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5/27/2018 Osteomyelitis Kuliah
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Agianto, S.Kep., Ns., MNS
Adult Nursing Department
School of Nursing UNLAM
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Nelaton (1834): coined osteomyelitis
The root words osteon (bone) and myelo
(marrow) are combined with i t is
(inflammation) to define the clinical state
in which bone is infected with
microorganisms.
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Common clinical problemDefined as a progressive infection of the
bone that results in inflammatory
destruction of the bone, bone necrosisand new bone formation
Classification by pathogenesis and
chronicity
Early diagnosis is difficult
Delay in diagnosis leads to decreased
cure rates and increased rates of
complication and morbidity
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The term acute osteomyelitis is
used clinically to signify a
newly recognized bone
infection. Patients usually
present within several days to
one weekafter the onset of
symptoms. In addition to local
signs of inflammation and
infection, patients have signs
of systemic illness
The relapse of a previously treated or
untreated infection is considered a
sign of chronic disease. Clinical signs
persisting for more than 10 days
correlate roughly with the development
of necrotic bone and chronic
osteomyelitis. The clinical pattern may
evolve over months or even years and
is characterized by lowgrade
inflammation; the presence of pus,
microorganisms,and sequestra ; a
compromised soft-tissue envelope;and
sometimes a fistula.
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Sequestrum :
is a devitalized avascularsegment of bone, surrounded, by pus
/infected granulation tissue and is more
dense than surrounding bone .Because ofavascularity , sequestrum does not decalcify ,
is more radio opaque and heavy , so sinks in
water
Its outer surface is usually jagged / irregular
due to erosive process by proteolytic
enzymes in granulation tissue
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.)
I nvolucrum :
is derived from the word volvere
i.e. to wrap .It is the result of reactive
new bone formed by periosteal
reaction , in an attempt to wall off the
infection by forming a thick tense wall
It is jagged on its inner surface
but smooth on its outer surface
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.)
Cloacae :
are single or multiple openings in
involucrum and are caused by rupture
of periosteum due to pus undertension .
Exudates , sequestra are extruded
through the cloacae on the surface
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According to the duration of the disease acute
chronic
On the basis of the pathogenesishematogenous
secondary to a contiguous focus of infection
associated with peripheral vascular disease
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Acute Osteo Sub-Acute Osteo Chronic Osteo
Begins with marrow
edema, cellular infiltration
and vascular engorgement
May progress to necrosis
and abscess formation
Spread within the
intramedullary cavityextension through cortex
by Havers and Volkmans
canalssubperiosteal
spaceperiosteum
soft tissues
Rupture of joint space
septic arthritis
Occurs in abnormal bone
or after inadequate
antibiotics
Localized pyogenic
process
Commonly appears as a
well-defined osteolyticmetaphyseal lesion
(Brodies abscess) with a
sclerotic margin that fades
peripherally (fuzzy
sclerotic margin)
S. aureus is most common
pathogen
Occurs after inadequate tx or in
pts with altered immunity
Distinguishing feature is
necrotic bone surrounded by
granulation tissue
Interruption of blood supply
necrosisdevitalized bonefragments (sequestra)
A thick sheath of new periosteal
bone can develop around the
sequestra (involucrum)
Fistula tract formation
Sharp interface between normal
and diseased marrow
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Age (adult v. child)Site (foot, vertebra, long bone)
Source (trauma/surgery, hematogenous, or
contiguous spread/cellulitis,)Presence or absence of foreign body (hardware)
Acute vs. chronic
SeverityComorbidity (e.g., diabetic, sickle cell)
Organism
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PATHOPHYSIOLOGY
Hematogenous Osteomyelitis
Contiguous-Focus Osteomyelitis
Peripheral Vascular Disease-associated
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PATHOPHYSIOLOGY
Microorganisms enter bone (Phagocytosis).
Phagocyte contains the infection
Release enzymes
Lyse bone
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PATHOPHYSIOLOGY
Bacteria escape host defenses by:
Adhering tightly to damage bone
Persisting in osteoblasts
Protective polysaccharide-rich biofilm
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PATHOPHYSIOLOGYPus spreads into vascular channels
Raising intraosseous pressure
Impairing blood flow
Chronic ischemic necrosis
Separation of large devascularized fragment
New bone formation
(involucrum)
(Sequestra)
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PATHOLOGY
Acute Infiltration of PMNs
Congested or thrombosed vessels
Chronic Necrotic boneAbsence of living osteocyteMononuclear cells predominate
Granulation & fibrous tissue
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Hematogenous
Osteomyelitis
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HEMATOGENOUS OSTEPMYELITIS
Rapidly growing bone
Children:Long bone, Femur, Tibia, Humerus
Older patients: Vertebral bone
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HEMATOGENOUS OSTEOMYELITIS
Neonate & infant < 1 year old
Septic arthritis is common.
