CHRONIC HEMATOGENOUS

OSTEOMYELITIS
Go Fillysia C. Gonsales
C111 11 190
Advisor : dr. Padlan , dr. Michael Benjamin
Supervisor : dr. Muhammad Ihsan Kitta, M.Kes., Sp.OT

1
Patient Identity
• Name : An. RK
• Age : 8 years old
• Sex : Male
• Date of Admission : June 26th 2016
• Medical Record : 761394

2
History Taking
• Chief complaint : Pain at the right knee.
• History of illness : Suffered since 2 months ago
and worsen this past 1 months. Pain wasn’t
radiated and felt continuously so he couldn’t
move his right leg. Initially, the knee was swollen
and red. The patient then felt intense pain at his
right knee. A few days later, there was a nodule
on his right knee which releases pus constantly.
History of intermittent fever (+). No history of
trauma.
• Pasient has history of cough since 3 months ago,
intermittent.
• No history of prior treatment. 3
Physical Examination
• General Status :
Moderate ilnnes/conscious/underweight
BMI : 18 kg / (1,25m)2 = 11,52 kg/m2
• Vital sign :
Blood Pressure : 100/60 mmHg
Heart Rate : 90 x/min
Respiratory Rate : 24 x/min
Axial Temperature : 36,9 °C
4
 LOCAL STATUS

Right Knee Region

Look Deformity (-), hematoma (-), swelling (+), sinus
with pus discharge (+) at medial aspect
Feel Tenderness (+), warmer compared to surrounding
Move • Active and passive movement of right knee
joint can’t be evaluated due to pain
NVD • Sensibility is good
• Pulsation of the dorsalis pedis and tibialis
posterior are palpable
• CRT <2”
Clinical Imaging

6
Laboratory Findings
Pemerikasaan Hasil Nilai normal
WBC 14,1 4.00-10.0 x103/uL
RBC 3,68 4.00-6.00 x106/uL
HGB 8,1 12.0-16.0 gr/dl
HCT 26 37.0-48.0 %
PLT 802 150-400 x103/uL
GDS 98 <140 mg/dl
SGOT 22 <38 U/L
SGPT 24 <41 U/L
Na/K/Cl 137/4,2/100 136-145/3.5-5.1/97-111 mmol/l
LED 80/120 <10 mm/jam
CRP 34,1 <5 mg/l
Prokalsitonin 0,69 < 0,05 ng/ml 7
Radiological Findings

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Right Knee X-Ray AP / Lateral View
Radiological Findings

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Right Femur X-Ray AP / Lateral View
Radiological Findings

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Right Cruris X-Ray AP / Lateral View
Resume
• A boy, 8 years old, was admitted to the
hospital with chief complaint pain at the right
knee suffered since 2 months ago and worsen
this past 1 months. Pain wasn’t radiated and
felt continuously so he couldn’t move his right
leg. Initially, the knee was swollen and red. The
patient then felt intense pain at his right knee.
A few days later, there was a nodule on his
right knee which releases pus constantly.
History of intermittent fever (+). No history of
trauma. Pasient has history of cough since 3
months ago, intermittent.
11
• On physical examination at the right knee
region, found swelling (+), sinus with pus
discharge (+) at medial aspect, Tenderness (+),
warmer compared to surrounding, Active and
passive movement of right knee joint can’t be
evaluated due to pain
• On Laboratory findings, there are leukocytosis,
anemia, thrombocytosis. LED, CRP and
Procalcitonin are increased
• On Radiological findings of Right Knee X-Ray
AP / Lateral View found multiple litic lesion at
methaphysis and diaphysis right tibia with
periosteal reaction and swelling soft tissue at
right tibia
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Diagnosis
Chronic Hematogenous
Osteomyelitis

DD :
- Cellulitis
- Acute Suppurative Arthritis

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Management
• IVFD RL 20 dpm
• Antibiotic
• Analgetic
• Plan for debridement
• Bacterial Culture and Sensitivity

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DISCUSSION

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STRUCTURE OF BONE

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STRUCTURE OF BONE

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18
 INTRODUCTION
• The root words osteon (bone) and myelo
(marrow) are combined with itis
(inflammation) to define the clinical state in
which bone is infected with microorganisms
• Infection of bone is characterized
by progressive inflammatory destruction of
the bone
• The infection may be limited to a single
portion of the bone or may involve
numerous regions, such as the marrow,
cortex, periosteum, and the surrounding soft
tissue.
Kishner, S. Osteomyelitis. Update August 24th 2015. Available at
http://emedicine.medscape.com/article/1348767-overview 19
Hatch, D. Shirley, E. Update June 7 2016. http://www.orthobullets.com/pediatrics/4031/osteomyelitis--pediatric
th
 EPIDEMILOGY
• Incidence
– 1 in 5000 children younger than 13 years old
• Demographics
– 50% of cases in patients younger than 5
years
– 2.5 times more common in boys
– more common in first decade of life due to
rich metaphyseal blood supply and
immature immune system
– not uncommon in healthy children
• Location
– typically metaphyseal via hematogenous
seeding
20
Hatch, D. Shirley, E. Update June 7th 2016. http://www.orthobullets.com/pediatrics/4031/osteomyelitis--pediatric
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth 21
Edition.
London. Hachette UK Company. 2010: p.29-41
 CLASSIFICATION
• Attempts to classify are based on :
• Acute : within 2 weeks
• Subacute : within one to several months
Timing • Chronic : after several months

