Case report
Chronic osteomyelitis of the right femur
writer :
Sofiuddin bin nordin
030.08.305
Lecturer :
Dr. Arsanto Triwidodo,SpOT,FICS, K Spine, MHKes
Surgery Departement Koja Hospital
Medicine Faculty Of Trisakti
Jakarta ,6 september t 27,2012
Period july 23th ,2012- September 29,30th
CONTENT
PREFACE ……………………………………………………………… PAGE 1
CHAPTER 1:
DEFINITION OF OSTEOMYELITIS ………………………………………………………………. PAGE 2
CHAPTER 2:
CASE REPORT ……………………………………………………………….. PAGE 3- 16
CHAPTER 3:
CASE REVIEW (OSTEOMYELITIS) …………………………………………………………………. PAGE 18- 33
CHAPTER 4:
REFERENCES ………………………………………………………………… PAGE 34
PREFACE
Assalamu’alaikum Wr Wb
I would like to thank to the one supreme God, Allah S.W.T for all blessing so through my
works I could finish this paper in time. This paper would not have been possible without
encourage from my family, my groupmate and my lecturer whom I most grateful.
Thank to our lecturer dr Arsanto triwidod, SpOT, FICS,K Spine,MHKes for his
guidance and help me to finish this paper, without him, I belived that my work will facing
some problem. This paper is all about ‘chronic osteomyelitis of the right femur’ that I
arranged in oder to completed my assignment for the department of surgery of koja hospital.
The case in this paper actually very complicated case because the patient not only have been
diagnosis suffered from bone infection but also having some fracture. So, because the title is
about bone infection, so in this paper we will be discuss only about osteomyelitis and some
part of fracture.
To many other individuals who contributed while I was writing this paper. This paper
is still not prefect. There are a lot of mistakes in the writing, grammar, medical term and also
theory of illness. I hope, after reading this paper, readers could give some advices and critics
that may develop my ability to write another better paper for the next time.
Finally, I apologize for all mistake that I made in this paper. I hope this paper could
be useful to the reader.
Wassalamu’alaikum Wr Wb
CHAPTER 1
DEFINITION
Osteomyelitis is inflammation of the bone caused by an infecting organism. Although
bone is normally resistant to bacterial colonization, events such as trauma, surgery, presence
of foreign bodies, or prostheses may disrupt bony integrity and lead to the onset of bone
infection. Osteomyelitis can also result from hematogenous spread after bacteremia. When
prosthetic joints are associated with infection, microorganisms typically grow in biofilm,
which protects bacteria from antimicrobial treatment and the host immune response.
Early and specific treatment is important in osteomyelitis, and identification of the
causative microorganisms is essential for antibiotic therapy. The major cause of bone
infections is Staphylococcus aureus. Infections with an open fracture or associated with joint
prostheses and trauma often require a combination of antimicrobial agents and surgery. When
biofilm microorganisms are involved, as in joint prostheses, a combination of rifampicin with
other antibiotics might be necessary for treatment
CHAPTER II
CASE REPORT
Name : Anggara sustina
Age : 18 years old
Sex : men
Religion : islam
Ethnic : sundanese
Education : SMA
Civil Status : single
Date of enter to hospital: 21.07.2012(from emergency room)
Date of examination: 02.08.2012
History taken have been done on 02.08.2012, 10.30 am
Chief complaint
Pain on the right knee and the right hip since 9 months ago
Additional complaint:
Fever with chill and malaise
History of present illness
The patient confessed that 9 months ago before admission, he get involved in
accident on october 2011. The patient was riding a motorcyle when his bike got hit by
another motorcyle from the right side and was dragged for approximately 7 meter with low
velocity.He refuse loss of consciousness and no trauma in his head. Blood come out from
wound on his leg. The size of that woud around 5cmx 2cm in his proximal femur and full
field with sand and very dirty. Patient was then assisted by a witnessing security guard and
bring him back to his home. His mother decided brought to bonesetter that night. During the
treatment the bonesetter was assume to manuever a traction on the broken leg. The wound on
his leg not sutured because he assume that its not to deep. He told to the patient that needed a
medical attention. After 2 days, he went to RS manuel in bandung and from x ray photo,
patient was suspected of having fractured neck of femur. And then he was sent to RS Hasan
Sadikin for futher treatment. Due to financial problem patient didnt get the operation needed.
