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Imaging Quiz Answer: Perplexing Shin Pain

Edward G. McFarland, MD; Eva H. Kraus

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 4 - APRIL 97


Diagnosis

Return to case presentation.

[FIGURE 3 AND 4] The plain radiographs revealed a destructive lesion, 3 to 4 cm in length, of the anterior tibial cortex in the distal tibia (figure 3). Inside the lesion was a faint area of sclerotic bone. The CT scan showed a focally destructive lesion in the anterior tibial cortex with sclerotic bone consistent with a sequestrum (figure 4). A bone scan showed increased uptake around the lesion but no other lesions. These findings pointed to a differential diagnosis of osteomyelitis versus osteoid osteoma.

Under sterile procedures, an incision was made in the anterior aspect of the lesion. The cortex was opened with a curette, and an area of abscess with a sequestrum was revealed. A portion of this tissue was sent for frozen section, and the diagnosis of osteomyelitis was made. Cultures for aerobic, anaerobic, fungal, and tuberculous organisms were taken for microbiology. A high-speed burr was used to remove all the reactive and abnormal bone. The wound was irrigated liberally with normal saline and closed primarily.

Cultures identified the organism as Salmonella typhi. Blood and stool cultures were negative. Ampicillin was prescribed but was switched to ceftriaxone because of sensitivities and ease of administration. The patient's leg was then placed in a cast, windowed over his wound, with a toe-touch weight-bearing status. Intravenous antibiotics were continued for 6 weeks.

Radiographs at 6 weeks showed early healing of the incisional biopsy site. Twelve weeks after surgery the patient was allowed full weight bearing. He eventually returned to play as a minor league baseball pitcher with no limitations.

Discussion

Shin pain is common in athletes. The most frequently reported causes are "shin splints," stress fractures, and stress reactions. Tumors and infections rarely present as shin pain in athletes (1).

In our patient, shin splints were unlikely since they are not usually associated with warmth or swelling. The physical findings did not readily distinguish his infection from a stress fracture. His symptoms were not specific, and an osteoid osteoma had to be excluded (1).

After plain radiographs revealed the bony lesion, further imaging was used to elucidate the extent of the lesion and to confirm the diagnosis. Although the patient's lesion appeared to be solitary, bone scanning helps to eliminate multifocal lesions. CT scanning is not always necessary, but assists in distinguishing cortical lesions of bone.

Hematogenous infection of long bones is uncommon in adulthood (2). When it occurs, Staphylococcus aureus is the most common pathogen (3). Salmonella is an uncommon cause of osteomyelitis (4-6); one estimate is that it causes 5% of cases (7). When salmonella is the pathogen, the patient usually has a history of salmonella infection (6,8,9), such as gastroenteritis, enteric fever, or bacteremia (8,10). With S typhi, a previous episode with gastroenteritis is the rule (9). From their intestinal habitat, the pathogens are disseminated via the bloodstream (7). This is the most common pathway for bone infection by salmonella species (5,10,11). The most common sites for salmonella infection in bone are the diaphyses of the femur, tibia, and humerus (9,10).

Although uncommon overall, salmonella osteomyelitis is common in patients with sickle cell disease or other preexisting illnesses (2,4,7,9,10,12). Bennett and Namnyak (12) reported that salmonella species occur in 71% of sickle cell patients who have osteomyelitis.

Trauma and age can also play a role in the development of bone infection. Salmonella osteomyelitis has been reported in children with closed fractures (13,14); this may be due to the different vascular anatomy in bones during childhood. Adeyokonnu and Hendrickse (2) found younger patients generally more susceptible to salmonella osteomyelitis than older patients.

Where the causative agent entered our patient's bloodstream is unknown, but the site is presumed to have been the gastrointestinal tract. Blood and stool cultures, however, were negative, indicating that the patient was not a carrier for S typhi. Identification of the pathogen was possible only by open biopsy.

