METHODICAL INSTRUCTION FOR STUDENTS OF THE 5TH COURSE
Medical Faculty
Content module 3. “Pediatric surgery”
LESSON № 4 (PRACTICAL – 6 HOURS)
Theme 1: Purulent-inflammatory disease of bones and joints.( acute and chronic osteomyelitis).-3h
Theme 2: Purulent-inflammatory disease of soft tissue.( neonatal phlegmon, neonatal omphalitis, mastitis, Perianal and Perirectal Abscess)-3h
Aim: To be able to identify the basic clinical and radiological signs of disease, basis of choice of optimal conservative, operative and health resort management.
To discover the basic clinical and supplementary signs of disease, choice of optimal conservative or operative treatment of purulent lesions.
Professional orientation of students: Acute hematogenous osteomyelitis (AHO) is one of the most widespread and serious purulent diseases in childhood. Children with osteomyelitis constitute 6-10% of hospitalized patients with purulent ailments. Early diagnosis with correct etio-pathogenetic treatment is of paramount importance in such cases. The problem of management of purulent infections is one of the longest standing in the history of surgery especially in childhood. Widespread use of anti-bacterial medication and consequent microbial resistance to these medications has lead to changes in the type and characteristics of infecting microbes. Important aspects of the study of this problem include early diagnosis with etio-pathogenetic treatment and prevention of these infections in childhood.
Individual students’ work with patients – 9.00-12.00
Methodology of Practical Class.
Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):
Work 1.
1. Friendly facial expression, smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Tactful and calm conversation with patient’s relatives, if it is necessary.
5. Explanation of planned actions of the patient’s treatment (hospitalization, performing certain examinations, etc.).
6. Conversation accomplishment.
7. Explain to a patient what examination will be performing and get his/her informed consent.
8. Prepare yourself to perform examination (clean and warm hands, warm phonedoscope, etc).
9. Explain the necessity of transportation to the examination place (medical examination room, ultrasonic investigation, computer tomography, endoscopy, etc).
10. Perform examination.
11. Explain to the patient results of his/her lab tests correctly and accessibly.
12. Conversation accomplishment.
13. Involve patient’s relatives into the conversation (compare present examination results with previous ones, clarify whether your explanations are clear for them).
14. Conversation accomplishment.
15. Get the patient’s agreement on bandaging.
16. Explain to the patient manipulation actions which are performed or will be performed in the future and strategy of further treatment.
17. Inform the patient with a stoma about possibility of further rehabilitation and improvement of life quality.
Individual Students Program.
Theme 1:
1. Anatomic and physiologic peculiarities of the skeletal system in childhood. Pathogenesis of acute and chronic H.O.
2. Clinical and radiological diagnosis of acute and chronic hematogenous osteomyelitis.
3.Symptoms of the basic clinical types: adynamic, septico-pyemic, local.
4.Clinical and laboratory diagnosis of intoxication, dehydration, acidosis, hypokalemia.
5. Anti-bacterial and infusion therapy, methods of bone drilling, aspiration, anesthesia.
6. Recuperation, health resort and sanatorium management.
Theme 2:
1. Anatomy of the skin and its functions.
2. Immunological reactions in childhood, importance of hospital infections.
3. Clinico-laboratory diagnosis of soft-tissue purulent infection.
4. Anti-bacterial and infusion therapy.
5. Methods and techniques of soft-tissue pus drainage.
6. Hospital infection and its management.
Break – 12.00-12.30
Seminar discussion of theoretical issues. – 12.30-14.00
1. Etio-pathogenesis, classification Pathogenetic stages of acute and chronic H.O.
2. Atypical forms of acute H.O
3. Clinical and supplementary diagnosis of acute and chronic H.O
4. Differential diagnosis of A.H.O
5. Conservative and surgical methods of management of acute and chronic H.O:
6. Etiopathogenesis of acute soft-tissue infections in childhood.
7. Clinical and laboratory diagnosis of acute soft-tissue infections in childhood.
8. Neonatal omphalitis: General symptoms in simple, phlegmonous and toxic types.
9. Special features of conservative treatment of patients with acute suppurative infections.
10. Special features of surgical methods of management of acute purulent infections in childhood.
Test evaluation and situational tasks.