• Hematogenous : bacteremia originated or transported by blood

• Contiguous focus : associated with previous surgery, trauma,
Mechanism of wounds, or poor vascularity
spread • Direct inoculation : penetrating injuries or surgical contamination
infection

Cierny

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Karadsheh, M. Update June 3th 2015. Available at http://www.orthobullets.com/trauma/1057/osteomyelitis--adult
 ETIOLOGY

Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth 23
Edition.
London. Hachette UK Company. 2010: p.29-41
PATHOPHYSIOLOGY
These are end-artery branches of the nutrient artery

acute inflammatory response due to infection

tissue necrosis, breakdown of bone

Obstruction

Avascular necrosis of bone

Squestra formation

Chronic osteomyelitis

Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth 24
Edition.
London. Hachette UK Company. 2010: p.29-41
 DIAGNOSIS
History Physical
Investigations
taking examination

• PELTOLA AND VAHVANEN’S CRITERIA

(if 2/4 are found)  for acute osteomyelitis
1. Purulent material on aspiration of the affected bone
2. Positive findings of bone tissue or blood culture
3. Localised classic physical findings
a. bonny tenderness
b. overlying soft tissue edema,erythema
4. Positive radiological imaging 25
 History Taking
Acute
Fever, chills, fatigue, lethargy, or irritability,
pseudoparalysis. The classic signs of inflammation,
including local pain, swelling, or redness.

Subacute

Limp and/or pain inhibition with weight-bearing, slight

swelling, muscle wasting

Chronic
- Patient presents because pain, pyrexia, redness and tenderness
have recurred (a 'flare'), or with a discharging sinus.
- The tissues are thickened and often puckered or folded in
where a scar or sinus is attached to the underlying bone. There
are also nonhealing ulcer and chronic fatigue

26
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 Physical Examination
• Inspection & palpation : edematous,
warm, swollen, tender limb ; evaluate
for point tenderness in pelvis, spine, or
Acute limbs
• Range of motion :restricted motion
due to pain

• Local tenderness
• A well-defined cavity in cancellous
Subacute bone – usually in the tibial metaphysis
– containing glairy seropurulent fluid
(rarely pus)

• Sinus tract drainage

Chronic • Bone deformity

27
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 INVESTIGATIONS
 WBC Count : elevated in 25% of patients
L and correlates poorly with treatment response
A  ESR : elevated in 90% of patients with osteomyelitis
B rises rapidly and peaks in three to five days, but
O declines too slowly to guide treatment
 CRP : elevated in 98% of patients with acute
R
hematogenous osteomyelitis, most sensitive to monitor
A therapeutic response
T  Plasma Procalcitonin : elevated in 58% of pediatric
O osteomyelitis cases, new serologic test that rises rapidly
R with a bacterial infection
Y  Blood culture : is positive only 30% to 50% of the
time and will be negative soon after antibiotics are
administered
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Hatch, D. Shirley, E. Update June 7th 2016. http://www.orthobullets.com/pediatrics/4031/osteomyelitis--pediatric
 INVESTIGATIONS
• X-ray examination
Bone resorption with thickening and sclerosis of surrounding bone,
I loss of trabeculation, area osteoporosis, periosteal thickening,
sequestra, or the bone crudely thickened and misshapen
M
A • Bone Scan
G Sensitive but not specific. Using 99m Tc-HDP for showing increased
I activity of perfusion and bone phase and 67 Ga-Citrate or In-
N labelled leucocytes for showing hidden foci of infection
G • CT and MRI
Show the extent of bone destruction and reactive edema, hidden
abscess and sequestra

29
Hatch, D. Shirley, E. Update June 7th 2016. http://www.orthobullets.com/pediatrics/4031/osteomyelitis--pediatric
 INVESTIGATIONS

30
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 INVESTIGATIONS

31
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 INVESTIGATIONS

32
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 DIFFERENTIAL DIAGNOSIS
• Selulitis
- Widespread superficial redness and lymphangitis.
- The source of skin infection may not be obvious and
should be searched for (e.g. on the sole or between the
toes).
- MRI will help to distinguish between bone infection and
soft-tissue infection.
- The organism is usually staphylococcus or streptococcus
• Acute suppurative arthritis
- Tenderness is diffuse, and movement at the joint is
completely abolished by muscle spasm.
- In infants the distinction between metaphyseal
osteomyelitis and septic arthritis of the adjacent joint is
somewhat theoretical, as both often coexist.
- A progressive rise in C-reactive protein values over 24–48
hours is said to be suggestive of concurrent septic arthritis33
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 TREATMENT
GOALS :
Success in the treatment is dependent on various
factors :
 Patient factors : immunocompetence of patient
and nutritional status
 Injury factors : severity of injury as demonstrated
by segmental bone loss
 Infection location : metaphyseal infections heal
better than mid-diaphyseal infections
 Other factors affecting prognosis and treatment
include : residual foreign materials and/or
ischemic and necrotic tissues, inappropriate
antibiotic coverage, and lack of patient
cooperation or desire
34
Karadsheh, M. Update June 3th 2015. Available at http://www.orthobullets.com/trauma/1057/osteomyelitis--adult
 TREATMENT
Nonoperative Operative

