Deep Soft Tissue Infection Research Articles

Imaging of musculoskeletal soft tissue infections

Prompt and appropriate imaging work-up of the various musculoskeletal soft tissue infections aids early diagnosis and treatment and decreases the risk of complications resulting from misdiagnosis or delayed diagnosis. The signs and symptoms of musculoskeletal soft tissue infections can be nonspecific, making it clinically difficult to distinguish between disease processes and the extent of disease. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of soft tissue infections. Computed tomography (CT), ultrasound, radiography and nuclear medicine studies are considered ancillary. This manuscript illustrates representative images of superficial and deep soft tissue infections such as infectious cellulitis, superficial and deep fasciitis, including the necrotizing fasciitis, pyomyositis/soft tissue abscess, septic bursitis and tenosynovitis on different imaging modalities, with emphasis on MRI. Typical histopathologic findings of soft tissue infections are also presented. The imaging approach described in the manuscript is based on relevant literature and authors' personal experience and everyday practice.

Influence of Adjuvant Hyperbaric Oxygen Therapy on Short-term Complications During Surgical Reconstruction of Upper and Lower Extremity War Injuries: Retrospective Cohort Study

To determine the effects of hyperbaric oxygen (HBO) therapy on short-term complications of complex war wounds to the upper and lower extremities in patients who were and those who were not treated according to North Atlantic Treaty Organization (NATO) emergency war surgery recommendations. We retrospectively analyzed data of 388 male patients undergoing reconstructive surgery for Gustilo type III A, B, and C war wounds to the extremities at the Department of Reconstructive Surgery, Split University Hospital Center, between 1991 and 1995. The occurrence of main wound complications (deep infection, osteomyelitis, skin grafts lyses, and flap necrosis) during hospitalization and time from wounding to granulation formation were analyzed with respect to the use of HBO therapy as a risk factor. Odds ratio (OR) with 95% confidence intervals (CI) was calculated for the occurrence of wound complications with respect to HBO therapy and adjusted for NATO surgical strategy by logistic regression. Of 388 patients, 310 (80%) were initially treated according to the NATO surgical strategy and 99 (25%) received HBO therapy. Deep soft-tissue infection developed in 196 (68%) patients who did not receive HBO therapy and in 35 (35%) who received it (P<0.001, xi(2) test). Osteomyelitis developed in 214 (74%) patients who did not receive HBO therapy and in 62 (63%) who received it (P=0.030). Skin graft lysis occurred in 151 (52%) patients who did not receive HBO therapy and in 23 (23%) who received it (P<0.001). Flap necrosis occurred in 147 (51%) patients who did not receive HBO therapy and in 15 (15%) who received it (P<0.001). Median time to granulation formation was 9 (5-57) days in patients who received HBO therapy, and 12 (1-12) days in those who did not (P<0.001, Mann-Whitney test). These results were consistent over the groups of patients stratified according to the wound severity and remained unaltered after the adjustment for NATO surgical strategy. The effect of HBO therapy was greater in non-NATO than in NATO treated patients in case of deep soft-tissue infection (OR, 10.7 vs OR, 3.8; P=0.031 for interaction). HBO therapy reduced the frequency of wound complications in patients with Gustilo type III wounds and shortened the time to granulation formation. HBO therapy was more effective in non-NATO than in NATO treated patients for the prevention of deep soft-tissue infection but not flap necrosis.

The Microbiology and Risk of Infection Following Open, Agricultural Upper Extremity Injuries

