Non Union Fracture

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Non union fracture 1/3distal left femur

susp.chronic

osteomyelitis

By Yanuar Aditya K

030. 08. 258


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Preface

Osteomyelitis is an infection of the bone Osteomyelitis develops when staphylococcus bacteria

enters the bone either through the blood stream oras a result of an injury.

Although bone is normally resistant to bacterialcolonization, events such as trauma, surgery,

presence of foreign bodies, or prostheses maydisrupt bony integrity and lead to the onset of boneinfection. When prosthetic joints are associated withinfection, microorganisms typically grow in biofilm,which protects bacteria from antimicrobial treatmentand the host immune response.

The major cause of bone infections is Staphylococcusaureus.

When biofilm microorganisms are involved, as injoint prostheses, a combination of rifampicin withother antibiotics might be necessary for treatment.2


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CASE REPORT


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CASE

PATIENT IDENTITY

Name : Mr. A

Age : 35 yo

Gender : Man

Status : Married

Religion : Islam

Occupation : -

Education : Senior High SchoolAddress : -

Date of admission : 17 3 - 2013


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Anamnese

History taken have been done from Autoanamnese on 28-03-2013, 10.30 am

Chief complaint :

Additional complaint:

Pain on the left thigh since 2 years ago

Fever with chill and malaise 3 daysbefore admission


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History of present illness:

The patient confessed that 2 years ago beforeadmission, he get involved in accident on august 2011.The patient was riding a motorcyle when his bike got hitby a car from the right side and was dragged forapproximately 2 meter with low velocity.He refuse loss

of consciousness and no trauma in his head. Blood comeout from wound on his leg.

He was admitted to the orthopaedic unit at 1 month ago.He experienced that his left thight pain. At admission, hewas afebrile but 3 days ago before admission the patient

feels fever.His left lower limb was shortened. He deny having thecrepitation on his knee.


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Anamnese

History of past illnes

He never having problem like this before. He have ahypertension since 3 years ago and never control atthe doctor.

History of past medical story

He never undergoes an operation and never consumethe medicine for a long time.

Family history

Never have the same illnes in his famly. His mothersuffered Hypertension. No diabetes mellitus, asthmaand heart disease

Habits of history

Never consume alcohol and Smoking. Take theBalanced diet(3x/every day + meet + vegetable)


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PHYSICAL EXAMINATION

Awareness : Compos mentis General State : Moderately sick

Mobility (active / passive) : Passive

Height : 168 cm

Weight : 76 kg

Heart Rate :

96times/minute

Blood pressure

160/90 mmHg

Respiratoryrate :

20

times/minute

Temperature :

36,7 C

VITALSIGN


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PHYSICAL EXAMINATION

normalcephaly, black hair with normaldistribution, difficult unpulg, no lesionand bump

normal shape, symmetric , pupile isokor,conjunctiva anemis(-/-), sclera icterik(-/-)direct light reflex(+/+) undirectly lightreflex(+/+)

normotia, no hyperemis, no secret(-/-),serumen(+/+), membran tympani intactwith light reflex at 5 oclock for right earand 7 oclock for left ear, corpus alenium(-/-)


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normal in shape, no deformity, septum

deviation(-), concha hyperthrophy(-/-).

No hyperemi, secret(-/-)

lips not dry trismus(-), tongue not dirty, teeth

normal, good oral hygien, phrynx not

anemia

normal in shape, no palpable the

enlargement of lymph node

Nose

Mouth

Neck


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Thorax ExaminationThoraks

Cor S1-S2 normal reguler, murmur(-), gallop (-)

Pulmo sound of breathing rightand left vesikuler, ronchi(-/-),

wheezing(-/-)


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ABDOMEN

Abdomen

Inspection: flat, smilling umbilicus(-),operation scar(-), veins dilatation(-),

Kidney: ballotement(-/-), CVA(-/-)

Palpation: supel, no compresive pain(-),defens muscular(-)

Liver: no palpable

Spleen: no palpable

Auscultation: sound of intestine (+)4x/min

Percusion: tympani, shiffting dullness(-)