Once again, patient went to alternatif treatment practitioner and was given some kind of
herbal ointment. A weeks after using the ointment the pain in the thigh of the right leg
started to worsen. Patient felt a sharp pain in his right knee. After 3 months later the pain
becoming worse day by day and the pain was spread to his right waist. The pain was
continously even in rest and feel very pain if try to walk. Patient complaint he found one hole
in the back of knee with discharge.the fluid that come out from the hole is yellow in color and
thick. Due to the pain, patient was avoiding to use the injured leg and his right leg started to
feel shrinking. Two weeks after that he found out he can not bent his leg anymore. The right
knee started to swelling , redness and also felt limited movement of his knee. He deny
having the crepitation on his knee. Now he feel the pain is less than before. After that he
decide to RSUD Koja on 21st july 2012. In 3 months prior admission patient complaint of
febrile fever and also chill. The tempreture will normal after he took paracetomal and tend to
increase again. He refused having vomiting, nausea and also long cough.
History of past illnes
He never having problem like this before. No hereditary illnes
History of past treatment
He never undergoes an operation and never consume the medicine for a long time.
History of illnes
Never have the same illnes in his famly. His mother suffered Hypertension. No diabetes
mellitus, asthma and heart disease
Habits of history
Play basketball and always warm up before played. He claim, he using the right technique
when playing basketball . playing basketball 5x every weeks. Never consume alcohol and
Smoking. Take the Balanced diet(3x/every day + meet + vegetable)
Physic examination
General codition : moderately illnes
Consciousness: compos mentis
Vital sign
Blood preasure: 120/80 mmHg
Heart rate: 76x/min
Temperature: 38oC
Respiration rate: 20x/min
Height: 150cm
Weight: 41kg
BMI: 17,77
Head: normalcephaly, black hair with normal distribution, difficult unpulg, no lesion
and bump
Eyes: normal shape, symmetric , pupile isokor, conjunctiva anemis(-/-), sclera icterik(-/-)
direct light reflex(+/+) undirectly light reflex(+/+)
Ears: normotia, no hyperemis, no secret(-/-), serumen(+/+), membran tympani intact with
light reflex at 5 oclock for right ear and 7 oclock for left ear, corpus alenium(-/-)
Nose: normal in shape, no deformity, septum deviation(-), concha hyperthrophy(-/-). No
hyperemi, secret(-/-)
Mouth: lips not dry trismus(-), tongue not dirty, teeth normal, good oral hygien, phrynx not
anemi
Neck: normal in shape, no palpable the enlargement of lymph node
Chest:
lung
Inspection: movement of brething left and right symmetric , retraction intercostal
space(-/-), lession(-)
Palpasion: vocal fremitus left and right symmetric, no compresive pain(-/-)
Percusion: sonor in both side of lung
Auscultation: sound of breathing right and left vesikuler, ronchi(-/-), wheezing(-/-)
Heart
Inspection: no pulsation of ictus cordis appearance
Palpation: ictus cordis palpable on intercostal space v, 1cm media from left
midclavicle
Percusion: right border: intercosta space v right parasterna line
Left border: intercosta space v, 1cm media from left midclavicula
Upper broder: intercosta space ii from lef parasternal line
Auscultation: sound of heart I-II reguler, gallop(-), murmur(-)
Stomach:
Inspection: flat, smilling umbilicus(-), operation scar(-), veins dilatation(-),
Auscultation: sound of intestine (+) 4x/min
Palpation: supel, no compresive pain(-), defens muscular(-)
Liver: no palpable
Spleen: no palpable
Kidney: ballotement(-/-), CVA(-/-)
Percusion: tympani, shiffting dullness(-)
Genital : no lession, no pain
Extrimity:
Right Left
Muscle atrophy Eutrophy
Tonnus normotony Normothony
Mass No abnormality No abnormality
Joints No abnormality No abnormality
Movement Not active Active
Strenght Weak Normal
Edem edema No edema
Local status (right proximal femur)
Right Left
look - scar (+)
- edema and redness in right distal
femur (+)
- sinus and discharge(+)
- fistule(-)
- no laceration
- no ecchymosis
-
- Deformity:
No Rotation
No angulation
-Deformity:
No rotation
No angulation
Feel -warmth
-tenderness
- circumference 31cm
DEFORMITY(discrepancy/shortening)
True length: 60 cm
Apparents length:50cm
- circumference 25cm
deformity(discrepancy/shortening)
True length: 67cm
Apparent length: 55cm
Anatomical length:25cm
Anatomical length:25cm
-No fluctuation
-no crepitation
- pulse(+)
Move Active( knee joint)
- Flextion : 40o ( normal range 0-
150o)
- Extention: -10o(normal 150-00)
Passive(knee joint)
- Flextion :60o
- Extention: -10o
Active( knee joint)
- Flextion : 150o ( normal
range 0-150o)
- Extention:00 (normal 150-
00)