Theme 1:
1. The first radiological features of acute osteomyelitis appear:
A. in the first few hours of illness
B. by the end of the first day
C. during the first week
D. after the first week
E. immediately the patient presents
2. The earliest radiologic finding in acute osteomyelitis is:
A. an elevated periosteum
B. osteomalacia
C. sequestration
D. fistula formation
E. osteoporosis
3. Which is not an atypical form of osteomyelitis?
A. Brodie’s abscess
B. Osteomyelitis antibiotica
C. Sclerosing osteomyelitis
D. Paget’s disease
E. Albuminous osteomyelitis
4. Presence of a sequestrum and fistulas is indicative of:
A. Acute osteomyelitis
B. Chronic osteomyelitis
C. Brodie’s abscess
D. Albuminous osteomyelitis
E. None of the above
5. Which of the following is not a likely outcome of an osteomyelitic process?
A. Spontaneous fractures
B. Involvement of the joints
C. Amyloid disease
D. Deformity
E. Pott’s disease
Clinical situation tests:
Test 55:
A 4 year old boy presented with marked pain in the right shin, soft-tissue swelling 3 days after trauma. Movement in the limb was painful. Body temperature was 38.7C, heart rate 138-142 per minute with a periodic productive cough. Radiographic investigations revealed signs of osteomyelitis of the right shin as well as clinical signs of bilateral pneumonia. What type of osteomyelitis has this patient?
Test 56:
An 8 year old girl complained of pains in the right thigh with pyrexia. The physical signs were: pallor, an increase in size of the lower third of the right thigh, tenderness on palpation and an elevation of the local temperature. A leukocytosis with a shift to the left was noticed in the blood analysis. No changes in bone structure were evident in a thigh radiograph. What is the diagnosis? At what pathologic stage is the disease?
Test 57:
A child of 12 was diagnosed with toxic form of acute osteomyelitis of the right thigh. There was marked intoxication and dehydration. What would be your course of conservative treatment of this case?
Test 58:
You have diagnosed acute osteomyelitis of the left thigh in a child of 6. The general condition was severe, the child being ill for 7 days. Soft-tissue fluctuation was evident in the lower third of the left thigh. What is the mainstay of surgical treatment in such a case?
Test 59:
Needle aspiration with subsequent conservative therapy was prescribed on account of acute osteomyelitis of the left tibia in a child of 7. Bilateral pneumonia complicated by a right-sided pleural empyema was diagnosed 6 days later. What would be the course of action?
Test 60:
Marked bone destruction associated with a spread of infection to the hip-joint was noticed in an 11 year old child with acute osteomyelitis of the upper third of the left thigh. The general condition was critical. What other complications could be expected? What course of action should be taken?
Test 61:
A child of 10 presented with pain in the left thigh, swelling and inability to walk 14 days after soft-tissue trauma of the thigh. Body temperature was found to be elevated to
Theme 2:
1. Which of the following, according to Greek classical medicine is not assign of inflammation?
A. calor
B. dolor
C. fetor
D. tumor
E. functio laesa
2. Which of the following is not an anorectal abscess type?
A. perianal
B. submucous
C. pelviorectal
D. ischiorectal
E. subrectal
3. The medical term for a boil is:
A. furuncle
B. carbuncle
C. cellulitis
D. apocrinitis
E. impetigo
4. Hidradenitis suppurativa is a purulent inflammatory process of the:
A. apocrine glands
B. hair follicles
C. subcutaneous tissues
D. eyelash follicles
E. None of the above
5. Which of the following is a likely late complication omphalitis?
A. Portal hypertension
B. Omphalocele
C. fistula
D. Internal hemorrhage
E. None of the above
Break – 14.00-14.15
Individual work 1415-1500
– Analysis of test tasks licensing examinations “Step” 2;
– Assessment of students who have not passed the day before the test control system «Moodle»;
– Putting the students practical skills in the entry metrical book.
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.