This study was designed to determine the microbiology and risk of infection following open, agricultural, upper extremity injuries. Specifically, we sought to evaluate the microbiology of the wounds at the time of initial treatment and the development of any subsequent infections, determine whether the development of subsequent infection was related to injury severity, and clarify whether the microorganisms isolated at the time of initial treatment and development of subsequent infection were susceptible to the initial antibiotic prophylaxis. A retrospective chart review of 214 patients was conducted. The initial injuries were classified into 1 of 3 groups, with 1 being the least severe and 3 being the most severe. Twenty-six were type 1 injuries, 94 type 2, and 94 type 3 injuries. Forty patients developed infection following the injury. Seventeen had superficial wound infection, 16 had deep soft tissue infections, and 7 developed osteomyelitis. Six went on to an amputation due to infection. Fifteen of the infections were polymicrobial. The number of patients who developed infection in the first 6 months following injury was 2, 14, and 24 for type 1, 2, and 3 injuries respectively (p=.07). Empiric antimicrobial regimens for the management of infection requiring surgical debridement following open upper extremity agricultural injury should be active against staphylococci, aerobic gram-negative bacilli, and anaerobes, but not necessarily against fungi. These antibiotics ideally should be administered on initial presentation of the patient to the emergency department. Prospective studies with emphasis on timely acquisition of cultures and sensitivities are needed to determine optimal prophylactic antimicrobial therapy for these injuries and directed antibiotic regimens for the infections that may develop. Prognostic II.

Subcutaneous abscess caused byClostridium perfringensand osteomyelitis in a dog

A case of a subcutaneous abscess caused by Clostridium perfringens infection in a five-month-old dog is reported in this study. Clinical examination, radiological findings and cytological analysis of abscess fluid were consistent with Clostridium induced disease. Treatment including drainage of the abscess and antibiotic therapy led to rapid clinical improvement. However, despite aggressive medical therapy and proper wound care, the deep soft tissue infection led to osteomyelitis with premature closure of the growth plates of the tibia and secondary bone shortening. Prolonged treatment with metronidazole and amoxicillin-clavulanic acid resulted in an excellent outcome with normal weight bearing.

Panton-Valentine Leukocidin Genes inStaphylococcus aureus

The pathogenicity of Staphylococcus aureus depends on various bacterial surface components and extracellular proteins. However, the precise role of single virulence determinants in relation to infection is hard to establish. The frequent recovery of staphylococcal isolates that produce leukocidal toxins from patients with deep skin and soft tissue infections, particularly furunculosis, cutaneous abscesses, and severe necrotizing pneumonia, suggests that the Panton-Valentine leukocidin (PVL) is 1 such virulence factor that has a major role in pathogenicity (1–3). In 1932, Panton and Valentine described PVL as a virulence factor belonging to the family of synergohymenotropic toxins (4). These toxins form pores in the membrane of host defense cells by synergistic action of 2 secretory proteins, designated LukS-PV and LukF-PV, which are encoded by 2 cotranscribed genes of a prophage integrated in the S. aureus chromosome (5). PVL is mostly associated with community-acquired methicillin-resistant S. aureus (MRSA) infections and distinguishable from nosocomial MRSA by nonmultidrug resistance and carriage of the type IV staphylococcal chromosome cassette element (SCCmec type IV) (6,7). Despite the presumed importance of PVL as a virulence factor, few data are available on its prevalence among S. aureus isolates from the nares of healthy persons compared with stains isolated from infections. This lack of data led us to investigate the frequency of PVL gene–positive S. aureus strains obtained from the nares of healthy carriers in the community. For this purpose, a single polymerase chain reaction method was used to detect both lukS-PV and lukF-PV genes (2). In a previous study, the population structure of S. aureus, isolated from the nares of healthy persons in the Rotterdam area, the Netherlands, was elucidated (8). Strains were obtained from healthy children ( 55 years). Invasive strains (blood culture, skin and soft tissue infections, and impetigo isolates) were included in this study (Table). All carriage and clinical isolates (n = 1,033) were mecA negative. We used the same strain collection to study the PVL prevalence in carriage and invasive isolates of S. aureus from a single geographic region. Table Panton-Valentine Leukocidin (PVL) distribution among carriage and invasive isolates per genetic cluster of Staphylococcus aureus Five PVL-positive S. aureus strains (0.6%) were found in the carriage group (n = 829), and 3 (2.1%) of 146 blood-culture isolates carried the PVL gene (Table). This finding is in agreement with previously reported low PVL prevalences by Prevost et al. (0% in 31 carriage isolates and 1.4% in 69 blood-culture isolates) and Von Eiff et al. (1.4% in 210 carriage isolates and 0.9% in 219 blood-culture isolates) (9,10). However, a higher prevalence of PVL (38.9%) was found in S. aureus strains causing abscesses and arthritis (Fisher exact test, p <0.0001) (8). This finding is also in agreement with the proposed involvement of PVL in severe and invasive (soft tissue) staphylococcal infections (1–3). No significant differences were found in the presence of PVL when carriage isolates were compared with invasive blood-culture isolates. PVL was found in each major genomic amplified fragment length polymorphism (AFLP) cluster, indicating that PVL has been introduced in distinct phylogenetic subpopulations of S. aureus (Figure). Multilocus sequence typing analysis of a subset of the strain collection showed that the 15 PVL-positive strains were within clonal complex (CC) 30 (n = 7), CC 121 (n = 3), CC 1 (n = 2), CC 8 (n = 1), CC 22 (n = 1), and CC 45 (n = 1) (Table) (8). Although PVL was found among several staphylococcal genotypes, it was slightly overrepresented in AFLP cluster IVb (CC 121) compared with major clusters I and III. Whether the prevalence of PVL in carriage- and blood-culture isolates is higher and differs among distinct genetic clusters of S. aureus in countries with endemic CA-MRSA has to be investigated further. Figure Principal component analysis of amplified fragment length polymorphism (AFLP) data of 1,033 Staphylococcus aureus strains. The different cubes (plotted in 3-dimensional space) represent every strain in the study. Each axis represents the score calculated ... In conclusion, we have shown that the PVL-encoding phage has entered distinct staphylococcal lineages, although its prevalence differs per clonal group. PVL is associated with skin and soft tissue infections but not with bacteremia, which suggests that PVL is not likely to be involved in the pathogenesis of bacteremia. Infections caused by PVL-positive S. aureus strains have been documented since the 1930s. Expansion and increased incidence of such infections, however, are more recent, and further epidemiologic studies for tracking this phenomenon are still warranted.