Passive(knee joint)
- Not examined
Neurological status
Sensory
Pain Light touch
upper part of the upper leg
(L2)
Feel the sensation symmetrical
left and right
Feel the sensation symmetrical
left and right
lower-medial part of the upper
leg (L3)
Feel the sensation symmetrical
left and right
Feel the sensation symmetrical
left and right
medial lower leg (L4) Feel the sensation symmetrical
left and right
Feel the sensation symmetrical
left and right
lateral lower leg (L5) Feel the sensation symmetrical
left and right
Feel the sensation symmetrical
left and right
sole of foot (S1) Feel the sensation symmetrical
left and right
Feel the sensation symmetrical
left and right
Motoric
Right left
Hip joint Normal power(5) Normal power(5)
Reflex
Physiology reflex Right Left
Knee reflex Not examined Positive normal
Achiles reflex Positive normal Positive normal
Patalogical reflex
Kerniq & laseq Not examined Negative
Barbinsky negative Negative
Laboratory finding
On JULY 27th 2012
Haematology
Hb : 10,2 g/dl (11,2-15,7 g/dl)
Leukocyte: 30. 100 /uL(3900-10 000/ul)
Hematokrit: 32%(39-45%)
Trombocyte: 430.000(140.000-440.000/ul)
Kidney function:
Creatine: 0,5 (0,4-0,7)
Ureum: 25(17-43)
Second laboratory test on august 15, 2012
Haematology
Hb : 11,4 g/dl (11,2-15,7 g/dl)
Leukocyte: 15.200/uL (3900-10 000/ul)
Eritrocyte sedimention rate: 20mm/hour(< 10mm/hour)
Hematokrit: 45%(39-45%)
Trombocyte: 303.000/uL(182000-39.000/ul)
Creatine: 0,5 (0,4-0,7)
Ureum: 25(17-43)
Eletrolyte
Na : 138 (135-247 mmol/L)
K : 3,98 (3,5-5,0 mmol/L)
Cl : 101 (9,6-108 mmol/L)
X ray
1st x ray 2nd x ray
Identity: -anggara -type: tibia and fibule (AP)
- 16 years old -good because can differentiate
- no date between air and bone
Type : pelvic x ray (AP) - soft tissue swelling in fracture
Not good to interprate because its area
Difficult to differentiate between air
And muscle
Proximal displacement of the neck - completes transverse fracture
Femur Shaft Of fibular shaft \displaced
3RD X RAY
Identity : anggara - good photo
16yr - luscent in both right and left lung
3/08/2012 - no cardiomegaly with CTR<50%
Type: Chest x ray(anterios posterior) - no active or passive process of
tuberculosis
Additional examination
Femur X ray( AP)
Biopsy
RESUME
Men, 18 years old came to RSUD Koja’s emergency unit with complain pain in right
tigh . The patient confessed that 9 months ago he get involved in accident on october 2011.
Wound on his leg with size around 5 cmx 2cm, dirty and not sutured. He went to bonesetter,
and was treating with some kind of herbal ointment and also apply the maneuver of traction.
A weeks after using the ointment the pain in the thigh of the right leg started to becoming
worsen. The distal femur started to swelling , redness and also felt limited movement of his
knee. In 3 months prior admission patient complaint of the episodic febrile fever with chill
and also malaise.
From physical examination, the tempreture is febrile 38oC and from local status in
right femur , look some lession on knee, edem and redness in knee. From feel, found out,
warm , compresive pain(+) and the size of knee convolution is 15cm, no active movement,
range of scope limited, pain on movement from Pasive movement positive but still imited
From laboratry finding, increasing of leucoyte(30. 100 /uL) and eritrosit sedimention
rate(20mm/hour). Decreasing of Hb (10,2 g/dl)
From thorax’s x ray photo didn’t find any problem, no active or passive process
of tuberculosis and CTR<50%. For pelvic x ray, found Proximal displacement of the femur
shaft and for X ray photo of tibia and fibula found the complete transverse fracture of fibular
shaft displaced
Working diagnosis
1) Post traumatic chronic osteomyelitis of the right distal femur
2) Neglected fracture of the right femur neck
Base of diagnosis
1. From anamneses
Patient involved an accident 9 month ago
Open wound around 5cmx2cm, dirty and not sutured
History of alternative treatment which is increasing the factor of
infection( applay some herbal ointment)
Felt Sharp pain on his knee which is spread to his hip , but day by day the
intensity of pain became less
Ferbrile fever with chill and malaise
2. From physical examination
Febrile tempreture ( 38oC)
From local status
look
scar (+)
edema and redness in right proximal femur (+)
feel
warmth
tenderness
circumference 31cm whereas the left side is 25cm
3. From laboratory finding
Found the increasing of leukocyte to 30.000/ul and also ESR 20mm/hour
Differential diagnosis
1) Septic Arthritis
2) osteosarcoma
3) Cellulitis
Management
Operative(30/7/2012) Non operative
- Debridement Supportive
Lay position with spinal anasthesis
Sepsis in operation area
(medioposterior distal femur)
Capsul was opened, move out the pus
and collect the pus to sent to lab.
