Bahan Osteomyelitis

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    OSTEOMYELITIS

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    Defnition o Osteomyelitis

     The root words osteon (bone) and myelo(marrow) are combined with itis(inammation)

    Osteomyelitis is an inectious process thatinvolves bone and its medullary cavity which

    leads to a subsequent Inammatory process.

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    lassifcation

    Based on onset!cutehronic

    Source of

    infection"emato#enous

    onta#enous

    Direct Inection

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    !cute Osteomyelitis

    • !cute haemato#enous osteomyelitis is mainlya disease o children

    •$tiolo#y% &taph. aureus' #ramne#ative bacili'#roup streptococcus

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    In infant: There is still a ree anastomosis

    between metaphyseal and epiphyseal

    blood vessel' inection can *ust aseasly lod#e in epiphysis.

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    • !cute Osteomyelitis in babies inection maysettle near the very end o bone% *ointinection and #rowth disturbance easly ollow.

    • In older children' metaphyseal inection isusual+ the #rowth disc acts as a barrier tospread

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    In children:

    Or#anisme usuallysettle in the methaphysis

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    Infection in the metaphysis may spreadtowards the surace' to orm a subperiostealabscess

    Some of the bone may die, and is encasedin periosteal new bone as a sequestrum

    The encasing involucrum is sometimesperorated by sinuses

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    ,

    Inammation

    athology

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    -atholo#y o

    acute ostemyelitisInfammation

    acute inammatoryreaction' vascularcon#estion' eudation ouid' infltration o -/0'increase o intraosseuspressure

    Suppuration&ubperiosteal abscess' endplate and intervertebraldisc inection

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    -atholo#y o

    acute ostemyelitisNecrosis

    avascular necrosis o#rowth plate in inant.

    acterial toins andleucocytic en1ymesalso may play theirpart in the advancin#

    tissue destruction.reactive new bone

    ormation

    resolution and healing.

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    NEW BONE FO!"#ION0ew bone orms rom the deep layers o

    the stripped periosteum.

     This is typical o pyo#enic inection and is

    usually obvious by the end o the secondwee2. 3ith rime the new bone thic2ens toorm an involucrum enclosin# theinected tissue and sequestra.

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    NEW BONE FO!"#IONI the inection persists' pus and tiny

    sequestrated splcules o bone maycontinue to dischar#e throu#h

    perorations (cloacae) in the involucrumand trac2 by sinuses to the s2in suraces+the condition is now established as achronic osteomyelitis.

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    ESO$%#ION

    Once common' chronic osteomyelitisollowin# on acute is nowadays seldomseen.

    I inection is controlled and intraosseouspressure released at an early sta#e' thisdire pro#ress can be aborted.

     The bone around the 1one o inection isat frst osteoporotic (probably due tohypcraemia).

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    &i#n 4 &ymptoms&i#ns and symptoms can vary si#nifcantly.

     The patient' usually a child' presents withsevere pain' malaise and a ever

    In inants' elderly patients' orimmunocompromised patients' clinical fndin#smay be minimal.

    -ain and local tenderness are common

    fndin#s.

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    5aboratory The most certain way to confrm the clinical

    dia#nosis is to aspirate pus rom themetaphyseal subperiosteal abscess or the

    ad*acent *oint. The 3 and 6- values are usually hi#h.

    lood culture is positive in only about hal the

    cases o proven inection.

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    &ot tissue swellin# (early)' bone deminerali1ation(9:9< days)' sequestra (dead bone withsurroundin# #ranulation tissue)' and involucrum

    (periosteal new bone) later.

    /6I % etremely sensitive' even in the early phaseo bone inection' and can help to di=erentiate

    between sottissue inection and osteomyelitis.

    6adioscinti#raphy

    &ensitive but not specifc.

