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