Curated and pair of drainase
IVFD asering
Na + diklofenat 2x 50 mg
Omeprazole 2x1
Ketopain 3xl
Bedrest
Normal diet
Mobilisation( after operation)
Antimicrobials
Hypobac 2x 500mg
Sopirom 2x 1gr
Prognosis
Ad vitam : bonam
Ad sanationam: dubia ad malam
Ad fungsionam: dubia ad malam
CHAPTER IV
CASE REVIEW
BONE
A long bone consists of several sections:
Diaphysis: This is the long central shaft
Epiphysis: Forms the larger rounded ends of long bones
Metaphysis: Area betweent the diaphysis and epiphysis at both ends of the bone
Epiphyseal Plates: Plates of cartilage, also known as growth plates which allow the
long bones to grow in length during childhood. Once we stop growing, between 18
and 25 years of age the cartilage plates stop producing cartilage cells and are
gradually replaced by bone.
Covering the ends of bones, where they form a joint with another bone, is a layer of hyaline
cartiage. This is a firm but elastic type of cartilage which provides shock absorbtion to the
joint and has no neural or vascular supply.
Bone Anatomy
If you were to cut a cross-section through a bone, you would first come across a thin layer of
dense connective tissue known as Periosteum. This can be divided into two layers, an outer
'fibrous layer' containing mainly fibroblasts and an inner 'cambium layer', containing
progenitor cells which develop into osteoblasts (the cells responsible for bone formation).
The periosteum provides a good blood supply to the bone and a point for musculaattachment.
Under the periosteum is a thin layer of compact bone (often called cortical bone), which
provides the bones strength. It consists of tightly stacked layers of bone which appear to form
a solid section, although do contain osteons, which like canals provide passageways through
the hard bone matrix.
Epidemiology
Approximately 20% of adult cases of osteomyelitis are hematogenous, which is more
common in males for unknown reasons.
The incidence of spinal osteomyelitis, as depicted in the image below, was estimated
to be 1 in 450,000 in 2001. However, the overall incidence of vertebral osteomyelitis is
believed to have increased in recent years because of intravenous drug use, increasing age of
the population, and higher rates of nosocomial infection due to intravascular devices and
other instrumentation
The overall incidence of osteomyelitis is higher in developing countries.
Etiology
Posttraumatic osteomyelitis accounts for as many as 47% of cases of osteomyelitis.
Other major causes of osteomyelitis include vascular insufficiency (mostly occurring in
persons with diabetes; 34%) and hematogenous seeding (19%).
Motor vehicle accidents, sports injuries, and the use of orthopedic hardware to manage
trauma also contribute to the apparent increase in prevalence of posttraumatic osteomyelitis.
Osteomyelitis may complicate puncture wounds of the foot, occurring in 1.8%-6.4% of
patients following injury
Causes
Most cases of osteomyelitis are caused by staphylococcus bacteria, a type of germ commonly
found on the skin or in the nose of even healthy individuals.
Germs can enter a bone in a variety of ways, including:
Via the bloodstream. Germs in other parts of your body — for example, from pneumonia or a
urinary tract infection — can travel through your bloodstream to a weakened spot in a bone.
In children, osteomyelitis most commonly occurs in the softer areas, called growth plates, at
either end of the long bones of the arms and legs.
From a nearby infection. Severe puncture wounds can carry germs deep inside your body. If
such an injury becomes infected, the germs can spread into a nearby bone.
Direct contamination. This may occur if you have broken a bone so severely that part of it is
sticking out through your skin. Direct contamination also can occur during surgeries to
replace joints or repair fractures.
Types of osteomyelitis
There are two main types of osteomyelitis:
Acute osteomyelitis is where the bone infection develops within two weeks of
an initial infection, injury or underlying disease and may respond to antibiotic
treatment.
Chronic osteomyelitis is where the bone infection has produced irreversible
bony changes that cannot be treated by antibiotics alone.
Acute osteomyelitis
There are two ways that acute osteomyelitis can occur:
Contiguous osteomyelitis is where an infection spreads directly into the bone
as a result of an injury, such as a fractured bone or animal bite, during surgery,
or as a result of another condition such as diabetes or vascular disease.
