, and cover with a sterile dressing. - Seek Professional Care: . Healthcare professionals should assess the wound for severity, perform any necessary debridement, and consider tetanus prophylaxis.   . Antibiotics may be prescribed for infected wounds   - Follow-Up Care : Regular monitoring for signs of infection, proper hygiene, and pain management are essential. In Amgad’s case, the surgeon's intervention for irrigation and antibiotic prescription was appropriate to address the infection. Early medical intervention and careful monitoring are crucial for preventing complications and ensuring recovery.

6. 3) Why did the doctor ask for x ray? to check for:   1. Foreign Bodies: Since the wound was caused by an axe, there is a risk of foreign materials (wood, dirt, metal fragments) being embedded in the soft tissue. An X-ray helps detect any retained objects that could lead to persistent infection or delayed healing . 2. Bone Involvement:   Given that the injury was deep and the patient experienced increasing pain and difficulty walking, the doctor needed to rule out a fracture or bone injury. If the bone were damaged, treatment would involve additional measures such as immobilization or surgery. 3. Detect Gas Formation:   In cases of spreading cellulitis or deep infections, an X-ray can help identify gas pockets in the tissues, which might suggest necrotizing fasciitis or gas gangrene, both of which are serious infections requiring urgent intervention . 4. Evaluate Soft Tissue Swelling: Although X-rays primarily visualize bones, they can provide some information on soft tissue swelling, which helps in assessing the extent of the infection and inflammation.

7. 4)Osteomyelitis   is a bone infection, often bacterial, and can be acute or chronic. Its management generally involves surgical intervention and long-term antibiotic therapy. When considering tetanus prophylaxis for a patient  with osteomyelitis, the following factors are important: 2. Vaccination History:   Evaluate the patient's tetanus vaccination status. If unvaccinated or status is unknown, administer tetanus immune globulin (TIG) for immediate protection and the tetanus vaccine for long-term immunity. 1. Wound Characteristics:   Assess the risk of tetanus if there is an open wound or trauma, especially if contaminated with soil or materials harboring Clostridium tetani spores .

8. 3. Clinical Presentation:  Look for systemic symptoms like muscle spasms or rigidity, which may indicate tetanus, although these are rare in osteomyelitis. Any suspicion warrants immediate prophylaxis. 4. Surgical Intervention: Ensure tetanus protection if surgical debridement or similar procedures are planned, particularly for open or contaminated wounds.

9. 5)Amoxicillin antibiotic : is a commonly prescribed antibiotic that belongs to the penicillin family of drugs. It is used to treat a wide range of bacterial infections. Here's an overview of amoxicillin and its major effects: Amoxil:   Formulation: Available as tablets, chewable tablets, oral suspension, and pediatric drops. Uses: Broad-spectrum antibiotic used to treat a variety of infections, including respiratory, ear, nose, throat, urinary tract, and skin infections. Effects: Effective against a wide range of bacteria; commonly used in pediatric populations due to its palatable formulations. Moxatag:  Formulation: Extended-release tablets. Uses: Primarily used for the treatment of tonsillitis and pharyngitis caused by Streptococcus pyogenes. Effects: Designed for once-daily dosing, which can improve patient compliance.  

10. Trimox:   Formulation: Available as tablets and oral suspension. Uses: Similar to Amoxil, used for a variety of bacterial infections. Effects: Provides a reliable treatment option with flexible dosing forms suitable for both adults and children. Augmentin: Formulation: Combination of amoxicillin and clavulanic acid, available as tablets, chewable tablets, and oral suspension. Uses: Used for more complex infections, especially those caused by beta-lactamase-producing bacteria, which are resistant to amoxicillin alone.

11. Effects:   Broade ns the spectrum of activity to include bacteria that are typically resistant to amoxicillin. Major Effects and Considerations: Efficacy:   All formulations are effective against susceptible bacteria, but the choice of formulation may depend on the type and severity of the infection, as well as patient preferences and compliance. Side Effects:   Common side effects include gastrointestinal issues like nausea, vomiting, and diarrhea. Allergic reactions can occur, ranging from mild rashes to severe anaphylaxis . Dosing: Dosing schedules vary depending on the formulation and the specific infection being treated. Extended-release formulations like Moxatag offer the convenience of once-daily dosing.