Biological debridement: maggots

Biological debridement: maggots M Jones (UK) When the orthopaedic surgeon William S. Baer presented his method and results of maggot therapy in 19311 his focus of interest was bone and soft tissue infection. Later, it was mainly the work of Ronald Sherman which enlarged the scope of indications to chronic wounds, like stasis ulcers and bed sores2 Presently, clinical emphasis is put to the problem of impaired wound healing as found in diabetic patients3 Maggots secrete digestive juices into the wound which contain growth factors, antiseptic substances and proteases. The high proteolytic activity liquefies necrotic tissue, which is the main food source of maggots4. Clinically, there is an effective, atraumatic debridement of the wound and contaminating bacteria are removed as well as dead tissue. Maggots may either be applied directly to the wound surface or enclosed in a porous pouch, so that there is only a fluid but not a physical contact to the wound. With regard to patients' comfort, ease of maggot application, hygiene and aesthetics the maggot pouch dressing revolutionizes maggot therapy5 In superficial defect wounds like stasis and diabetic ulcers or some bed sores mechanical macro-debridement (scalpel etc.) should be performed as a first measure, mainly to accelerate healing and reduce costs of treatment. Maggots are then used for microdebridement and as an antiseptic agent. In deep soft tissue and bone infections the septic focus is either completely removed by surgery or extensively exposed by tissue incisions or excisions to give maggots and their secretions enough space to do their work. To prevent suffocation of maggots when put into deep wounds either textile spacers or polyvinyl-alcohol sponges are introduced to keep the wound edges apart. Profuse wound secretions need to be drawn off with drainage systems. To enhance the survival rate of maggots in particularly deep wounds special drains for ventilation purposes may be necessary. Having achieved a clean, healing wound by maggot therapy vacuum dressings may be applied for acceleration of wound healing and external skin expansion for rapid closure of remaining wound defects (Concept of Biosurgical-Mechanical Wound treatment, BMW). Maggots are an excellent low-risk tool for the therapy of necrotic, infected and chronic wounds, given that it is embedded in an effective concept of interdisciplinary wound management.