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- -

- -

Oedema

+ +

+ +

Warm

EXTREMITY


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EXTREMITY

Right Left

Muscle Atrophy Eutrophy

Tonnus Normotony Hypothony

Mass No abnormality No abnormality

Joints No abnormality No abnormality

Movement Active Not Active

Strenght Normal Weak

Edem No Edema Edema


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LOCAL STATUS (LEFTDISTAL FEMUR)


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Right Left

Look - Scar (-)

- Edema and redness in right

distal femur (-)

- No laceration

- No ecchymosis

- Deformity:

No Rotation

No angulation

- Scar (+)

- Edema (+)

- Redness in right distal femur

(-)

- No laceration

- No ecchymosis

- Deformity:

No Rotation

No angulationFeel - Warm (-)

- Tenderness (-)

- Circumference 32 cm

- No fluctuation

- No crepitation

- Pulse (+)

- Warm (-)

- Tenderness (+)

- Circumference 34 cm

- DEFORMITY(discrepancy/sho

rtening)

True length: 67 cm Apparents length:57cm

Anatomical length:10cm

- No fluctuation

- No crepitation

- Pulse (+)


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Right Left

Move Active( knee joint)

- Flextion : 150o ( normal

range 0-150o)

- Extention: 0o(normal 150-00)

Passive(knee joint)

- Normal

Active( knee joint)

- Flextion : 40o ( normal range

0-150o)

- Extention: 100 (normal 150-

00)

Passive(knee joint)

- Flextion :50o

- Extention: -10o


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Neurological status

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


right

medial lower leg (L4) Feel the sensation symmetrical left and

right


right

lateral lower leg (L5) Feel the sensation symmetrical left and

right


right

sole of foot (S1) Feel the sensation symmetrical left and

right


right

Sensory


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Neurological status

Right left

Hip joint Normal power(5) Normal power(5)

Motoric

Reflex

Physiology reflex Right Left

Knee reflex Positive normal Not examined because pain

Achiles reflex Positive normal Positive normal

Pathological reflex

Kerniq & laseq Negative Negative

Barbinsky Negative Negative


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Result Normal

Haemathology

Hb 12,7 13,5 17,5 g/dl

Ht 39 41 53 %

Leukocyte 10.400 4.100 10.900 /ul

Thrombocyte 333.000 140.000 440.000 /ul

ESR 47 < 10 mm / hour

APTT 32,9 27 42 second

PT 14,4 12 19 second

Liver functionAlbumin 4,69 4,0 5,2 g/dl

Globulin 4,05 1,3 2,7 g/dl

Total protein 8,74 6 8 g/dl

AST 17 10 35 u/l

ALT 25 9 43 u/l


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y

Result Normal

Renal function

Ureum 29 20 40 mg/dl

Creatinin 2,1 0,7 1,5 mg/dl

Electrolite

Na 146 135 147 mmol/l

K 4,2 3,5 5,0 mmol/l

Cl 103 96 108 mmol/l


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Radiology Examination

1st x ray

Identity : Mr. Andiyas

Age : 35 yo

Date : 19/02/2013

Type : Os Femursinistra (AP Lateral)

Description : There is old fracture at left femur distal

section and the fracture fragments are not

straight at distal section, part of the bone is

not intact.

looks osteolytic and sclerotic at the distalfemur

Summary : Susp.Osteomyelitis chronic


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Radiology Examination

2nd X RAY

Identity : Mr. Andiyas

Age : 35 yo

Date : 19/02/2013

Type : Chest x ray (anteriorposterior)

Description : Cor and pulmo arenormally


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RESUME

Men, 35 years old came to RSUD Kojas with complain painin left tight . The patient confessed that 2 years ago he getinvolved in accident on august 2011. He went tobonesetter, and was treating with some kind of herbalointment and also apply the maneuver of traction. In 3days prior admission patient complaint of the episodicfebrile fever with chill and also malaise. From physicalexamination, the tempreture is afebrile 36,7oC and fromlocal status in left femur , look some scar on knee. Fromfeel, found out, warm , compresive pain(+), no activemovement, range of scope limited, pain on movement frompassive movement positive but still imited From laboratryfinding, increasing of eritrosit sedimention rate(47mm/hour).

