PubMed · 11328640
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J P Fogelman. 2001. Lividoid vasculitis.. https://pubmed.ncbi.nlm.nih.gov/11328640/
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In a patient with a high a priori risk of peripheral vascular disease, the positive predictive value of an abnormal physical diagnostic examination is high. In patients with a low prior probability of peripheral vascular disease, the physical examination makes little contribution to the diagnosis or exclusion of arterial insufficiency. For this purpose the ankle-brachial systolic pressure index is preferable. Peripheral arterial disease is unlikely when this index is normal. However, a low ankle-brachial index necessitates further investigations to determine possible arterial insufficiency in the lower extremities.
A systematic approach of the surgical management of a calcaneal fracture can minimize the potential of soft tissue complications. When reducing a closed calcaneal fracture, the incision used affects the postoperative complications. The L-shaped incision with the horizontal limb lying on the lateral glabrous junction ensures maximum blood flow to either side of the incision. Whether or not the wound can be closed primarily depends on the preexisting edema, the lost calcaneal height, and the delay between the fracture and reduction (Fig. 20). The wrinkle test is a good indicator that the incision can be closed primarily if the amount of height restored is minimal. If the edema is too great, steps should be taken to reduce it sufficiently to allow successful wound closure. If the wound, after reduction, is too wide to allow primary closure, an ADM flap laterally or an AHM flap medially should be used. For larger defects, a free flap should be considered. The three important steps to reconstruction of soft tissue defects around the calcaneus include good blood supply, a infection-free wound, and the simplest soft tissue reconstructive option that covers the wound successfully. Adequate blood supply can be determined by the use of Doppler. If the supply is inadequate, revascularization is necessary before proceeding. Achieving a clean wound requires aggressive debridement, intravenous antibiotics, and good wound care. Adjuncts that can help in achieving a clean wound include topical antibiotics (silver sulfadiazine), the VAC, and hyperbaric oxygen. Osteomyelitis has to be treated aggressively. Any suspicious bone has to be removed. Only clean, healthy, bleeding bone is left behind. Antibiotic beads can be useful when there is doubt as to whether the cancellous bone is infection-free. The beads are not a substitute for good debridement, however. Soft tissue reconstruction ranges from delayed primary closure to the use of microsurgical free flaps (Fig. 21). When bone or hardware is exposed, a muscle flap should cover the wound because of the extra blood supply it carries with it. The soft tissue option depends on the width of the wound. For wounds 1 cm wide or less, the options include allowing the wound to close by secondary intention (VAC), delayed primary closure, or a local muscle flap. For wounds 2 cm wide or less, allowing the wound to close by secondary intention (VAC) and a local muscle flap are the best options. For wider wounds, one has to assess whether the local muscle flap has sufficient bulk to close the defect. If it does, it is the simplest solution. If the local muscle is inadequate, a microsurgical free flap has to be used. The VAC sometimes can convert a large wound to a smaller wound so that a local muscle flap can be used. This procedure takes time, however, and adds to the cost of the repair.
UNLABELLED: We report two cases of osteoarticular brucellosis in childhood, which illustrate the diagnostic difficulties in non-endemic areas. CASE REPORT: A 12-year-old boy was admitted for a unilateral sacroiliitis for which the brucellosis origin was established by serological and blood cultures (without fever). Autoimmunity was detected and disappeared following the treatment of the affection. A six-year-old girl was admitted for a monoarthritis of the left ankle (with fever) for which the brucellosis origin was also established by serology and blood cultures. COMMENTS: The above cases underline the importance of knowing the atypical varieties of brucellosis. The brucellosis serologies need to take part in the etiological workup of an infectious osteoarthritis when a classic infectious cause cannot be proved. Blood cultures on a specific medium are essential to carry out, even in the case of apyrexia. Finally, the possibility of autoimmunity signs for the brucellosis has to be known to avoid orientating the diagnosis towards an autoimmune systemic disease.