Management of early deep infection after rotator cuff repair surgery

Deep soft-tissue infection occurs infrequently after rotator cuff repair surgery. We retrospectively reviewed the clinical presentation in 14 patients whose rotator cuff repair was complicated by an early deep infection (<6 weeks). The functional outcome after treatment in 12 of these patients was analyzed at a mean follow-up of 37.5 months (range, 11-122 months). The diagnosis of infection was most often made within 3 weeks from the date of surgery (mean, 18 days; range, 3-41 days). Common presenting symptoms included localized wound erythema and drainage. The blood leukocyte counts were usually normal, but the erythrocyte sedimentation rates and C-reactive protein levels were elevated. A mean of 2.6 surgical debridements were required to clean the wound effectively in each case. Eight of twelve patients were dissatisfied at final assessment. Most patients reported reasonably good relief of pain, but they had residual shoulder stiffness and weakness. Retention of suture anchors in the humeral head did not preclude successful eradication of the infection.

Clinical efficacy, tolerability, and cost savings associated with the use of open-label metronidazole plus ceftriaxone once daily compared with ticarcillin/clavulanate every 6 hours as empiric treatment for diabetic lower-extremity infections in older males

Background: Patients with diabetes mellitus, particularly those with poor glucose control, commonly experience various medical complications related to the disease (eg, renal impairment, decreased peripheral vascular circulation, suppressed immune function). Infections of the lower extremities can range from superficial cellulitis to ulcerative, deep soft-tissue infections to osteomyelitis that necessitates some degree of amputation. Objective: This study compared the efficacy, tolerability, and cost differences associated with the use of metronidazole plus ceftriaxone (MTZ/CTX) given once daily with those of ticarcillin/clavulanate potassium (T/C) given every 6 hours in hospitalized older males with diabetic lower-extremity infections. Methods: This prospective, open-label study was conducted at a Veterans Affairs Medical Center. Male patients with diabetes and a lower-extremity infection were randomized to receive MTZ/CTX 1 g once daily or T/C 3.1 g every 6 hours. Treatment success was determined at 96 hours or on discontinuation of antibiotic. Success was measured in terms of body temperature <38.3°C (100.6°F), normalization of the finger-stick blood sugar concentration, improvement in wound staging, or a white blood cell count <10,000 cells/mm 3. Medication acquisition costs per treatment arm were calculated and compared. Results: Seventy patients were enrolled in the study (36 MTZ/CTX, 34 T/C). The study population had a mean (SD) age of 63.8 (10.8) years, a duration of diabetes of 12.4 (9.1) years, 0.5 (0.7) diabetes-related comorbidities, and an initial creatinine clearance of 67.1 (26.0) mL/min. There were no significant differences between groups at randomization. At 96 hours, treatment success was achieved in 31 (86%) patients in the MTZ/CTX group, compared with 28 (82%) patients in the T/C group ( P = NS). Twenty-six patients were considered successfully treated on the final day of therapy in both the MTZ/CTX group (72%) and the T/C group (76%) ( P = NS). There were no significant differences in primary or secondary measures of success between the 2 groups. No single or multiple baseline factors predicted treatment success or failure. No patient experienced adverse events considered related to study medication. MTZ/CTX was associated with savings of $61.06 per hospital admission, or $2198.05 for all patients who received this combination. Conclusion: In this population of older males, once-daily MTZ/CTX was as well tolerated and effective as T/C in the treatment of diabetic lower-extremity infections and was associated with reduced institutional costs.

Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus--an emerging problem for the management of skin and soft tissue infections.