From thoraxs x ray photo didnt find any problem, noactive or passive process of tuberculosis and CTR


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Working diagnosis

Non-union fracture at 1/3 left distalfemur

Susspected osteomyelitis chronic


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Base of diagnosis

From anamnese History of accident 2 years ago at left femur

History of alternative treatment which is increasing thefactor of infection

Febrile and malaise 3 days before admission

Felt Sharp pain on his knee which is spread to his hip , butday by day the intensity of pain became less

From local status Physical examination

Look

Scar (+) at left knee

Edema (+)

Feel

Warm

Tenderness

Circumferences 34 cm and the difference height of right foot and leftfoot about 10 cm


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Base of diagnosis

From laboratory finding ESR rate 47 mm/hour

From radiology finding

There is old fracture at left femur distal section andthe fracture fragments are not straight at distal

section, part of the bone is not intact.

looks osteolytic and sclerotic at the distal femur


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Management

Operable Debridement

Use external fixation


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PROGNOSIS

Ad vitam : dubia ad bonamAd functionam : dubia ad malam

Ad sanationam : dubia ad malam


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OSTEOMYELITIS

CASE REVIEW


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BONE

The adult humanskeleton has a totalof 213 bones,excluding the

sesamoid bones.

The appendicularskeleton has 126bones, axialskeleton 74 bones,

and auditoryossicles six bones.


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The four general categories ofbones

Long bones the clavicles, humeri, radii, ulnae, metacarpals,

femurs, tibiae, fibulae, metatarsals, andphalanges

Short bones the carpal and tarsal bones, patellae, and

sesamoid bones

Flat bones

the skull, mandible, scapulae, sternum, and ribsIrregular bones

the vertebrae, sacrum, coccyx, and hyoid bone


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The skeleton serves a variety offunctions

Structural support for the rest of thebody,

Permit movement and locomotion by

providing levers for the muscles,Protect vital internal organs and

structures,

Provide the environment for

hematopoiesis within the marrowspaces


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Definition

Osteomyelitis is an infection in abone. Infections can reach a bone bytraveling through the bloodstream orspreading from nearby tissue.Osteomyelitis can also begin in thebone itself if an injury exposes thebone to germs.


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Epidemiology

Approximately 20% of adult cases of osteomyelitis arehematogenous, which is more common in males for unknownreasons. Acute hematogenous osteomyelitis is decreasing inincidence, whereas the incidence of osteomyelitis due to directinoculation or contiguous focus of infection is increasing. Thisis attributed to the increase in both trauma (due to motor

vehicle accidents) and orthopedic surgical procedures. Osteomyelitis secondary to open fractures occurs in 3% to

25% of cases, usually in young men in their twenties andthirties.

Vertebral osteomyelitis is responsible for 2% to 4% of allcases of osteomyelitis, with an annual incidence of 5.3 cases

per million persons. Men are more commonly affected thanwomen, with a mean age at presentation of 61 years

Foot ulcers occur in 2% of patients with diabetes every year,15% of whom will develop osteomyelitis. Recurrent infectionoccurs in up to 36% of patients with diabetes.


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Risk factors

Diabetes mellitus Immunocompromise Neuropathy Vascular insufficiency Intravenous drug use

Open fractures Local trauma Orthopedic hardware (including prosthetic

joints) Hemodialysis

Sickle cell disease Dental infections Urinary tract infections Catheter-related bloodstream infection


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PATHOPHYSIOLOGY

Bone is normally resistant to infection. However, when microorganisms are introduced into bone

hematogenously from surrounding structures or from directinoculation related to surgery or trauma, osteomyelitis can occur.

Bone infection may result from the treatment of trauma, whichallows pathogens to enter bone and proliferate in the traumatized

tissue. When bone infection persists for months, the resultinginfection is referred to as chronic osteomyelitis (depicted in theimage below) and may be polymicrobial. Although all bones aresubject to infection, the lower extremity is most commonlyinvolved.

Some important factors in the pathogenesis of osteomyelitisinclude the virulence of the infecting organism, underlying

disease, immune status of the host, and the type, location, andvascularity of the bone.