Growth deformities is common.
Soft tissue involvement is common.
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HEMATOGENOUS OSTEOMYELITIS
Children: 116 years old
Most frequent in the metaphysis of long bone.
Slugging blood flow through asinusoidal venous system.
Deficiency of phagocytic cells.
Poor collateral circulation
Susceptibility of this region to trauma.
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HEMATOGENOUS OSTEOMYELITIS
Children: 116 years old
History of antecedent trauma in 30%
Involucrum
Sequestration
Associated septic arthritis
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HEMATOGENOUS OSTEOMYELITIS
Adult
Less common
Spread infection to joint space.
Vertebral Osteomyelitis is common> 50y
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HEMATOGENOUS OSTEOMYELITIS
Special considerationSickle cell disease
Injection drug users (IDUs)HemodialysisHIV/AIDS
ImmunosuppressionProsthetic orthopedic device
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HEMATOGENOUS OSTEOMYELITIS
Microbiologic featuresStaphylococci Aureus, EpidermidisStreptococci Group A & B
Haemophilus influenzaeGram-negative enteric bacilliAnaerobes
PolymicrobialMycobacterialFungi
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HEMATOGENOUS OSTEOMYELITIS
Clinical manifestationClassic presentation: Sudden onsetUsually presentation: Slow, insidious
High fever, Night sweatsFatigue, Anorexia, Weight loss
Restriction of movementLocal edema, Erythema, & Tenderrness
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HEMATOGENOUS OSTEOMYELITIS
Differentials
CellulitisGas gangreneNeoplasmAseptic bone infection
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Clenched fist
osteomyelitis
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upLab study:
WBC May be elevated, Usually normal
C-Reactive Protein (CRP)Erythrocyte Sedimentation Rate(Usually is elevated at presentation
Falls with successful therapy)
Blood culture
( Acute osteomyelitis + ve > 50% )
{
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
ImagingRadiology:NormalSoft tissue swellingPeriosteal elevation
Lytic changeSclerotic changew
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upImaging
MRI:Early detectionSuperior to plan X ray & CT Scan &
radionuclide bone scan in slectedanatomic location.Sensitivity 90100%
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
ImagingRadionuclide bone scan:
A 3-phase bone scan ( Technetium 99m )
Positive as early as 24 h afteronset of symptoms.
False positive Tumor, osteonecrosis
Artheritis, Cellulitis,
Abscess
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
ImagingCTScan:
Useful in evaluation of Spinal, pelvic,Sternum, Calcaneus
Provides exellent images of bone corteIs used for biopsy localization
Os + gaz in diabetic foot
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Septic arthritis
Of
Right hip
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upUltrasonography
Simple & inexpensive
Demonstration anomaly 12 days after onset
Soft tissue abscess, Fluid collection, &Periosteal elevation
It allows for aspiration
It doesnt allow for evaluation of bone cortex.
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HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-upNeddle Aspiration or Open biopsy:
From: Soft tissue collection
Subperiosteal abscessIntraosseos lesions
For: SmearCulturePathology
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TREATMENTInitial treatment shoud be aggressive.
Inadequate therapy Chronic disease
Antibiotic use:
Surgery
ParenteralHigh dosesGood penetration in boneFull course
Empiric therapy
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TREATMENT
Empiric Initial TherapyNeonate S.aureus PRP +Infant
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TREATMENTMonitoring Therapeutic Response
1.Symptoms & Signs
2.ESR & CRP
3.Radiography
4.Serial Bone Scan?
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TREATMENT
Indication for Surgery
Diagnostic
Hip joint involvementNeurologic complicationPoor or no response to IV therapy
Sequestration
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S U R G I C A L M A N A G E M E N T
General principles of surgical therapy include
1.To remove dead , devitalized and infected bone
2.To obliterate any dead space left after
debridement
3.To obtain soft tissue coverage of exposed bone
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PROGNOSIS
Is related to:Causative organisms
Duration of symptoms & sign
Patient age
Duration of antibiotic therapy
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COMPLICATION
Bone abscessBacteremia
FractureLoosing of the prosthetic implant
Overlying soft-tissue cellulitisDraining soft-tissue tract
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Septic Osteomyelitis
Osteomyelitis Scar
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Osteomyelitis Deformity of the Forearm
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Plain radiograph of the tibia
and fibula in a 14 y/o patient
demonstrating a pathologic
fracture of the proximalfibula with periosteal
reaction and erosion of the
cortical bone secondary to
subacute osteomyelitis
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CONTIGUOUS-FOCUSOSTEOMYELITIS
Contiguous focus Osteomyelitis
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Contiguous-focus Osteomyelitis
Clinical setting:
Postoperative infection
Contamination of bone
Contiguous soft tissue infection
Puncture wounds
Contiguous focus Osteomyelitis
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Contiguous-focus Osteomyelitis
Microbiologic featuresStaphylococci Aureus, Epidermidis
Gram-negative bacteria
Anaerobic infection
Unusual organismsClostridia, Nocardia
Contiguous focus Osteomyelitis
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Contiguous-focus Osteomyelitis
DiagnosisLeukocyte countBlood culture (infrequently positive)
ESR & CRPRadiologic evaluation
Technetium bone scanOpen bone biopsy
Culture of wound & draining sinuses??