Haematogenous osteomyelitis is where an infection spreads into a bone from
the bloodstream.
Contiguous osteomyelitis is the most common type of acute osteomyelitis, accounting
for four out of five cases. It mainly affects adults.
People who have a condition that affects the blood supply to certain parts of their body, such
as type 2 diabetes, have an increased risk of developing contiguous osteomyelitis. Any
surgical procedure on the skeleton may introduce infection into bone.
Haematogenous osteomyelitis mostly affects younger children, although adult cases may
occur in anyone with a weakened immune system, such as those with rheumatoid
arthritis or HIV.
People who regularly inject drugs, such as heroin, also have an increased risk of developing
haematogenous osteomyelitis.
Chronic osteomyelitis
Chronic osteomyelitis can sometimes start as acute osteomyelitis. If acute osteomyelitis is not
treated properly it can become established and produce permanent, destructive changes to
bone, resulting in pain, discharge and loss of function.
As with acute osteomyelitis, the infection can be spread through the blood or directly into the
bone as a result of injury or other trauma.
Chronic osteomyelitis can also develop as a complication of a pre-existing infection such
as tuberculosis (a bacterial infection) or syphilis (a sexually transmitted infection), although
this is uncommon in the UK today.
Symptoms of osteomyelitis
Acute osteomyelitis
Most cases of acute osteomyelitis involve one of the long bones in the legs. However,
sometimes the bones in the arm or the vertebrae (in the back) can be affected.
The symptoms of acute osteomyelitis include:
a sudden high temperature (fever) of 38°C (100.4°F) or above, although this
symptom is often absent in children under one year old
bone pain, which can often be severe
swelling, redness and warmth at the site of the infection
a general sense of feeling unwell
the affected body part is tender to touch
the range of movement in the affected body part is restricted
lymph nodes (glands) near the affected body part may be swollen
Young children who cannot talk may be unable to report their painful sym
ptoms to you. You should look out for the following signs and symptoms:
irritability
eating much less than usual
reluctance to use the affected body part
Chronic osteomyelitis
Once chronic osteomyelitis is established, the person affected may have periods of almost no
symptoms. However, symptoms can flare up at any time. For example, you may experience:
bone pain
feeling persistently tired
pus draining from the sinus tract (a passageway that develops near the infected
bone)
local swelling
skin changes
excessive sweating
chills
Pathophysiology
Acute osteomyelitis presents as a suppurative infection accompanied by oedema,
vascular congestion, and small-vessel thrombosis. In early acute disease, the vascular supply
to the bone is decreased by infection extending into the surrounding soft tissue. Large areas
of dead bone (sequestra) may be formed when the medullary and periosteal blood supplies
are compromised. Acute osteomyelitis can be arrested before dead bone develops if treated
promptly and aggressively with antibiotics and surgery (if necessary). In an established
infection, fibrous tissue and chronic inflammatory cells form around the granulation tissue
and dead bone.
Pathological features of chronic osteomyelitis are the presence of necrotic bone, the
formation of new bone, and the exudation of polymorphonuclear leukocytes. New bone forms
from the surviving fragments of periosteum and endosteum in the region of the infection. An
encasing sheath of live bone, an involucrum, surrounds the dead bone under the periosteum.
The involucrum is irregular and is often perforated by openings through which purulence
may track into the surrounding soft tissue and eventually drain to the skin surface, forming a
chronic sinus.
Most infections in orthopaedics, including osteomyelitis, are caused by biofilm-forming
bacteria. A biofilm is a highly structured community of bacterial cells that adopt a distinct
phenotype, communicate through cell-cell signals, and adhere to an inert or living surface.
Biofilm-forming bacteria exist in 1 of 2 states - the planktonic state or the stationary state.