Bacteria may possess various factors that may contribute to thedevelopment of osteomyelitis. For example, factors promoted by Saureus may promote bacterial adherence, resistance to hostdefense mechanism, and proteolytic activity.


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Staging (Cierny-Mader)

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 openfracture.

Stage 3 osteomyelitis often responds well to limited surgical interventionthat preserves bony stability.

Stage 4

Osteomyelitis represents extensive disease involving multiple bony andsoft tissue layers.

This stage is complex and requires a combination of medical andsurgical therapies, with postsurgical stabilization as an essential part oftherapy.

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p y g

Ci M d l ifi ti t


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Cierny-Mader classification systemdescribes the physiologic status of thehost

Class A hosts

normal physiologic, metabolic, and immune functions.

Class B hosts Systemically (Bs) or locally (Bl) immunocompromised.

Class C hosts

Treatment poses a greater risk of harm thanosteomyelitis itself.


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Clinical Manifestation

The classic signs of inflammation, includinglocal pain, swelling, or redness, may alsooccur and normally disappear within 5-7 days.

Fever, chills, fatigue, lethargy, or irritability On physical examination, scars or local

disturbance of wound healing may be notedalong with the cardinal signs of inflammation. Range of motion, deformity, and local signs of

impaired vascularity are also sought in theinvolved extremity. If periosteal tissues areinvolved, point tenderness may be present.


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Laboratory Studies

Complete blood cell count A complete blood cell (CBC) count is useful for

evaluating leukocytosis and anemia.

Leukocytosis is common in acute osteomyelitis before therapy.The leukocyte count rarely exceeds 15,000/L acutely and isusually normal in chronic osteomyelitis.

Erythrocyte sedimentation rate and C-reactive protein levels areusually increased.

Culture Blood cultures are positive in only 50% of cases of osteomyelitis.

They should be obtained before or at least 48 hours afterantibiotic treatment. Although sinus tract cultures do not predict

the presence of gram-negative organisms, they are helpful forconfirming S aureus.

Bone biopsy leads to a definitive diagnosis by isolation ofpathogens directly from the bone lesion.


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Imaging Studies

Radiography Conventional radiography is the initial imaging study

at presentation of acute osteomyelitis. It is helpful tointerpret current and old radiographs together.Radiographic findings include periosteal thickening orelevation, as well as cortical thickening, sclerosis, andirregularity.

Ultrasonography The presence of fluid collection adjacent to the bone

without intervening soft tissue usually suggestsosteomyelitis. Other findings on ultrasonographyinclude elevation and thickening of the periosteum

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Imaging Studies

CT scanning CT is useful for guiding needle biopsies in closed

infections and for preoperative planning to detectosseous abnormalities, foreign bodies, or necroticbone and soft tissue.

MRI MRI is a very useful modality in detecting

osteomyelitis and gauging the success of therapybecause of high sensitivity and excellent spatialresolution. The extent and location of osteomyelitis is

demonstrated along with pathologic changes of bonemarrow and soft tissue.

MRI shows a localized marrow abnormality inosteomyelitis.


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Diagnostic Procedure

Open bone biopsy with histopathologic examination andculture is the criterion standard for the microbiologicdiagnosis of osteomyelitis.

This procedure may not be necessary if blood culturesare positive with consistent radiologic findings.

Needle biopsy may also be used to obtain bone foranalysis. When clinical suspicion is high with negative

blood cultures and needle biopsy, a repeat needle biopsyor open biopsy should be performed. A bone sample can be collected at the time of

debridement for histopathologic diagnosis in patientswith compromised vasculature.


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Therapy

Medical Clindamycin, rifampin, trimethoprim-sulfamethoxazole, and

fluoroquinolones.

Surgery

Surgery is indicated when the patient has not responded tospecific antimicrobial treatment.

The Cierny-Mader classification system plays an importantrole in guiding treatment. As described above, stage 1 and2 disease usually do not require surgical treatment,whereas stage 3 and 4 respond well to surgical treatment.

Operative treatment consists of adequate drainage,extensive debridement of necrotic tissue, management ofdead space, adequate soft-tissue coverage, andrestoration of blood supply.