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    /ana#ement

    &upportive treatment or pain anddehydration

    &plinta#e o the a=ected part !ntibiotic therapy &ur#ical draina#e

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    omplication

    &uppurative arthritis -atholo#ical racture hronic osteomyelitis

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    hronic Osteomyelitis

    hronic osteomyelitis represents a continuation ounresolved acute inection

    0ow days' it more requently ollows an openracture or operation.

    >sual or#anisms are staphylococcus aureus'$scherichia coli' &treptococcus pyo#ens' -roteusand -seudomonas.

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    &ta#in# ?or !dult hronic Osteomyelitis byierny et al. (;::@)

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    -atholo#yone is destroyed or devitali1ed in a discrete area

    at the ocus o inection.

    avities containin# pus and pieces o dead bone(sequestra) are surrounded by vascular tissue'and beyond that by areas o sclerosis the result ochronic reactive new bone ormation.

     The histolo#ical picture is one o chronicinammatory cell infltration around areas oacellular bone or microscopic sequestra.

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    linical eatures-ain' pyreia' redness and tenderness have

    recurred' or with a dischar#in# sinus.

     There may be a seropurulent dischar#e andecoriation o the surroundin# s2in.

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    5aboratory$&6 and white blood cell count may be

    increased

    Or#anisms cultured rom dischar#in# sinuses

    should be tested repeatedly or antibioticsensitivity.

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    Ima#in#7ray eaminationone resorption with thic2enin#

    and sclerosis o surroundin# bone

    "owever' there are mar2ed variation%there may be no more than

    locali1ed loss o trabecculation'

    or a area osteoporosis'

    periosteal thic2enin#' sequestrashow up as unnaturally dense ra#ments.

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    adioscintigrapb) with AAm Tc"D-reveals increased activity in boththe perusion phase and the bonephase.. It has relatively low

    specifcity and other inammatorylesions can show similar chan#es.

    In doubtul cases' scannin# with

    Bacitrate or In labelledleucocytes may be morerevealin#.

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    !I is etremely sensitive' evenin the early phase o boneinection' and can help todi=erentiate between sottissue

    inection and osteomyelitis. The most typical eature is a

    reduced intensity si#nal in T9

    wei#hted ima#es.

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    In!estigations

    #he most certain wa) to con&rm theclinical diagnosis is to aspirate pus romthe metaph)seal subperiosteal abscess orthe ad1acent 1oint.

     The white cell count and reactiveprotein values are usually hi#h and the

    haemo#lobin concentration diminished+

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    In!estigations

     The $&6 also rises but it may ta2e severaldays to do so and it oten remainselevated even ater the inectionsubsides.

    lood culture is positive in only about halthe cases o proven inection.

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    "i#erential diagnosis

    ellulitis

    &treptococcal necroti1in# myositis

    !cute suppurative arthritis

    !cute rheumatism&ic2lecell crisis

    BaucherCs disease

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     Treatment

    &upportive treatment or pain anddehydration+

    &plinta#e o the a=ected part+

    !ntibiotic therapy @ E wee2s+ and

    &ur#ical draina#e

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     $%TIBIOTI& T'E$TME%TOlder children and ft adult %

    Staph)lococcus group?lucloacillin and usidic acid i.v 9 ;

    wee2sOrally antibiotics @ E wee2s

    hildren F < years - 2aemophilus groupand gram negatie organisms3ephalosporins 4ceuro'ime or ceota'ime5

    i.v or orall)  "mo'icillin(clavulanic acid combination

    4co(amo'iclav* a 6(lactamase inhibitor5

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    /ana#ement!ntibiotics

    5ocal Treatment

    Operation %

    DebridementDealin# with the dead space&ot tissue cover

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    omplication! patholo#ic racture

    0on union or se#mental bone loss

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    S(B$)(TE OSTEOMYELITIS

    6elative mildness

     The or#anism bein#less virulent(Staph)lococcus

    aureusor ) and thepatient moreresistance (or both)+

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    S(B$)(TE OSTEOMYELITIS

    /ore variable ins2eletal distributionthan acuteosteomyelitis

     The Distal emur andthe proimal anddistal tibia areavorite sites.