Planktonic bacteria are free-floating; the body’s host defences can easily eradicate the
organism through the usual immunological mechanisms. In contrast, stationary bacteria
within the biofilm appear to be phenotypically different from their planktonic types. They
have a slower rate of growth and are less metabolically active, and are thereby less
susceptible to the effects of chemotherapeutic agents. In chronic osteomyelitis and implant-
associated infections, bacteria grow within biofilms attached to the surface of the dead bone
or foreign material. This protective mode of growth shields bacteria from antibiotic agents
and host defence mechanisms, and enables the infection to persist. The concept of biofilm
science must be applied to the diagnosis, treatment, and prevention of chronic orthopaedic
infection
Open wounds/fractures
Microorganisms gain entryby way of blood
Predisposing factors:-Vascular insufficiency-disordersgenitourinary infections-respiratory infections-IV drug use-immunocompromising diseases-history of blood- stream infections-Indwelling prosthetic devices
Pain Tenderness
Fever HA Nausea/Vomiting
Erythema Swelling
Sinus Tract Drainage
Microorganisms grow
Site for continued microorganism growth
Enlarged sequestrum
drainage from sinus tracts
Increase pressure
Microorganisms lodge intoan area where circulation slows
Vascular compromiseof the periosteum
Removal by the normali mmune process
Involcrum
fever, night sweats,chills, restlessness,nausea and malaiseconstant bone pain,swelling, tenderness,warmth at the infection site,restricted movementof the affected part
Sequestrum move out to the soft tissueDevelopment of sinus tract
Continues to be an infected island
Systemic signs maybe diminished withconstant bone pain,Swelling, tenderness,warmth at the infection site of organ function
Formation of new bone
Remission and exacerbation
Infection through the boned cortex and marrow
Difficulty to reach by blood borne antibiotics
revascularized
Separation of devitalized bone from living bone
cortical devascularization
Chronic stage
Turns to scar tissue
Debridementnecrosis
healing
ischemi
amputation
Limp Fluctuence
Diagnosing osteomyelitis
Physical examination
To confirm a diagnosis of suspected osteomyelitis, your GP will first carry out a physical
examination of your affected body part to check for signs of redness, swelling and tenderness.
They will want to know about your recent medical history, such as whether you have recently
had an injury, surgery or a previous infection.
Blood test
Your GP may refer you for a blood test. This cannot confirm osteomyelitis, but it can indicate
whether you have a high number of white blood cells in your blood, which may suggest that
you have an infection. Also, if the osteomyelitis was caused by bacteria spreading in your
blood, a blood test may be useful for detecting the bacteria.
Imaging tests
If osteomyelitis is suspected, it is likely that you will be referred for further imaging testing.
There are several imaging tests that may be able to detect bone damage caused by
osteomyelitis. They include:
X-rays, in which low levels of radiation are used to create an image of the
affected bone
magnetic resonance imaging (MRI) scan, which is where a strong magnetic
field and radio waves are used to build up a picture of the inside of the
affected bone
computerised tomography (CT) scan, which is where a series of X-rays of
your affected bone are taken and a computer is used to assemble them into a
more detailed three-dimensional image
ultrasound scan, which is where high-frequency sound waves are used to
create an image of the affected bone to highlight any abnormalities
Biopsy
If earlier testing suggests that you have osteomyelitis, it is usually necessary to remove a
small sample of bone for further testing. This is known as a biopsy.
A biopsy is usually necessary to confirm a diagnosis of osteomyelitis and it can help to
establish the exact type of bacteria or fungus that is causing your infection. This can be very
useful when deciding on the most effective treatment. A biopsy is usually combined with
surgery in chronic cases
Diferential diagnosis
1. Gout
According to the Mayo Clinic, gout is a treatable yet complex disorder characterized
by symptoms like extreme arthralgia (joint pain) and inflammation. The condition
usually affects your big toe's joint but it can also affect ankles, wrists, hands, knees
and feet. Without treatment, it usually lasts between 5 and 10 days and then subsides.
It is diagnosed with a blood test and a test of your joint fluid.
2. Inflammatory Arthritis
Inflammatory arthritis is an umbrella term which covers all types of arthritis which
are connected with your immune system. This includes rheumatoid arthritis
(autoimmune disease which attacks the membrane around your joints); ankylosing
spondylitis (characterized by inflammation of the large joints and spine); lupus
(affects your organs and connective tissue); Reiter's syndrome (affects tendons,
skeleton, mucous membranes and joints); and psoriatic arthritis (your joints and skin
become inflamed).
3. Bone Cancer
The types of bone cancer which must be ruled out include osteosarcoma and Ewing
sarcoma. According to the American Cancer Society, osteosarcoma is the most
common form of bone cancer and can metastasize (spread) beyond the bone. Ewing
sarcoma is a tumor which is more common in children than adults and is more
responsive to radiation treatment than osteosarcoma.
4. Traumatic Fractures and Stress Fractures
Fractures caused by trauma are relatively easily diagnosed using X-ray technology.
Stress fractures, however, are slightly more complicated. These tiny cracks in your
bone are created by repetitive force and overuse (like long-distance running) or from
normally using a bone which has been weakened. Anyone who has broken a bone can
recognize symptoms of a traumatic fracture (swelling and pain with use). According
to the Mayo Clinic, stress fractures may be characterized by swelling, pain which
increases as time goes by, pain occurring earlier in each consecutive workout session
and pain which decreases while resting and increases while active. These types of
fractures usually do not appear on an X-ray for 3 to 4 weeks after you develop
symptoms.