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Complication

Pin-tract infections and cellulitis,Flexion contractures above and below

the frame,

Limb edema, and

Bone fragment rotation withmalunion.

The most common complication in

children with osteomyelitis isrecurrence of bone infection.


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Prognosis

Inadequate therapy may lead to relapsinginfection and progression to chronicinfection.

Because of the avascularity of bone, chronicosteomyelitis is curable only with radical

resection or amputation. These chronic infections may recur as acuteexacerbations, which can be suppressed bydebridement followed by parenteral and oralantimicrobial therapy.

Rare complications of bone infection includepathologic fractures, secondary amyloidosis,and squamous cell carcinoma at the sinustract cutaneous orifice.


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FEMUR FRACTURE


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Definition

A femoral fracture is a break in thethigh bone, which is called the femur.The femur bone is also known as thethigh bone. It runs from the hip to the

knee and is the longest and strongestbone in the body. It usually requires agreat deal of force to break the femur.


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Fractures of the femur are commonand may affect the femoral neck, thefemoral shaft or distal(supracondylar) femur, which often

also involve the knee joint.Fractures of the femoral neck are far

more common in the elderly butfractures of the femoral shaft and

supracondylar fractures are usuallycaused by violent trauma and mostoften occur in adolescents and youngadults.


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Causes

High energy trauma Motor vehicle trauma (eg, motorcycle accidents, motor vehicle

accidents, plane crashes, pedestrian car accidents)

Falls (eg, from height: mountain climbing, abseiling, workplaceaccidents)

Sports (eg, high-speed and contact sports with direct trauma,

skiing, downhill mountain bike riding) Gunshot wounds

Low energy trauma People who have decreased bone density due to osteoporosis.

Elderly women are at greatest risk of this.

People who have had cancer that has spread to the bones

People who have been on long term corticosteroids. This has theeffect of decreasing bone density leading to weaker bones.


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Causes

Stress fractures The third way to fracture the femur is through

repetitive trauma.

This occurs most commonly in athletes

undergoing heavy training or military recruits.It is more common in women, particularly inwomen who are not menstruating. It is rare tohave a stress fracture affecting the lower part

of the femur. Most stress fractures of the femur affect the

mid shaft area.


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Types of Femoral Shaft Fractures

Transverse fracture In this type of fracture, the break is a straight

horizontal line going across the femoral shaft.

Oblique fracture This type of fracture has an angled line across the

shaft. Spiral fracture The fracture line encircles the shaft like the stripes on

a candy cane. A twisting force to the thigh causes thistype of fracture.

Comminuted fracture In this type of fracture, the bone has broken into three

or more pieces.


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Symptom

Pain and swelling This will always be present in the instance of a

femoral fracture.

DeformityNumbness or weakness

Bruising or bleeding

In the case of a stress fracture, there willstill be pain and swelling but not deformity,bruising or nerve damage. The pain and

swelling will often come on gradually ratherthan immediately in the case of a fracturedue to an accident.


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Clinical assessment

The first step in diagnosing any problemis to obtain a thorough history of theproblem.

An examination of the the whole lowerleg (ankle, knee, hip and pelvis) will be

carried out. As femoral fractures areoften caused by accidents involving alarge amount of force, other areas maybe damaged as well as the thigh bone.

The doctor will also assess whether the

nerves and blood vessels of the lowerlimb are working properly or whetherthey have been affected by the brokenbone.


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IMAGING

X-rays

This is an important

first step in confirming

that a fracture ispresent, but also the

exact location and

extent of the damage.


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IMAGING

CT scans CT scan may be necessary

to give the doctors a clearerpicture of the fracture.

This is particularly important

if surgery is required to fixthe broken bone.

The advantage of CT over X-ray is that it provides a 3Dimage of the leg and a moreaccurate picture of how far

the fracture has spread,particularly if it affects thejoint surfaces of the knee


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IMAGING

Bone scan

This test may be

required if a stress

fracture is suspected. Bone scan is a more

accurate tool to

diagnose a stress

fracture.