(the instructor has tests & situational tasks)
Student should know:
Theme 1:
1. Etio-pathogenesis of acute and chronic H.O.
a). Role of open sources of infection, soft tissue trauma and exposure to cold.
b). Role of disturbances in soft tissue and bone circulation.
c). Pathogenic stages of acute osteomyelitis.
d). Basic principles of formation, pathogenesis of chronic osteomyelitis
2. Classification of acute and chronic osteomyelitis:
a). Clinical:
1. Toxic (adynamic) type.
2. Septico-pyemic type.
3. Local.
4. Chronic.
b). According to localization:
1. Epiphyseal.
2. Metaphyseal.
3. Diaphyseal.
4. Meta-diaphyseal.
5. Pelvic.
6. Other localization.
c).Pathogenetic stages:
1. Bone marrow phlegmon.
2. Periosteal abscess.
3. Soft tissue phlegmon.
4. Dermal fistula.
d). Atypical forms:
1. Brodie’s abscess.
2. Albuminous osteomyelitis.
3. Osteomyelitis antibiotica.
4. Sclerosing osteomyelitis
3. Clinical and supplementary diagnosis of acute and chronic H.O:
a). Determination of clinical type, localization and pathogenetic stage
1. Clinical and radiological diagnosis: increase in limb size.
2. Evaluation of local rise in temperature.
3. Radiological definition of destructive changes in bone structure.
4. Clinical and radiological diagnosis of metastatic pneumonia
b). Technique and evaluation of osteotonometry.
c). Laboratory signs of A.H.O
d). Laboratory analysis of bone marrow and joint exudates.
4. Differential diagnosis of A.H.O:
a). Intra-muscular abscess.
b). Bone trauma.
c). Bone diseases: rheumatic, typhoid, tuberculosis, actinomycosis, syphilis.
d). Bone neoplasms.
5. Conservative and surgical methods of management of acute and chronic H.O:
a). Conservative methods;
1. Correction of homeostatic imbalances.
2. Anti-bacterial therapy.
3. Desensitization and anti-proteolytic therapy.
4. Vitamin therapy.
5. Limb immobilization.
6. Physiotherapy.
b). Surgical methods:
1. Needle aspiration
2. Intra-dermal lavage.
3. Aspiration and drainage of joints.
4. Sequestrum debridement.
5. Bone packing after debridement.
6. Long-term outcomes of management of acute and chronic H.O:
a). Spontaneous fractures.
b). Spontaneous dislocations.
c). Ankylosis.
d). Chronic osteomyelitis.
e). Malignization of fistulae.
f). Shortening and deformation of limbs.
7. Basic methods of prevention of A.H.O:
a). Early physical conditioning.
b). Sanitation of sources of infection.
c). Prevention of childhood trauma.
d). Management of nosocomial infections in maternity wards.
e). Sanitary enlightenment of the populace.
Theme 2:
1. Etiopathogenesis of acute soft-tissue infections in childhood.
a). Special features of immunological reactions in childhood.
b). Neuro-endocrine response.
c). Special anatomical features of the skin and subcutaneous tissues in childhood.
d). Special features of local lesions and the importance of phagocytosis.
2. Clinical and laboratory diagnosis of acute soft-tissue infections in childhood.
a). Neonatal phlegmon:
1. General symptoms in simple, toxic and septico-pyemic types.
2. Local symptoms (pain, local rise in temperature, erythema, swelling ).
3. Laboratory diagnosis.
b). Neonatal omphalitis:
1. General symptoms in simple, phlegmonous and toxic types.
2. Local symptoms.
3. Laboratory diagnosis.
c). Adenophlegmon
1. General symptoms.
2. Local symptoms.
3. Laboratory diagnosis.
d). Pseudo-furunculosis
1. General symptoms.
2. Local symptoms.
3. Laboratory diagnosis
3. Special features of conservative treatment of patients with acute suppurative infections.
a). Anti-bacterial therapy.
b). Intensive infusion therapy of homeostatic dysbalance.
c). Passive and active immunization.
d). Symptomatic treatment.
e). Desensitization and hormonal therapy.
f). Physiotherapy (compresses, warm baths, UHF, ultra-violet therapy).
4. Special features of surgical methods of management of acute purulent infections in childhood.
a). Special features of surgical management of neonatal phlegmon (multiple cuts in the zone of the lesion
including the border with healthy tissue and frequent dressing every 6-8 hours).
b). Special features of surgical management of neonatal omphalitis depending on clinical type.
c). Special features of surgical management of mastitis.