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    $T*OLO+Y 3ell defned cavity in cancellous bone  

    #lairy seropurulent uid (rare pus)

    avity is lined by #ranulation tissue o

    miture o acute and chronicinammatory cells.

     The surroundin# bone trabeculae areoten thic2ened

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    )linical features The patient % child or adolescent

    -ain near one o the lar#er *oints orseveral wee2s or even months

    ! limp or sli#ht swellin#' muscle wastin#and local tenderness

    0ormal temperature to sli#ht hi#her

    3hite cell count may be normal but $&6

    is raised

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    IM$+I%+-lain 76ay! circumscribed' oval or round cavity 9 ;

    cm in diameter on tibia or emoralmetaphysis or in epiphysis or in cuboidal

    bone (calcaneus)avity surrounded by halo o sclerosis (the

    classic rodieGs abscess)/etaphysis lesion  little or no periosteal

    reactionDiaphysial lesion  periosteal new bone

    ormation and cortical thic2enin#

    6adioisotope scan

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    "I$+%OSISDi=erential dia#nosis % Osteoid osteoma

    with appearance as mali#nant bonetumour

    ertain eamination by iopsy orbacteriolo#ical culture.

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    T'E$TME%Tonservative

    Immobili1ation and antibiotics(ucloacillin and usidic acid) or E

    wee2s than thereater or E 9; monthsurreta#e+ indicate or lesion ater biopsyand also or the case with no healin# withconservative treatment.  !ntibiotics

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    )*'O%I) OSTEOMYELITIS

     The usual or#anisms (and with time thereis always a mied inection) are Staph.aureus* E. coti* S. p)ogenes* 7roteus and7seudomonas-

    In the presence o orei#n implantsStaph. cpidermidis* which is normallynonpatho#enic' is the commonest o all.

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     Pathology one is destroyed or devitali1ed in a

    discrete area at the ocus o inection ormore di=usely alon# the surace o aorei#n implant.

    avities containin# pus and pieces odead bone (sequestra) are surrounded byvascular tissue' and beyond that by areas

    o sclerosis the result o chronic reactivenew bone ormation.

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     Pathology  The sequestra act as substrates

     The histolo#ical picture is one o chronicinammatory cell infltration around areas

    o acellular bone or microscopicsequestra.

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    )hronic osteomyelitis chronic bone inection' with a persistentsequestrum' may be a sequel to acute osteomyelitis (a). /oreoften it ollows an open racture or operation (b). Occasionally itpresents as a brodieCs abscess (c).

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    Clinical features

     There may be a seropurulent dischar#eand ecoriation o the surroundin# s2in.

    In posttraumatic osteomyelitis the bonemay be deormed or nonunited.

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    Imaging

    7ray eaminationBone resorption with thicening andsclerosis o surrounding bone* loss otrabeculation* area osteoporosis*

     periosteal thicening* se8uestra* or thebone crudel) thicened and misshapen

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    Imagingadioisotope scintigraph) 

    Sensitive but not speci&c. %sing 99m #c(2:7

    or showing increased activit) o perusionand bone phase and ;

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     Investigations

    $&6 and blood white cellcount may beincreased+  are helpul

    in assessin# the pro#resso bone inection but theyare not or dia#nostic.

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     Investigations

    Or#anisms cultured romdischar#in# sinusesshould be testedrepeatedly or antibiotic

    sensitivity+ with time'they oten chan#e theircharacteristics andbecome resistant to

    treatment.

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    T*$%&S

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    Breene'3. 0etterGs Orthopaedic 9st ed

    !pley' !pleyGs &ystem O Orthopaedics !nd?ractures Hth $dition

    &alter' 6obert ' /D' Tetboo2 o Disordersand In*uries o the /usculos2eletal system