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TREATMENT

Non-surgical treatment Traction:

This involves pulling on the part of the bone below the

break to ensure that the two ends of the bone line up

and will heal without deformity. Casting and bracing:

If the two ends of the broken bones are lined up well, it

may be possible to simply apply a cast or a brace and

wait for the bones to mend of their own accord. This approach can only be taken if there is good

alignment of the bones following the break and there is

not multiple pieces of broken bones.


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TREATMENT

Non-surgical treatment Traction:

This involves pulling on the part of the bone below the

break to ensure that the two ends of the bone line up

and will heal without deformity. Casting and bracing:

If the two ends of the broken bones are lined up well, it

may be possible to simply apply a cast or a brace and

wait for the bones to mend of their own accord. This approach can only be taken if there is good

alignment of the bones following the break and there is

not multiple pieces of broken bones.


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TREATMENT

Surgical TreatmentExternal fixation

This means that the bones are held in placeusing a metal frame that is outside the body

with pins that then penetrate the bones. Thisapproach is favoured where the fracture haslead to damage of the surrounding musclesand skin.

External fixation is often used to hold thebones together temporarily when the skin andmuscles have been injured.


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TREATMENT

Internal fixation This approach means that the surgeon places

supports around the bone on the inside of the leg.

There are two main approaches used that come

under the category of internal fixation: Intramedullary nailing

This involves a specifically designed rod to be placedthrough the centre of the bone shaft. The rod will cross theline of the fracture and keep the two ends of the bonetogether.

Plates and screws This involves the use of metal plates and screws to hold

together the fragments of bone created by the fracture.


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Complications

Infection

Bone healingProblems

Compartmentsyndrome

Nervedamage

Complications specific to the type of


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Complications specific to the type offemoral fracture

Distal femoral fracture Stiffness of the knee which may resolve very

slowly and may not fully resolve. Another way thistype of fracture can affect the knee is bypredisposing to osteoarthritis. This is most likely if

the fracture line passes into the joint, disruptingthe smooth layer of cartilage that lines the joint.

Mid shaft fracture ligament damage to the knee which may require

an operation in order to repair the damage

Mid shaft fractures in teenagers and children maysuffer leg length discrepancy where one leg islonger than the other.


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REFERENCES

Reksoprodjo S, kumpulan ilmu bedah bahagian kedokteraan FKUI 1st

edition Jakarta;binarupa aksara Pub sept 2002 Apley, A. Graham et al. Buku Ajar Ortopedi dan Fraktur Sistem Apley

edisi ke-7. Widya Medika. Jakarta : 1995 Advanced Trauma Life Support 6th ed. American College of Surgeons

Committee on Trauma. USA: 1997. Medscape, osteomyelitis(online). Available from URL:

http://emedicine.medscape.com/article/1348767-overview#a0112,accessed on 6 April 2013

NHS.UK: different between acute and chronic osteomyelitis, 2012 july30 available from URL: http://www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspx

Mayoclinic, Osteomyelitis, 2012 Agust 1 available from URL:http://www.mayoclinic.com/health/osteomyelitis/DS00759/

Orthopedic examination 2012 Agust 1 available from URL:http://www.netterimages.com/image/8246.htm

Cluett, J. Fracture femur. Available athttp://orthopedics.about.com/od/brokenbones/a/femur.htm,accessed on 6 April 2013

LOGO
http://emedicine.medscape.com/article/1348767-overviewhttp://emedicine.medscape.com/article/1348767-overviewhttp://www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspxhttp://www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspxhttp://www.mayoclinic.com/health/osteomyelitis/DS00759/http://www.mayoclinic.com/health/osteomyelitis/DS00759/http://www.netterimages.com/image/8246.htmhttp://www.netterimages.com/image/8246.htmhttp://orthopedics.about.com/od/brokenbones/a/femur.htmhttp://orthopedics.about.com/od/brokenbones/a/femur.htmhttp://orthopedics.about.com/od/brokenbones/a/femur.htmhttp://www.netterimages.com/image/8246.htmhttp://www.mayoclinic.com/health/osteomyelitis/DS00759/http://www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspxhttp://emedicine.medscape.com/article/1348767-overviewhttp://emedicine.medscape.com/article/1348767-overviewhttp://emedicine.medscape.com/article/1348767-overview


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Non Union Fracture