The antibiotics normally used for treatment of salmonella osteomyelitis are chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole (2,10,13,15). The patient in this case was treated with 1 g of ceftriaxone twice a day because it has been reported to be a successful antibiotic for multidrug-resistant salmonella osteomyelitis (16 ).Concurrent antibiotic and surgical treatment is important for preventing recurrence of the bone infection and promoting complete healing.

Watch for the Unusual

Although this is rare, osteomyelitis can present as shin pain in athletes. Skeletal pain in athletes should be evaluated with radiographs or other scans if it does not improve with treatment. The diagnosis of salmonella infection should be considered in individuals at risk.

References

  1. Martin DF, Micheli LJ, Silberstein CE: Anterior tibial pain in a baseball player. Phys Sportsmed 1990;18(4):84-90
  2. Adeyokunnu AA, Hendrickse RG: Salmonella osteomyelitis in childhood: a report of 63 cases seen in Nigerian children of whom 57 had sickle cell anaemia. Arch Dis Child 1980;55(3):175-184
  3. Mader JT, Calhoun J: Osteomyelitis, in Mandell GL, Bennett JE, Dolan R (eds): Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, ed 4. New York City, Churchill Livingstone, 1995
  4. Allard S, O'Driscoll J, Laurie A: Salmonella osteomyelitis in aplastic anaemia after antilymphocytic globulin and steroid treatment. J Clin Pathol 1992;45(2):174-175
  5. Cobos JA, Calhoun JH, Mader JT: Salmonella typhi osteomyelitis in a nonsickle cell patient: a case report. Clin Orthop 1993;288(Mar):277-281
  6. Monsivais JJ, Scully TJ, Dixon BL: Chronic osteomyelitis of the hand caused by Salmonella typhimurium: a case report. Clin Orthop 1988;226(Jan):231-234
  7. Vaida AJ, Mattiucci CJ, Shapiro SA, et al: Use of an ambulatory infusion pump in a 12-year-old with Salmonella osteomyelitis. Drug Intel Clin Pharm 1989;23(5):379-381
  8. Black PH, Kunz LJ, Swartz MN: Salmonellosis: a review of some unusual aspects. N Engl J Med 1960;262(16):811-817
  9. Carlson DA, Dobozi WR: Hematogenous Salmonella typhi osteomyelitis of the radius: a case report. Clin Orthop 1994;308(Nov):187-191
  10. Cohen JI, Bartlett JA, Corey GR: Extra-intestinal manifestations of salmonella infections. Medicine 1987;66(5):349-388
  11. Montejo M, Aguirrebengoa K, Garcia-Alonso JA, et al: Chronic osteomyelitis caused by Salmonella fyris, letter. Clin Infect Dis 1994;19(1):221
  12. Bennett OM, Namnyak SS: Bone and joint manifestations of sickle cell anaemia. J Bone Joint Surg (Br) 1990;72(3):494-499
  13. Birch T, Levin T, Glaser JH: Salmonella osteomyelitis complicating an acute fracture in a healthy child, letter. Clin Infect Dis 1994;19(3):545-546
  14. Underhill TJ, White M: Subacute Salmonella osteomyelitis following a greenstick fracture of the radius. Injury 1988;19(4):277-278
  15. Oritz-Neu C, Marr JS, Cherubin CE, et al: Bone and joint infections due to Salmonella. J Infect Dis 1978;138(6):820-828
  16. Sherman JW, Conte JE Jr: Ceftriaxone treatment of multidrug-resistant Salmonella osteomyelitis. Am J Med 1987;83(1):137-138

Dr McFarland is an assistant professor in the department of orthopaedic surgery, section of sports medicine, at Johns Hopkins University in Baltimore. Ms Kraus is a medical student at the University of Freiburg in Freiburg, Germany. Address correspondence to Edward G. McFarland, MD, Johns Hopkins University, Section of Sports Medicine, 2360 West Joppa Rd, Suite 205, Baltimore, MD 21093.


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