PREOPERATIVE DIAGNOSIS:
Infected left olecranon bursa with Nocardia.
POSTOPERATIVE DIAGNOSIS:
Infected left olecranon bursa with Nocardia.
PROCEDURE:
Irrigation and debridement of left elbow wound (8.0 cm) and wound
Closure.
SURGEON:
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 41-year-old right-hand dominant white male with
history of injury to his left elbow while riding a mountain
bike several weeks ago. He has had swelling of the elbow and
has had repeat aspiration. He was noted on repeat aspiration
to have possible infection. Initial cultures have grown up
Nocardia but sensitivities are pending. He had some
improvement, but had recurrence of the swelling and infection.
Options of continued conservative care versus surgery were
discussed with him at length. He requested surgical
treatment. About 3 days ago he underwent excision of the
infected bursa and debridement of the wound. Because of
infection, the wound was packed open. He was kept on
antibiotics. With the Nocardia, Infectious Disease was
contacted previously and they recommended Septra and he was
kept on this. He is now for repeat irrigation and debridement
and possible closure.
DESCRIPTION OF PROCEDURE:
After obtaining informed consent, the patient was brought to the
operating room and placed on the operating room table in supine position. After administration
of general LMA anesthesia, the tourniquet placed on the left
upper arm, a time-out was performed. The patient was identified,
appropriate body site was marked, and he received appropriate
antibiotics. Next, the dressing was removed and the left arm
was sterilely prepped and draped in a routine manner with
Betadine. The wound, about 8.0 cm in length was explored and appeared clean with good
granulation tissue. No abscess or infection was noted. The
area was debrided and then copiously irrigated with pulse lavage irrigation
with 2 bags of bacitracin also. Adequate hemostasis was noted
in the wound. Next, interrupted Vicryl sutures used to
approximate the deep tissue and fascia and nylon sutures were
used to approximate the skin edge. The area was debrided down
to the olecranon and triceps tendon. Good debridement was
noted prior to closure. Good closure was noted. A sterile
dressing was applied. The patient was placed in a padded posterior splint
and transferred to recovery in stable condition.
I stressed with he and his mother the importance of limiting
use of the arm. He works as an auto repair mechanic and has
been trying to work with. I told him to decrease the
likelihood of recurrence of infection, he needs to be very careful
with limited use of the arm and avoid flexion and extension of
the elbow for at least the next 1-2 weeks. He is going to
continue his Septra. He has some occasional tramadol and
Valium to help with his pain. He gets claustrophobic with the
dressing. He is to follow up on Tuesday for recheck and we
will try and get him some kind of brace with a hard padded elbow
support. Return sooner for any problems. He is aware of the
risk of recurrence evidence of infection. He has been poorly
compliant with recommendations for limited use of the arm. He
actually showed me how he is bending the elbow up and down
even in dressing and splint, prior to surgery.
Addendum: The wound was about 8 cm in length, about 4 cm wide and 2 cm deep. It went down to the olecranon bone and triceps tendon. The entire area was debrided down to the bone. The infection did not get into the bone but the periosteum and soft tissue were debrided down to the bone and the triceps tendon.
Infected left olecranon bursa with Nocardia.
POSTOPERATIVE DIAGNOSIS:
Infected left olecranon bursa with Nocardia.
PROCEDURE:
Irrigation and debridement of left elbow wound (8.0 cm) and wound
Closure.
SURGEON:
ANESTHESIA:
General LMA.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
BRIEF CLINICAL HISTORY:
This is a 41-year-old right-hand dominant white male with
history of injury to his left elbow while riding a mountain
bike several weeks ago. He has had swelling of the elbow and
has had repeat aspiration. He was noted on repeat aspiration
to have possible infection. Initial cultures have grown up
Nocardia but sensitivities are pending. He had some
improvement, but had recurrence of the swelling and infection.
Options of continued conservative care versus surgery were
discussed with him at length. He requested surgical
treatment. About 3 days ago he underwent excision of the
infected bursa and debridement of the wound. Because of
infection, the wound was packed open. He was kept on
antibiotics. With the Nocardia, Infectious Disease was
contacted previously and they recommended Septra and he was
kept on this. He is now for repeat irrigation and debridement
and possible closure.
DESCRIPTION OF PROCEDURE:
After obtaining informed consent, the patient was brought to the
operating room and placed on the operating room table in supine position. After administration
of general LMA anesthesia, the tourniquet placed on the left
upper arm, a time-out was performed. The patient was identified,
appropriate body site was marked, and he received appropriate
antibiotics. Next, the dressing was removed and the left arm
was sterilely prepped and draped in a routine manner with
Betadine. The wound, about 8.0 cm in length was explored and appeared clean with good
granulation tissue. No abscess or infection was noted. The
area was debrided and then copiously irrigated with pulse lavage irrigation
with 2 bags of bacitracin also. Adequate hemostasis was noted
in the wound. Next, interrupted Vicryl sutures used to
approximate the deep tissue and fascia and nylon sutures were
used to approximate the skin edge. The area was debrided down
to the olecranon and triceps tendon. Good debridement was
noted prior to closure. Good closure was noted. A sterile
dressing was applied. The patient was placed in a padded posterior splint
and transferred to recovery in stable condition.
I stressed with he and his mother the importance of limiting
use of the arm. He works as an auto repair mechanic and has
been trying to work with. I told him to decrease the
likelihood of recurrence of infection, he needs to be very careful
with limited use of the arm and avoid flexion and extension of
the elbow for at least the next 1-2 weeks. He is going to
continue his Septra. He has some occasional tramadol and
Valium to help with his pain. He gets claustrophobic with the
dressing. He is to follow up on Tuesday for recheck and we
will try and get him some kind of brace with a hard padded elbow
support. Return sooner for any problems. He is aware of the
risk of recurrence evidence of infection. He has been poorly
compliant with recommendations for limited use of the arm. He
actually showed me how he is bending the elbow up and down
even in dressing and splint, prior to surgery.
Addendum: The wound was about 8 cm in length, about 4 cm wide and 2 cm deep. It went down to the olecranon bone and triceps tendon. The entire area was debrided down to the bone. The infection did not get into the bone but the periosteum and soft tissue were debrided down to the bone and the triceps tendon.