Osteomyelitis

• Is an infection of the bone

The bones become becomes infected in three ways:

• Extension of soft tissue infection

- infected pressure or vascular ulcer

- incisional infection

• Direct bone contamination from bone surgery, open fracture, or traumatic injury

• gunshot wound

• Hematogenous (blood borne) spread from the other sites of infection

• Infected tonsils, boils, infected teeth, upper respiratory infection

Osteomyelitis resulting from hematogenous spread typically occurs in a bone in an

area of trauma or lowered resistance, possibly from subclinical (nonapparent) trauma

High Risk for Osteomyelitis:

• those who are poorly nourished

• elderly

• obese

• other patient at risk include those with impaired immune system, those with
chronic illnesses (diabetes, rheumatoid arthritis)

• and those receiving long term corticosteroid therapy or immunosuppressive

agents
Pathophysiology:

Staphylococcus Aureus (70% and 80%)

Proteus, Pseudomonas

Escherichia coli

(other pathogenic organisms that are frequently found in Osteomyelitis)

↓
↑ The incidence of penicillin resistant, nosocomial, gram-negative, and anaerobic infections

The initial response is Inflammation

After 2 or 3 days, thrombosis of the blood vessels occurs in the area

( resulting in ischemia with bone necrosis)

The infection extends into the medullary cavity

Under the periosteum

Spread into adjacent soft tissues and joints

Unless the infective process is treated promptly

a bone abscess forms.

the resulting abscesses cavity contains dead bone tissue (the sequestrum)
 which does not easily liquefy and drain.

So the cavity cannot collapse and heal

New bone growth ( involucrum )

Forms and surrounds the sequestrum

healing appears to takes place

A chronically infected sequestrum remains and produces recurring abscesses throughout the
patient’s life (it referred to as chronic Osteomyelitis)

Clinical Manifestation:

• manifestation of sepsis

- chills

- high fever

- rapid pulse

- general malaise

• as the infection extends through the cortex of the bone, it involves the periosteum and
the soft tissue

- the infected area becomes painful

- swollen

- and extremely tender

• the patient may describe a constant, pulsating pain that intensifies with movement as a
result of the pressure of the collecting pus

• the area is swollen warm painful and tender to touch

• the patient with chronic Osteomyelitis presents with a continuously draining sinus or
recurrent periods of pain, inflammation, swelling and drainage
Diagnostic Finding

Acute Osteomyelitis

• x-ray findings

- demonstrate soft tissue swelling

- in 2 weeks areas of irregular decalcification

- bone necrosis

- periostal elevation

- and new bone information are evident

• Radioisotope bone scans , Isotope-labeled white blood cell (WBC)

scan, Magnetic Resonance Imaging

• Help with early definitive diagnosis

• Wound and blood culture

• Performed to identify appropriate antibiotic

therapy

Chronic Osteomyelitis

• X-ray findings

• Large, irregular cavities, raised periosteum,

sequestra, or dense bone formations are seen

• Bone Scan

- May performed to identify areas of infection

• ESR and WBC

- Usually normal,

- Anemia associated with chronic infection, may

be evident

Prevention

• Prevention of Osteomyelitis is the goal

• Elective orthopedic surgery should be postponed if the patient has a current infection
(like urinary tract infection, sore throat) or a recent history of infection
 • During orthopedic surgery, careful attention is paid to the surgical environment and to
techniques to decrease direct bone contamination

• Prophylactic antibiotics- administered to achieve adequate tissue levels at the time of

surgery and for 24 hours afterf surgery

• Urinary catheters and drains are removed as soon a spossible to decrease the
incidence of hematogenous spread of infection

• Aseptic postoperative wound care reduces the incidence of superficial infections and
osteomyelitis

• When patients who had joint replacement surgery undergo dental procedures or other
invasive procedure .prophylactic antibiotic are frequently recommended

Medical Management

The initial goal of therapy is to control and halt the infection process.

• Supportive measure (hydration, diet high in vitamins and protein , correction

of anemia) should be instituted

• The area affected with Osteomyelitis is immobilized to decrease discomfort

and to prevent pathologic fracture of the weakened bone

• Warm wet soaks for 20 minutes several times a day may be prescribed to
increase circulation to the affected area

Pharamacologic Therapy

• As soon as the culture specimens are obtained, IV antibiotic therapy begins,

based on the assumption of that infection results from a staphylococcal
organism that is sensitive to a semisynthetic Penicilin or Cephalosphorin

(the aim is to control the infection before the blood supply to the area
diminishes as the result of thrombosis)
 • Around the clock dosing is necessary to achieve a sustained blood level of the
antibiotic

• After the result of the culture and sensitivity studies are known, an antibiotic
to which the causative agent organism is sensitive is prescribed.

• IV therapy continues for 3 to 6 weeks

• After the infection appears to be controlled, the antibiotic may be administered

orally for up to 3months- to enhance absorption of the orally administered
medication,

• AVOID: antibiotics should not be administered with food

Surgical Management.

• Surgical Debridement

- If the infection is chronic

- Also reserved for patients with acute Osteomyelitis that does

not respond to antibiotic therapy

- The result of it is weakens the bone ,internal fixation or

external support devices may be needed to stabilize or support
the bone to prevent pathologic fracture.

• Sequestrectomy

- The removal of enough involucrum to enable the surgeon to

remove the sequestrum

Nursing Management

• Monitors the neurovascular status of the affected extremity

• Elevation reduces swelling and associated discomfort

• Pain is controlled with prescribed analgesics and other pain-reducing techniques

• Must be protected by immobilization devices and avoidance of stress on the bone

• The patient must understand the rationale of for the activity of restriction

• Encourage patient to have a full participation in ADL’s within the physical limitations
to promote general well-being

• Monitor the patients response to antibiotic therapy

• Observes the IV access for evidence of phlebitis, infection, or infiltration,

• With long term intensive antibiotic therapy (monitors the patient for sign of infection
like oral or vaginal candidiasis, loose or fouling-smelling stool

• If surgery is necessary (take measures to ensure adequate circulation to the affected

area (wound suction to prevent accumulation, elevation of the area to promote venous
drainage, avoidance of pressure on the grafted area) to maintain needed immobility,
and to ensure the patients adherence of to weight bearing restrictions.

• Changes dressings using aseptic technique (to promote healing and to prevent cross-
contamination

• Diet high in protein and Vitamin C (promotes a positive nitrogen balance and healing

• Encourage adequate hydration as well

Reference:Management of patients with Musculoskeletal Disorders page 2413-2415

in Brunner and Suddarths Textbook of Medical-Surgical Nursing Eleventh Edition
Volume:2