5. Basic methods of prevention of acute suppurative infections in childhood.
a). Detection of carriers of infection amongst medical personnel of maternity wards and their treatment.
b). Measures against hospital infection (departmental sanitation and hygiene).
c). Early diagnosis and isolation of patients with purulent infections.
d). Sanitary enlightenment of the populace.
Student should be able to:
Theme 1:
1. Define general symptoms.
2. Define local symptoms (size of limb, tenderness, swelling, erythema, local rise in temperature, fluctuation, decrease in range of motion).
3. Prepare patients for radiographic investigation and its interpretation.
4. Diagnostic needle aspiration of bone canal, joints, sub-periosteal and intra-muscular abscesses.
5. Interpret changes in bone canal pressure.
6. Administer drugs IV and IM.
2. Define blood groups, rhesus factor.
3. Set up the IV infusion set.
4. Perform wound dressing.
5. Place casts and plasters.
6. Surgically manage purulent wounds
7. Open and drain abscesses.
8. Assist in operations.
9. Perform joint aspiration and drainage.
10. Take care of bed-ridden patients.
Theme 2:
1. Define general symptoms (phlegmon, mastitis, neonatal omphalitis, adenophlegmon, pseudo-furunculosis).
2. Define local symptoms (tenderness, swelling, erythema, local rise in temperature, fluctuation).
3. Collect pus for culture and sensitivity.
4. Define blood groups, Rhesus factor.
5. Set up a detailed plan of conservative and surgical management.
6. Set up IV infusion sets.
7. Perform IV and IM administration of drugs.
8. Assist in operations.
9. Perform wound dressing.
10. Remove sutures.
11. Administer physiotherapeutic procedures.
12. Take care of bed-ridden and post-operative patients.
Correct answers of test evaluations and situational tasks:
Theme 1:
Multiple-choice tests:
1. D
3. D
4. B
5. E
Clinical situation tests:
Test 55 – Septico-pyemic osteomyelitis
Test 56 – Acute osteomyelitis, bone marrow abscess stage
Test 57 – Limb immobilization, anti-bacterial therapy, correction of homeostatic imbalances, desensitization and anti-proteolytic therapy, vitamin therapy, physiotherapeutic procedures.
Test 58 – Surgical evacuation of abscesses – intra-dermal lavage, needle aspiration of bone tissues.
Test 59 – Aspiration of empyema, review of anti-bacterial prescription.
Test 60 – Spontaneous fractures, septicemia and pyemia; limb immobilization.
Test 61 – Acute osteomyelitis of the left thigh. Periosteal abscess stage.
Theme 2:
Multiple-choice tests:
2. E
References:
А – Basic:
1. K.W. Ashcraft, T.M. Holder “Pediatric Surgery”. W.B. Saunders Co., Philadelphia 2010. 1101pages.
2. Practical classes materials
3. Lecture №3
4. Gallagher PG, Shah SS. Omphalitis: Overview. Available at http://emedicine.medscape.com/article/975422-overview (accessed 15 December 2008).
5. Mullany LC, Darmstadt GL, Katz J, et al. Risk factors for umbilical cord infection among newborns of southern Nepal. Am J Epidemiol 2007; 165:203–211. Kouame DB, Dick KR, Ouattara O, Gouli JC, Odehouri KT, Coulibaly C. Traitement des osteomyelites compliquees de l’enfant au CHU de Yopougon, Abidjan (Cote d’Ivoire). Cahiers Sante 2005; 15(2):99–104.
В – Additional:
1. Mander SM. Infectious Disease Update. Dermatol Clin 2001;19(4):749-756.
2. Schwartz R, Kapila R. Necrotizing Fasciitis. EMedicine Journal 2002;3(7):1-19.
3. Ogle JW,
4. Elliot D, Kufera J, Myers R. The Microbiology of Necrotizing Soft Tissue Infections. Am J Surg 2000;179(5):361-366.
5. File TM Jr, Tan JS. Group A streptococcus necrotizing fasciitis. Comprehensive Therapy 2000;26(2):73-81.
Methodical Instruction has been worked out by Ass. Prof. P.V. Hoschynsky
Methodical instruction was discussed and adopted at the Pediatrics # 1 with Pediatric Surgery Department sitting
26 of June, 2013 . Minute № _10__
Methodical instruction was adopted and reviewed at the Department sitting
__________201 . Minute № ___