Staging
Two classification systems are commonly used for osteomyelitis.
Waldvogel et al (1970) classified bone infections based on pathogenesis and proposed the
original osteomyelitis staging system. This system groups bone infections as either
hematogenous or osteomyelitis secondary to a contiguous focus of infection. Contiguous-
focus osteomyelitis is further classified based on the presence or absence of vascular
insufficiency. Both hematogenous and contiguous focus may then be classified as either acute
or chronic.[23]
The staging system designed by Cierny-Mader et al (2003) is more recent and more
commonly used. It considers host immunocompetence in addition to anatomic osseous
involvement and histologic features of osteomyelitis.[24, 1]
Stage 1 disease involves medullary bone and is usually caused by a single organism.
Stage 2 disease involves the surfaces of bones and may occur with deep soft-tissue wounds
or ulcers.
Stage 3 disease is an advanced local infection of bone and soft tissue that often results from
a polymicrobially infected intramedullary rod or open fracture. Stage 3 osteomyelitis often
responds well to limited surgical intervention that preserves bony stability.
Stage 4 osteomyelitis represents extensive disease involving multiple bony and soft tissue
layers. Stage 4 disease is complex and requires a combination of medical and surgical
therapies, with postsurgical stabilization as an essential part of therapy.
The second part of the Cierny-Mader classification system describes the physiologic status
of the host.
o Class A hosts have normal physiologic, metabolic, and immune functions.
o Class B hosts are systemically (Bs) or locally (Bl) immunocompromised. Individuals
with local and systemic immune deficiencies are labeled as ‘‘Bls.’’
o In Class C hosts, treatment poses a greater risk of harm than osteomyelitis itself. The
state of the host is the strongest predictor of osteomyelitis treatment failure, so the
physiologic class of the infected individual is often more important than the anatomic
stage.
Other classification systems for long bone osteomyelitis
Gordon classification classifies long bone osteomyelitis based on osseous defects. The system
uses infected tibial nonunions and segmental defects.
Type A includes tibial defects and nonunions without significant segmental loss
Type B includes tibial defects greater than 3 cm with an intact fibula
Type C includes tibial defects of greater than 3 cm in patients without an intact fibula
The Ger classification is used to address the physiology of the wound in osteomyelitis, which
is categorized as simple sinus, chronic superficial ulcer, multiple sinuses, or multiple skin-
lined sinuses. Bone infection persists if appropriate wound management is not undertaken. It
is important to cover open tibial fractures with soft tissue early in the disease to prevent
infection and ulceration.
The Weiland classification categorizes chronic osteomyelitis as a wound with exposed bone,
positive bone culture results, and drainage for more than 6 months. This system also
considers soft tissue and location of affected bone. It does not recognize chronic infection if
wound drainage lasts less than 6 months.
Type I osteomyelitis was defined as open exposed bone without evidence of osseous
infection but with evidence of soft-tissue infection.
Type II osteomyelitis showed circumferential, cortical, and endosteal infection,
demonstrated on radiographs as a diffuse inflammatory response, increased bone density,
and spindle-shaped sclerotic thickening of the cortex. Other radiographic findings included
areas of bony resorption and often a sequestrum with a surrounding involucrum.
Type III osteomyelitis revealed cortical and endosteal infection associated with a segmental
bone defect
Therapy
Treating acute osteomyelitis
Acute osteomyelitis can usually be successfully treated using antibiotics
These medicines are usually given as a six-week course. For part of the treatment course you
will need to take the medicine intravenously (directly into a vein).
Depending on your general state of health, you may need to stay in hospital during this time.
Otherwise, you may be able to receive the injections as an outpatient (where you go home the
same day). You will usually be able to switch to tablets for the rest of the treatment course
once you are well.
In cases of osteomyelitis, there is usually a choice of antibiotics available to treat the
infection and often two antibiotics are used in combination. This is known as dual therapy.
Occasionally, the bacteria causing the infection are resistant to standard antibiotics and less-
frequently-used antibiotics are needed.
A much less common cause of osteomyelitis is a fungal infection.
In cases of fungal osteomyelitis, an antifungal medication called voriconazole is usually the
treatment of choice.
Treating chronic osteomyelitis
People with chronic osteomyelitis will usually require a combination of antibiotics
medication and surgery to remove any damaged bone. A surgeon may need to make an
incision (cut) near the site of the infection to drain away any pus.
If there is extensive bone damage, it will be necessary to surgically remove any diseased bone
and tissue. This procedure is known as debridement. Debridement can often leave an empty
space in the bone, which is sometimes packed with antibiotic-loaded cement. If the surgeon
does this, a second operation will be required to remove the cement within a few weeks of the
first. Not all centres use cement and no difference is found in the clearance of infection.