12. Resistance:   The combination of amoxicillin with clavulanic acid in Augmentin helps combat antibiotic resistance by inhibiting beta-lactamase enzymes produced by some bacteria. Interactions: Potential interactions with other medications, such as probenecid and methotrexate, should be considered. 6) Types of Wounds 1 .According to Skin Loss: 1. Closed Wounds:  - Skin surface intact, no loss of skin. - Contusion: Diffuse blood and exudate, treated conservatively. - Hematoma: Localized blood collection with no inflammation signs. Types include:  - Subcutaneous - Subperiosteal - Subfascial - Intramuscular

13. 2. Opened Wounds: . Skin surface interrupted with loss of skin. - Abrasions: Superficial skin injury from friction. - Incised Wounds: Caused by sharp objects, resulting in clean edges and less infection risk but potential for severe bleeding. - Lacerated Wounds: Result from heavy blunt trauma, leading to significant tissue damage and a higher infection risk with minimal bleeding. - Crushed Wounds : Extensive tissue damage. - Punctured Wounds: Caused by sharp objects penetrating the skin.

14. 2. Classification of Wounds According to Bacterial Contamination:   1. Clean Wound (Class I):  - No infection risk (<2%), typically from clean operations. 2. Clean-Contaminated Wound (Class II): - Elective surgeries in gastrointestinal, urinary, or respiratory tracts without significant spillage (2-5% infection risk).   3. Contaminated Wound (Class III): - Open wounds within 4 hours, gross gastrointestinal spillage, or septic operations (10-20% infection risk). 4. Heavily Contaminated Wound (Class IV): - Traumatic wounds older than 4 hours, purulent infections, or necrotizing soft tissue infections, with a high infection risk (up to 40%). Often includes foreign bodies or severe septic conditions.

15. Objective 2 1) Causes of wound not responding to management:   1. Wound Infection (Likely Cause) Why it happens:   Delayed treatment allowed bacteria (possibly from the axe, soil, or environment) to enter and proliferate. Signs: Redness, swelling, warmth, increased pain, pus or foul-smelling discharge, fever. Possible Pathogens: Staphylococcus aureus (including MRSA) Streptococcus pyogenes Environmental bacteria (e.g., Clostridium species) Complications: If untreated, can lead to cellulitis, abscess formation, or systemic infection (sepsis). 2. Cellulitis Why it happens:   A bacterial skin infection spreading from the wound into surrounding tissues. Signs:  Expanding area of redness, warmth, swelling, severe pain, and sometimes fever. Risks: Can rapidly spread along tissue planes and lead to deeper infections or sepsis.   3. Abscess Formation Why it happens:   If pus collects beneath the skin or in deeper tissues due to infection, it can form an abscess. Signs:  Localized swelling, fluctuant (soft) area, redness, warmth, throbbing pain. Management: Requires drainage in addition to antibiotics—if not drained, healing won’t occur.

16. 4 . Necrotic Tissue (Non-Viable Tissue) Why it happens: The axe may have caused tissue death, especially if blood flow was compromised. Dead tissue becomes a breeding ground for bacteria and prevents healing. Signs: Black, brown, or grayish tissue, foul odor, delayed healing. Management: Surgical debridement is necessary to remove necrotic tissue. 5. Foreign Body Retention Why it happens: Wood splinters or debris from the axe or environment may have entered the wound and were not removed. Signs: Chronic inflammation, persistent drainage, non-healing wound. Diagnosis: Imaging (X-ray, ultrasound) may reveal retained materials 6 . Tetanus Infection Why it happens:​  Soil-contaminated wounds, especially from dirty tools like axes, carry a risk of Clostridium tetani infection. Signs: Muscle stiffness (especially jaw — lockjaw), spasms, difficulty swallowing, and general malaise. Prevention: Tetanus toxoid vaccination and tetanus immunoglobulin (if vaccination history is unknown or incomplete). ​ ​

17. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 ​ 8 . Compromised Blood Supply (Ischemia) Why it happens:​  Vascular injury from the axe or swelling compressing blood vessels can impair circulation, delaying healing. Signs: Coolness or pallor in the limb, weak pulses, delayed capillary refill, worsening pain. Risks: Can lead to tissue necrosis and require surgical intervention.​ ​ 9. Delayed Medical Care and Improper Wound Management Why it happens:​  A week-long delay before seeking care increases the risk of infection, contamination, and complications. Potential Issues: Improper cleaning or dressing No initial antibiotic coverage Continued use of the injured leg worsening tissue damage​ ​ 10. Underlying Health Conditions Affecting Healing Why it happens:​  Certain conditions can impair wound healing: Diabetes Mellitus: Causes poor circulation and weakens immune response. Peripheral Vascular Disease: Reduces blood flow to the extremities. Malnutrition: Limits the body's ability to heal wounds. Signs: Chronic, non-healing wound, poor granulation tissue, recurrent infections.​

18. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 2) bone infection: Bacteria or other germs may spread to a bone from infected skin, muscles, or tendons next to the bone. This may occur under a skin sore. The infection can start in another part of the body and spread to the bone through the blood. Investigations : Blood cultures Bone biopsy (the sample is cultured and examined under a microscope) Bone x-ray MRI of the bone . 3 )Confirming a bone infection (osteomyelitis) after a wound requires a combination of clinical, radiological, and laboratory investigations. 1. Clinical Assessment: Symptom :Persistent pain, swelling, warmth, erythema, fever, delayed wound healing, or pus drainage. Risk Factors: Open fractures, diabetes, immunosuppression, previous infections.