In the community non-localized or deep staphylococcal skin and soft tissue infections are typically managed with beta-lactamase stable penicillins. The aims of this review are (1) to evaluate the evidence for the emergence of new strains of community-acquired methicillin resistant Staphylococcus aureus (MRSA), (2) to identify the reasons for their significant association with cutaneous infections, and (3) to consider how they arose and how big a threat they pose to the management of such infections outside hospitals. MRSA are emerging as significant community pathogens, especially in previously healthy children with no recognizable risk factors, and are predominantly associated with skin and soft tissue infections (especially abscesses and cellulitis). When present, risk factors are generally similar to those for infection with methicillin susceptible S. aureus. The MRSA isolates associated with such infections may not be entirely 'new', but could represent the displacement of some hospital clones (e.g. EMRSA-15 or variants thereof) to the community as well as the de-novo generation of novel MRSA clones by multiple horizontal transmissions of the mecA gene into methicillin susceptible S. aureus with different genetic backgrounds, some of which are already circulating globally. Community-acquired MRSA from diverse locations are non multiresistant and almost always contain the novel type IV SCCmec commonly found in coagulase-negative staphylococci, but also in hospital-associated gentamicin susceptible MRSA from France, the paediatric clone and in EMRSA-15. More local data on CA-MRSA infections are needed so that dermatologists and community physicians can assess the risk of such infections amongst their patients and avoid the inappropriate administration of beta-lactams. No simple change in prescribing practices will entirely alleviate selective pressure for the spread of community-acquired MRSA and not exacerbate resistance in pyogenic streptococci, commonly found together with S. aureus in skin and soft tissue infections. The importance of hygiene in preventing the spread of community-acquired MRSA in the community must be reemphasized.

Treatment of periprosthetic soft tissue infection of the groin following vascular surgical procedures by means of a polyvinyl alcohol-vacuum sponge system.

Deep groin infections after prosthetic vascular surgical procedures represent a serious complication of surgical practice. Septicemia and/or erosive hemorrhage can both be consequences. In this situation, removal of the graft appears to be the only option. However, if the infection is detected early (type Szilagyi III), local treatment to eradicate the infection could serve as an alternative. Twenty-four patients with confirmed infection of the soft tissue adjacent to the prosthetic material in the groin were treated locally by implantation of a vacuum sponge system. Duration of this treatment was 2 weeks. All patients showed excellent tissue granulation of the wound area and the microbial stains were negative at the end of therapy. In 21 patients the wound could be primarily closed after explantation of the sponge. Three patients underwent open treatment because of a skin defect. After 12 months, the wounds had healed well in all patients. Histologic evaluation revealed a physiological healing process. Deep soft tissue infections of the groin adjacent to prosthetic vascular material (type Szilagyi III) can be treated effectively and safely with the vacuum sponge system. The treatment is inexpensive, easy to perform, and the initial vascular reconstruction can be preserved.

The application of bioimplants in the management of chronic osteomyelitis.

The management of musculoskeletal infections is an increasing challenge to clinicians. Bioimplants provide a unique system for skeletal specific drug delivery. Antibiotic-impregnated beads and spacers can be used to treat chronic osteomyelitis and deep soft-tissue infections locally with higher antibiotic concentrations, while avoiding potential systemic side effects.

Selective antibiotic use to prevent postoperative wound infection after external dacryocystorhinostomy.

The use of systemic antibiotic prophylaxis in lacrimal drainage surgery is controversial. Some studies have reported high rates of postoperative infection and surgical failure after lacrimal drainage surgery when systemic antibiotic prophylaxis was not routinely administered. Many ophthalmologists have traditionally used antibiotics only in selected patients undergoing dacryocystorhinostomy (DCR), and this study evaluates the success of this strategy. This was a retrospective interventional case series of 138 consecutive patients who underwent 163 external DCR procedures. Antibiotics were given only when inflammatory signs were present in the medial canthal region or when purulent material was noted during surgery. Patients with persistent external medial canthal inflammatory signs received amoxicillin/clavulanate or cephalexin orally 3 to 7 days before and 1 week after surgery. Patients in whom purulent lacrimal sac material was noted during surgery received cefazolin intravenously. Postoperative results were evaluated in terms of wound infection and related complications and surgical success. Systemic antibiotics were given in 15 of 163 (9%) cases. Nine (6%) cases received intraoperative (intravenous) antibiotics; 5 (3%) cases received perioperative (oral) antibiotics; and 1 (1%) case received both. None of the patients had postoperative deep soft tissue infection (cellulitis). Skin changes compatible with superficial wound infection occurred in 2 (1%) cases and responded well to topical treatment. Surgery was successful in 157 of 163 (96%) cases. Of 6 failures, none were associated with postoperative wound infection. Selective use of antibiotics limited to patients with signs of lacrimal sac inflammation appears sufficient to prevent soft tissue infection after DCR.