Contiguous focus Osteomyelitis
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Contiguous-focus Osteomyelitis
Treatment
Surgery is essential.
Antibiotics SpecificDuration
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ASSOCIATED WITHPERIPHERAL VASCULAR DISEASE
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Clinical Features
erythema and drainage
either no pain (if there is advanced neuropathy) or excruciating pain
(if the destruction of bone has been acute).
patients are afebrile,
present with an ulcer without evidence of surrounding inflammation.
The ulcer size (> 2 cm2) and depth (> 3 mm) are predictive of the
likelihood of bone involvement. If bone can be felt with a sterile blunt
probe, the likelihood of osteomyelitis is high.
a high ESR, especially if it is over 70 mm/hour, is helpful in making
the diagnosis of osteomyelitis
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Found almost exclusively in the feet in
patients with a long history of diabetes
mellitus and peripheral neuropathy.
Bone involvement usually occurs after an
extension of soft tissue infection involving a
plantar ulcer.
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ETIOLOGY
Most infections are polymicrobialS. aureus remains the most common
pathogen
others include Enterococcus faecalis,group B streptococci, Enterobacteriaceae,
anaerobic bacteria (especially peptococci,
peptostreptococci, and Bacteroides
species), and P. aeruginosa
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Vertebral
Osteomyelitis
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Risk factors: Male
Age > 50
IVDU
Etiology
Virtually always hematogenous
Lumbar more common then cervical
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Localized pain and tenderness
Diagnosis often missed ordelayed
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Plain films
MRI best
CT-guided needle biopsy
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Staph Aureus in about 50%
Other organisms:
Gram negative aerobes
Streptococcus sp.
Tuberculosis
Pseudomonas and candida in
IVDU
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6 to 12 weeks IV antibiotics if medicaltreatment alone
Surgical treatment indicated if
abscess
cord compression
failure of medical treatment
Can follow CRP for reoccurrence or
failure of treatment response
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Modality of choice for initial evaluation
Advantages Inexpensive
Exclude other conditions
May help guide further work-up
DisadvantagesOften normal for the first 10 to 21 days of
infectionSensitivity: 43-75%
Specificity: 75-83%
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Earliest finding deep softtissue swelling
Active infection for 1-2 weeks bone destruction and periostealreaction
Localized osteoporosisPathologic fracture
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Assessment11 functional of Gordon,
Intans Screening Diagnoses Assessment
(ISDA)
Nursing Diagnoses (NDx)NANDA-I2012-2014
Nursing OutcomesNOC (2008)
Nursing InterventionNIC (2008) Implementation
Evaluation
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Deficient diversional activity r/t prolonged
immobilization, hospitalization.
Fear, parental r/t concern regarding
possible growth plate damage caused byinfection, concern that infection may
become chronic.
Ineffective health maintenance r/tcontinued immobility at home, possible
extensive casts, continued antibiotic
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Hyperthermia r/t infectious process
Impaired physical mobility r/t imposed immobility
as a result of infected area.
Acute pain r/t inflammation in affected extremity. Risk for constipation: risk factor: immobility
Risk for infection: risk factor: inadequate primary
and secondary defenses
Risk for impaired skin integrity: risk factor:irritation from splint or cast
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Definition: decreased stimulation from (or
interest or engagement in) recreational or
leisure activities.
Defining characteristics: Clients statements regarding boredom (e.g., wish
there was something to do, to read, etc.); usual
hobbies cannot be undertaken in hospital
Related factors (r/t): environmental lack of
diversional activity
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NOC Suggested outcomes
Leisure participation as evidence by the following
indicators: expresses satisfaction with leisureactivities/feels relaxed from leisure activities/enjoys
leisure activities.
Play participation
Social involvement
Client outcomes
Client will (specify time frame):
Engage in personally satisfying diversional activities.
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NIC Suggested NIC interventions
Recreation therapy
Self-responsibility facilitation Ng intervention & rationales (activities)
Example for recreation therapy: assist the client to
identify meaningful recreational activities; provide safe
recreational equipment.
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