Supporting Debridement
treatment and Drainage

Hardware
Splintage
removal

Dead space
Aspiration
management

Antibiotic Stabilization

Hyperbaric
oxygen
therapy
35
Karadsheh, M. Update June 3th 2015. Available at http://www.orthobullets.com/trauma/1057/osteomyelitis--adult
 TREATMENT
GENERAL SUPPORTIVE TREATMENT
• Give analgesics for treat pain
• Fluid intravenously for prevent
dehydration
SPLINTAGE
• Partly for comfort but also to
prevent joint contractures and
helps to prevent dislocation.

36
Solomon L. Warwick, D. Nayagam, S. Infection : Apley’s System of Orthopaedics and Fractures Ninth Edition.
London. Hachette UK Company. 2010: p.29-41
 TREATMENT
ASPIRATION
• Indications
– helps guide medical management when
organism identified (50% of the time)
– cultures allow for better antibiotic
management with knowledge of
susceptibility
• Technique
– large bore needle utilized to aspirate the
subperiosteal and intraosseous spaces
under fluoroscopic or CT-guidance
– start antibiotics after aspiration
37
Hatch, D. Shirley, E. Update June 7th 2016. http://www.orthobullets.com/pediatrics/4031/osteomyelitis--pediatric
TREATMENT
ANTIBIOTIC
• To suppress the infection and prevent its
spread to healthy bone and to control
acute flares.
• The choice of antibiotic depends on
microbiological studies, but the drug must
be capable of penetrating sclerotic bone
and should be non-toxic with long-term use.
• Administered for 4–6 weeks (starting from the
beginning of treatment or the last
debridement) before considering operative
treatment.

38
1) The time interval between the onset of infection
and the institution of treatment (ideally within the
first 3 days; treatment begun between 3-7 days
attenuates infection but is too late to prevent
bone destruction; treatment after the first week
may control septicemia and be life saving but has
little effect on the relentless progression of the
local pathological process within the bone)
2) Effectiveness of the antibacterial drug against the
specific causative bacteria
3) The dosage of the antibacterial drug
4) The duration of antibacterial therapy (treatment
given less than 3-4 weeks frequently results in
either chronic or recurrent osteomyelitis)
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40
TREATMENT
DEBRIDEMENT
• All devitalized and necrotic tissue should be
removed
• Extensive debridement is essential to eradicate
infection
• Sequestrum must be eliminated from the body, or
infection is likely to recur
DRAINAGE
• If pus is found – and released – there is little to be
gained by drilling into the medullary cavity. If there is
no obvious abscess, it is reasonable to drill a few
holes into the bone in various directions.
• If there is an extensive intramedullary abscess,
drainage can be better achieved by cutting a small
window in the cortex.
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 TREATMENT
HARDWARE REMOVAL
 Any non-essential hardware should be removed
DEAD SPACE MANAGEMENT
 The goal is to replace dead bone and scar tissue
with vascularized tissue
 Options include : vascularized bone grafts, local
tissue flaps or free flaps, antibiotic-impregnated
acrylic beads, vacuum-assisted closure
STABILIZATION
 Bony stability is required for successful eradication
of infection
 External fixation preferred to internal fixation
 Mechanism is thought to be related to improved
angiogenesis
42
Karadsheh, M. Update June 3th 2015. Available at http://www.orthobullets.com/trauma/1057/osteomyelitis--adult
COMPLICATION
Complication of Acute Osteomyelitis :
• Early complications include death, abscess
formation, and septic arthritis (especially in the hip
joint).
• Late complications include chronic osteomyelitis,
either persistent or recurrent, pathological fracture,
joint contracture, and local growth disturbance
(either overgrowth from stimulation of prolonged
hyperemia or premature cessation of growth from
epiphyseal plate damage).
Complications of Chronic Osteomyelitis include joint
contracture, pathological fracture, and malignant
changes in the epidermis (epidermoid carcinoma) of
a sinus track in which infection has been allowed to
persist for many years.
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PROGNOSIS
• Inadequate therapy may lead to relapsing
infection and progression to chronic infection.
Because of the avascularity of bone, chronic
osteomyelitis is curable only with radical resection
or amputation.
• These chronic infections may recur as acute
exacerbations, which can be suppressed by
debridement followed by parenteral and oral
antimicrobial therapy.
• Prognosis should always be guarded; local trauma
must be avoided and any recurrence of
symptoms, however slight, should be taken seriously
and investigated. The watchword is ‘cautious
optimism’ – a ‘probable cure’ is better than no
cure at all.
Kishner, S. Osteomyelitis. Update August 24th 2015. Available at 44
http://emedicine.medscape.com/article/1348767-overview
45