Risks to feet in the top end: outcomes of diabetic foot complications.

The foot complications of diabetes are severe, disabling, costly and common in the Northern Territory. An understanding of the pathogenesis, the disease spectrum and treatment efficacy, however, is poor. The patterns of disease are documented in the present study; factors associated with good and poor outcomes are identified; and improved management strategies are proposed. All patients presenting to the High Risk Foot Service at Royal Darwin Hospital between March 1997 and March 2000 were included in the present study, and details regarding the status of their feet, their demographics, their treatment and their outcomes were recorded prospectively. Logistic regression analysis was undertaken to determine associations between factors of interest and outcomes of healing and amputation. One hundred and twenty-six patients were recorded, 41% of whom had neuropathic ulcers and 63% of whom had severe disease at presentation. Two types of diabetic foot pathology were recognized that are not usually classified: acute injury without neuropathy (10%) and deep soft tissue infection alone (9%).Thirty-seven percent and 23% of patients required minor and major amputations, respectively. The total number of hospital bed-days was 5813. Total contact casting was associated with good healing rates in 16 patients. Major amputation was associated with ischaemia, severe disease at presentation and increasing age. Patterns of diabetic foot disease which are not commonly recognized are described in the present study; the severity and cost of the problem are documented; and some factors which lead to poor outcome, such as late presentation, are identified. Attention should be paid, through a multidisciplinary team, to timely referral from primary care, patient education, total contact casts and appropriate revascularization.

Foot and ankle infections after surgery.

Infection after foot and ankle surgery or trauma can range from the common superficial cellulitis to the less common deep soft tissue or bone infections that can have disastrous consequences. The emergence of antibiotic-resistant organisms has made treatment of infection more difficult, even though promising new antibiotics are being developed. Prevention of infection, through proper patient selection and meticulous surgical technique, is essential to satisfactory outcomes.

Complications of K-wire fixation of fractures and dislocations in the hand and wrist.

Kirschner wire (K-wire) fixation of fractures and dislocations of the hand and wrist is a common procedure. Of the 590 K-wire fixations performed on 236 patients, 36 (15.2%) experienced complications which included osteomyelitis, tendon rupture, nerve lesion, pin tract infection, pin loosening or migration. There were no deep soft-tissue pin infections or pyarthrosis. Technical failure, mainly when the procedure was performed by residents, and poor patient compliance were the major causes of complications. K-wire fixation is a simple but demanding procedure that cannot be left to an inexperienced resident. Elimination of technical failure, supervision in the operating room, close monitoring, prompt treatment upon discovery of a complication, and improvement of patient compliance can reduce the rate of complications.

Limb Salvage of Lower-Extremity Wounds Using Free Gracilis Muscle Reconstruction

An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.