In some cases, it may also be necessary to transfer muscle and skin from another part of the
body to repair the tissue surrounding the affected bone.
Hyperbaric oxygen therapy
Some researchers have argued that a type of non-surgical treatment called hyperbaric oxygen
therapy may be useful in treating cases of both acute and chronic osteomyelitis that do not
respond to conventional treatment.
During hyperbaric oxygen therapy, you are placed in a specially designed chamber that is
similar to a decompression chamber used by divers.
The chamber is filled with oxygen, which is administered at a much higher pressure
(hyperbaric) than the normal level of oxygen in the atmosphere. The high levels of oxygen
are thought to speed up the healing process and slow the spread of infection.
There is currently only limited evidence supporting the effectiveness of hyperbaric oxygen
therapy for treating osteomyelitis. From the evidence available, it would appear that it is most
effective in treating osteomyelitis associated with a diabetic foot ulcer.
The most common treatments for osteomyelitis are antibiotics and surgery to remove portions
of bone that are infected or dead.
Medications
A bone biopsy will reveal what type of germ is causing your infection, so your doctor can
choose an antibiotic that works particularly well for that type of infection. The antibiotics are
usually administered through a vein in your arm for at least six weeks. Side effects may
include nausea, vomiting and diarrhea.
Surgery
Depending on the severity of the infection, osteomyelitis surgery may include one or more of
the following procedures:
Drain the infected area. Opening up the area around your infected bone allows your surgeon
to drain any pus or fluid that has accumulated in response to the infection.
Remove diseased bone and tissue. In a procedure called debridement, the surgeon removes
as much of the diseased bone as possible, taking a small margin of healthy bone to ensure that
all the infected areas have been removed. Surrounding tissue that shows signs of infection
also may be removed.
Restore blood flow to the bone. Your surgeon may fill any empty space left by the
debridement procedure with a piece of bone or other tissue, such as skin or muscle, from
another part of your body. Sometimes temporary fillers are placed in the pocket until you're
healthy enough to undergo a bone graft or tissue graft. The graft helps your body repair
damaged blood vessels and form new bone.
Remove any foreign objects. In some cases, foreign objects, such as surgical plates or
screws placed during a previous surgery, may have to be removed.
Amputate the limb. As a last resort, surgeons may amputate the affected limb to stop the
infection from spreading further
Complications of osteomyelitis
Recurring osteomyelitis
The underlying factors that often cause osteomyelitis, such as poor circulation or a weakened
immune system, can be difficult to treat, particularly if you have severe diabetes or HIV.
Therefore, if you have had a previous episode of osteomyelitis, there is a chance that it could
return.
The risk factors for recurring osteomyelitis vary depending on your circumstances. It may be
possible to reduce your risk by making lifestyle changes, such as lowering the amount of
saturated fat in your diet and by taking precautions against infection.
Bone death (osteonecrosis). An infection in your bone can impede blood circulation within
the bone, leading to bone death. Your bone can heal after surgery to remove small sections of
dead bone. If a large section of your bone has died, however, you may need to have that limb
amputated to prevent spread of the infection.
Septic arthritis. In some cases, infection within bones can spread into a nearby joint.
Impaired growth. In children, the most common location for osteomyelitis is in the softer
areas, called growth plates, at either end of the long bones of the arms and legs. Normal
growth may be interrupted in infected bones.
Skin cancer. If your osteomyelitis has resulted in an open sore that is draining pus, the
surrounding skin is at higher risk of developing squamous cell cancer
REFERENCES
1) Reksoprodjo S, kumpulan ilmu bedah bahagian kedokteraan FKUI 1st edition
Jakarta;binarupa aksara Pub sept 2002
2) Apley, A. Graham et al. Buku Ajar Ortopedi dan Fraktur Sistem Apley edisi ke-7.
Widya Medika. Jakarta : 1995
3) Advanced Trauma Life Support 6th ed. American College of Surgeons Committee
on Trauma. USA: 1997.
4) medscape, osteomyelitis(online), 2012 july 30 available from URL:
http://emedicine.medscape.com/article/1348767-overview#a0112
5) NHS.UK: different between acute and chronic osteomyelitis, 2012 july 30 available
from URL:
http:// www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspx
6) Mayoclinic, Osteomyelitis, 2012 Agust 1 available from URL:
http://www.mayoclinic.com/health/osteomyelitis/DS00759/
7) Orthopedic examination 2012 Agust 1 available from URL:
http://www.netterimages.com/image/8246.htm