19. 2. Laboratory Tests ↑ WBC, ESR, CRP → Indicators of inflammation/infection. Blood cultures → May identify bacteremia in hematogenous osteomyelitis. 3. Radiological Imaging (Key for diagnosis) X-ray (1st-line, but low sensitivity early on) May show bone destruction, periosteal reaction, or sequestrum (if chronic). Changes appear 10–14 days after infection onset. MRI (Best for early detection) Shows bone marrow edema (early sign), soft tissue involvement, abscess formation. High sensitivity and specificity. CT Scan (Useful for chronic cases or surgical planning) Detects bone destruction, sequestrum, or involucrum. Nuclear Imaging (if MRI is contraindicated) Bone scan (Technetium-99m): Increased uptake in infected areas. WBC-labeled scan (Indium-111 or Gallium-67): More specific for infection. 4. Microbiological & Pathological Confirmation (Gold Standard) Bone biopsy (Definitive diagnosis) Obtained via percutaneous or open surgical method. Sent for Gram stain, culture, and histopathology. Pus/wound culture (Less reliable due to contamination).   5. Surgical Evaluation ( if needed ) If an abscess, necrotic bone (sequestrum), or non-healing wound is present, surgical exploration may be required. Intraoperative findings (pus, necrotic bone) can support the diagnosis.

20. 4)General Principles for Prescribing Antibiotics in Acute Osteomyelitis:   1. Pharmacological Considerations: • Empirical Therapy: Start with broad-spectrum IV antibiotics before culture results, usually vancomycin + ceftriaxone/cefepime. • Targeted Therapy: Once culture and sensitivity results are available, switch to narrow-spectrum antibiotics.  • Duration: Typically 4–6 weeks, with IV antibiotics initially, then oral if the patient improves.  • Tissue Penetration: Choose antibiotics that penetrate bone well, like fluoroquinolones, clindamycin, and linezolid. • Bactericidal Effect: Use bactericidal rather than bacteriostatic drugs to eradicate deep-seated infections.

21. 2. Pathological Considerations:   • Causative Organism: Most common is Staphylococcus aureus, but in specific cases (like diabetic foot infections), consider Pseudomonas or anaerobes.  • Inflammatory Response: Antibiotics should target both bacterial load and inflammation, preventing necrosis.  • Biofilm Formation: Chronic osteomyelitis can involve biofilms, requiring prolonged and high-dose therapy. • Bone Necrosis & Sequestrum: If present, surgery may be needed alongside antibiotics for effective treatment.

22. Objective 3 1 )Clinical Signs Apparent on the Skin in Chronic Osteomyelitis: 1. Ulceration: • Open wounds on the skin surface. • May contain pus or inflamed tissue. 2. Erythema (Redness): • Red discoloration around the wound area. • Indicates active inflammation and infection. 3. Swelling : • Noticeable edema around the site of trauma. • Suggests underlying infection spreading to soft tissues. 4. Discoloration: • Darkened or unhealthy skin appearance. • Often brownish or reddish due to chronic inflammation and poor blood supply. .

23. 5. Oozing and discharge: • Suggests ongoing infection and poor wound healing. 6. Sinus Tract Formation: • Abnormal channel between infected bone and skin surface. • Often drains pus and is a key sign of chronic osteomyelitis. 7. Scarring and Fibrosis: • Thickened and hardened skin over the infected area. • Results from repeated inflammation and healing attempts. 8. Tenderness: • Skin and underlying tissue become painful to touch. • Indicates active infection and possible bone involvement.

24. The right mid-tibial shaft shows intramedullary edema signal associated with cortical thickening and a small cortical defect along its ventro-lateral aspect (cloaca). Periosseous soft tissue edema signal is noted. Post contrast enhancement of the tibia and the surrounding soft tissue planes are noted. In most instances, osteomyelitis results from hematogenous spread, although direct extension from trauma and/or ulcers is relatively common (especially in the feet of diabetic patients). In the initial stages of infection, bacteria multiply, triggering a localized inflammatory reaction that results in localized cell death. With time, the infection becomes demarcated by a rim of granulation tissue and new bone deposition

25. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 Objective 4 What are the characteristic microbiology features of chronic osteomyelitis? Chronic osteomyelitis is characterized by several microbiological features, including: 1. Polymicrobial Infection – Unlike acute osteomyelitis, which is often caused by a single organism, chronic osteomyelitis can involve multiple bacterial species. 2. Predominance of Staphylococcus aureus – The most common pathogen, including methicillin-resistant S. aureus (MRSA). 3. Biofilm Formation – Bacteria form biofilms on necrotic bone and implanted foreign material, making the infection resistant to antibiotics and host immune responses. 4. Presence of Anaerobes – Anaerobic bacteria, such as Bacteroides and Peptostreptococcus, are frequently involved, especially in post-traumatic or post-surgical infections. 5. Gram-Negative Bacilli – Organisms like Pseudomonas aeruginosa, Escherichia coli, and Klebsiella spp. are often isolated, particularly in immunocompromised patients or those with diabetes.

26. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 6. Low Bacterial Load – In chronic cases, bacterial cultures may yield low or even negative results due to intermittent bacterial shedding and sequestration within necrotic bone. 7. Intracellular Persistence – Some bacteria, like S. aureus, can persist intracellularly within osteoblasts, evading immune clearance and contributing to recurrence. why did Amgad developed osteomyelitis? Osteomyelitis is a bone infection that can develop due to various causes. If you’re referring to a specific case, the reasons for developing osteomyelitis would depend on factors like: Hematogenous Spread – The infection could have spread through the bloodstream from another site of infection (e.g., pneumonia, urinary tract infection, or infective endocarditis). This is more common in children and immunocompromised patients. 2. Direct Inoculation – Trauma, open fractures, or surgical procedures could introduce bacteria directly into the bone. This is often seen in orthopedic surgeries or deep puncture wounds.

27. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 3 . Contiguous Spread – The infection may have spread from nearby infected tissues, such as soft tissue infections (e.g., diabetic foot ulcers, cellulitis, or deep abscesses). 4. Compromised Immune System – Conditions like diabetes, HIV, or prolonged corticosteroid use can increase susceptibility to infections, including osteomyelitis. 5. Poor Vascular Supply – In individuals with peripheral vascular disease, such as diabetics or smokers, reduced blood flow to the bone can make it more prone to infection and impaired healing

28. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 Objective 5 Antibiotic sensitivity testing is the measurement of the susceptibility of bacteria to antibiotics. It is used because bacteria may have resistance to some antibiotics. Sensitivity testing usually occurs in a medical laboratory, and uses culture methods that expose bacteria to antibiotics, or genetic methods that test to see if bacteria have genes that confer resistance. Culture methods often involve measuring the diameter of areas without bacterial growth, called zones of inhibition, around paper discs containing antibiotics on agar culture dishes that have been evenly inoculated with bacteria. The minimum inhibitory concentration, which is the lowest concentration of the antibiotic that stops the growth of bacteria, can be estimated from the size of the zone of inhibition. In this case, Antibiotics should be included in antibiotic sensitivity testing:

29. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 For MRSA : - Vancomycin (IV) - Daptomycin (if vancomycin-resistant or in cases of poor response) - Linezolid - Clindamycin (if susceptibility is confirmed) For Gram-negative bacteria (pseudomonas aergineusa): antibiotics like ciprofloxacin, levofloxacin, piperacillin-tazobactam, meropenem, and amikacin are commonly tested for sensitivity

30. 1 2 3 4 5 6 7 8 10 20 30 40 50 60 70 80 90 100 Objective 6 The new condition Amgad developed is nephrotic syndrome or protein-losing nephropathy. Reasoning: 1. Soft pitting edema – This is a hallmark sign of fluid retention, often seen in kidney or liver disorders. 2. Low serum albumin (1.6 g/dL) – Severe hypoalbuminemia indicates significant protein loss, commonly due to nephrotic syndrome. 3. Chronic infection (osteomyelitis) – Chronic infections can lead to systemic inflammation and secondary kidney damage, contributing to protein loss through the kidneys. Nephrotic syndrome is characterized by: • Proteinuria (loss of protein in urine) • Hypoalbuminemia • Edema • Hyperlipidemia (not mentioned but often present) This condition could be a result of amyloidosis, chronic inflammation, or sepsis-related kidney damage due to his prolonged osteomyelitis

31. SUB-GROUP 2 Al-Shimaa Ibrahim Amal Shehab Amany Fathy Mohamed Afnan ElAnsari Aya Mansour Basant ElMohamady Pasant Ahmed Basmala Abdelghany Tasneem Saied Tasneem Ehab Tasneem Mohamed Lotfy Jana Ahmed Gehad Mohamed Hasnaa Ibrahim Hasnaa Hashem Omnia Khalid m RESOURCES h ttps://www.orthobullets.com/trauma/1057/osteomyelitis--adult?utm_source=chatgpt.com • https://en.wikipedia.org/wiki/SAPHO_syndrome?utm_source=chatgpt.com • https://autoimmune.org/disease-information/chronic-recurrent-multifocal-osteomyelitis-crmo/?utm_source=chatgpt.co m https://pmc.ncbi.nlm.nih.gov/articles/PMC6166254/

32. Thank you