Case Presentation (Part One): You Make the Call
41 year old male Ankle Osteomyelitis


		David Davidson, DPM

HPI: The patient is a 41 y/o male with T10 paraplegia who presented with a history of a chronic ulcerations along the medial and lateral aspects of both ankles. He relates that they have been there for approximately seven years. He has had multiple failed skin grafts and other conventional wound care, but they never resolved. He further related that he has been treated by multiple providers including his primary care doctor, orthopedic surgeons and vascular surgeons. He has had multiple hospital admissions for "infections".

PMH: T 10 paraplegia, anxiety, chronic infections of ankle wounds, depression, multiple suicide attempts

PSHx: Multiple skin grafts; multiple spinal surgeries

FAMHx: Noncontributory

Meds: Ditropan 5mg bid; Seroquel 25mg bid; Dulcolax; Trazadone 50mg bid; Magnesium; Multiple vitamins.

Social: Denies ETOH or recreational drug use; Former cigarette smoker.

Physical Exam: The patient is an undernourished and somewhat hostile male who presents in significant distress. He has been paraplegic since being involved in an automobile accident 15 years earlier. He lives alone and, in spite of his paralysis, seems to be reasonably self-sufficient.

Upon exam of the bilateral lower extremities, he demonstrates pedal pulses that are palpable +2/4. He has loss of protective sensation, proprioception and vibratory sensation. Deep tendon reflexes are absent. He is wheelchair bound. Along the right ankle, the patient demonstrates a medially based ulceration measuring approximately 3.5 x 2.0 x 0.1 in greatest dimension located directly over the medial malleolus (Figure 1). There is a similar wound over the lateral malleolus measuring 1.6 x 1.5 x 0.1 (Figure 2) and similar wounds on the medial (2.5 x 2.2 x .1) and lateral (2.5 x 1.0 x 0.5) aspects of the left ankle (Figures 3 and 4). All wounds exhibit exuberant hypergranulation with serous drainage. He does state that when sleeping, his legs "spasm" and constantly "flop" from one side to the next.

Imaging Studies: Radiographs of the both ankles were obtained and revealed some periosteal proliferation under the medial right ankle wound.

Figure 1

Figure 2

Figure 3

Figure 4

The bilateral ankle wounds have been present for several years failing skin grafting and other wound care by various specialists. Initially, the wounds exhibited exuberant amounts of granulation tissue but never any frank, purulent drainage.

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