Deep Foot Infections in Patients with Diabetes and Foot Ulcer: An Entity with Different Characteristics, Treatments, and Prognosis

We report findings in 223 consecutively included people with diabetes, foot ulcer and a deep foot infection treated by a multidisciplinary diabetic foot care team at the University Hospital in Lund, Sweden. The aim of the present study was to evaluate type and characteristics of deep foot infections and their relation to choice of treatment and outcome. Three different groups of deep foot infections were identified; osteomyelitis only ( n = 112), deep soft tissue infection only ( n = 46) and combined infections (osteomyelitis and deep soft tissue infection, n = 65). The various types of deep foot infections had different characteristics, treatment and prognosis. Patients with a deep soft tissue infection only or a combined infection had a significantly ( p < 0.05) higher; (1) body temperature (38.0 and 38.0 vs. 37.3°C), (2) erythrocyte sedimentation rate (75 and 80 vs. 56 mm/h) and (3) white blood count (11.0 and 12.0 vs. 8 × 10 9) at diagnosis compared with those who had osteomyelitis only. Patients with a deep soft tissue infection only or a combined infection also had a significantly ( p < 0.05) shorter time to surgery (2 and 4 vs. 10 days), higher mean number of surgical procedures (1.9 and 2.1 vs. 1.4 procedures) and higher percentage of patients had intravenous antibiotics (87 and 84 vs. 46%) compared with those who had osteomyelitis only. Amputation before healing was more common in patients with a combined infection (62%) compared with those who had osteomyelitis only (37%) or a deep soft tissue infection only (30%). The findings in the present study indicate that deep foot infections in patients with diabetes is a heterogeneous entity, in which the type of deep foot infection is related to choice of treatment strategy and to outcome. Therefore, these various types of infections has to be considered in future studies of deep foot infections in people with diabetes.

Hypothenar hammer syndrome diagnosed by ultrasound

A 30-year-old right handed man whose occupation involved working with paving stones presented to the Emergency Department with a painful left hand of one week duration. The only clinical ®nding was tenderness over the left hypothenar eminence. This was nonspeci®c. Plain radiographs of the hand failed to demonstrate bony abnormality or radio-opaque foreign body. A diagnosis of a deep soft tissue infection was made and the patient prescribed antibiotics and a wrist splint. Over the next 6 months, he attended the department on 3 occasions. His symptoms improved with rest, analgesia and antibiotics each time, but returned with work. On his third visit, an ultrasound examination of the hypothenar eminence was requested. This demonstrated thrombosis in the ulnar artery (Fig. 1). The patient later underwent surgery to resect the thrombosed segment of the ulnar artery (Fig. 2). This was reconstructed with a vein graft. Subsequent follow-ups showed the patient was symptom free and able to return to work.

Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion.

Closed internal degloving is a significant soft-tissue injury associated with a pelvic trauma in which the subcutaneous tissue is torn away from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. It commonly occurs over the greater trochanter but may also occur in the flank and lumbodorsal region. When this closed internal degloving occurs over the greater trochanter, it is known as a Morel-Lavallée lesion. We reviewed 24 patients who sustained a closed internal degloving injury. Cultures from the closed internal degloving injury were positive in 46% (11 of 24 cases). The incidence of positive cultures was not dependent on the time from injury to debridement. All wounds were treated by thorough debridement before or during pelvic or acetabular surgery. Three patients subsequently developed deep-bone infections, only one of whom had a positive culture at the initial debridement. One patient whose wound was primarily closed over suction drains developed a chronic deep soft-tissue infection requiring multiple debridements. The development of hematoma in the zone of operation reduces the safety of early operative intervention by increasing the risk of infection. An expanding hematoma in a closed internal degloving injury may further compromise the skin vascularity if not promptly drained. The injured soft tissues should be debrided early, either before or at the time of fracture fixation. The wound should be left open, and repeated surgical debridement of the injured tissue is recommended.

Deep soft-tissue infections caused byStreptococcus pneumoniae

Three cases of deep soft-tissue infections caused by Streptococcus pneumoniae are presented. All patients were previously healthy adults. The first case was a man with a protracted illness in whom pelvic and inguinal abscesses developed at the site of a scar from a traumatic injury several years earlier. The second patient, a woman, had mastitis with systemic symptoms. The third patient was a woman who developed a gluteal abscess after an intramuscular injection of a contraceptive. Cellulitis and deep soft-tissue infections caused by Streptococcus pneumoniae are uncommon, but may occur even in immunocompetent adults.