Chronic osteomyelitis of the right femur

writer :

Sofiuddin bin nordin

030.08.305 Lecturer :

Dr. Arsanto Triwidodo,SpOT,FICS, K Spine, MHKes

Surgery Departement Koja Hospital Medicine Faculty Of Trisakti

Purulen discharge Sweeling Eritema

Form of new boneinvolucrum Sinus tract squestrum

NAME : ANGGARA SUSTINA AGE : 18 YEARS OLD SEX : MALE RELIGION : ISLAM ETHNIC : SUNDANESE EDUCATION : HIGH SCHOOL CIVIL STATUS : SINGLE DATE OF ENTER TO HOSPITAL: 21.07.2012(FROM EMERGENCY ROOM) DATE OF EXAMINATION: 02.08.2012

Chief complaint
Pain on the right knee and the right hip since 9 months ago

Additional complaint:
Fever with chill and malaise

History of present illness

The patient confessed that 9 months ago before admission he get involved in accident on october 2011. The patient was riding a motorcyle when his bike got hit by another motorcyle from the right side and was dragged for approximately 7 meter with low velocity.He refuse loss of consciousness and no trauma in his head. Blood come out from wound on his leg. The size of that woud around 5cmx 2cm in his proximal femur and full field with sand and very dirty. Patient was then assisted by a witnessing security guard and bring him back to his home. His mother decided brought to bonesetter that night. During the treatment the bonesetter was assume to manuever a traction on the broken leg. The wound on his leg not sutured because he assume that its not to deep. He told to the patient that needed a medical attention. After 2 days, he went to RS manuel in bandung and from x ray photo, patient was suspected of having fractured neck of femur. And then he was sent to RS Hasan Sadikin for futher treatment. Due to financial problem patient didnt get the operation needed. Once again, patient went to alternatif treatment practitioner and was given some kind of herbal ointment. A weeks after using the ointment the pain in the thigh of the right leg started to worsen. Patient felt a sharp pain in his right knee. After 3 months later the pain becoming worse day by day and the pain was spread to his right waist. The pain was continously even in rest and feel very pain if try to walk. Due to the pain, patient was avoiding to use the injured leg and his right leg started to feel shrinking. Two weeks after that he found out he can not bent his leg anymore. The right knee started to swelling , redness and also felt limited movement of his knee. He deny having the crepitation on his knee. Now he feel the pain is less than before. After that he decide to RSUD Koja on 21st july 2012. In 3 months prior admission patient complaint of febrile fever and also chill. The tempreture will normal after he took paracetomal and tend to increase again. He refused having vomiting, nausea and also long cough.

Got involved in accident when riding motorcycle

brought to bonesetter

manuever a traction on the broken leg

got hit by another motorcyle from the right side and was dragged for approximately 7 meter with low velocity

assisted by a witnessing security guard

The wound on his leg not sutured

Didnt loss of conscious and trauma on the head

wound on his leg 5cmx 2cm in his proximal femur and full field with sand and very dirty

went to RS manuel in bandung and from x ray photo, patient was suspected of having fractured neck of femur.

sent to RS Hasan Sadikin

1 week after that the pain become worse with sharp pain sensation

Refuse the operation

alternatif treatment practitioner and was given some kind of herbal ointment

6 months ago
The pain becoming worse day by day and the pain was spread to his right waist Patient complaint he found one hole in the back of knee with discharge, yellow and thick

was continously even in rest and feel very pain if try to walk

. The right knee started to swelling , redness and also felt limited movement of his knee

2 months ago
No crepitation on his knee. febrile fever and also chill. The tempreture will normal after he took paracetomal and tend to increase again. He refused having vomiting, nausea and also long cough.

History of past illnes He never having problem like this before. No hereditary illnes History of past treatment He never undergoes an operation and never consume the medicine for a long time. History of illnes Never have the same illnes in his famly. His mother suffered Hypertension. No diabetes mellitus, asthma and heart disease Habits of history Play basketball and always warm up before played. He claim, he using the right technique when playing basketball . playing basketball 5x every weeks. Never consume alcohol and Smoking. Take the Balanced diet(3x/every day + meet + vegetable)

Physic examination
General codition : moderately illnes Consciousness: compos mentis Vital sign Blood preasure: 120/80 mmHg Heart rate: 76x/min Temperature: (38oC) Respiration rate: 20x/min Height: 150cm Weight: 41kg Analysis: 1) Increasing of temp(febrile),It shows that BMI: 17,77 the process of infection occur

Head: normalcephaly, black hair with normal distribution, difficult unpulg, no lesion and bump Eyes: normal shape, symmetric , pupile isokor, conjunctiva anemis(-/-), sclera icterik(-/-) direct light reflex(+/+) undirectly light reflex(+/+) Ears: normotia, no hyperemis, no secret(-/-), serumen(+/+), membran tympani intact with light reflex at 5 oclock for right ear and 7 oclock for left ear, corpus alenium(-/-) Nose: normal in shape, no deformity, septum deviation(-), concha hyperthrophy(-/-). No hyperemi, secret(-/-) Mouth: lips not dry trismus(-), tongue not dirty, teeth normal, good oral hygien, phrynx not anemi Neck: normal in shape, no palpable the enlargement of lymph node

Chest: lung

Inspection: movement of brething left and right symmetric , retraction intercostal space(-/-), lession(-) Palpasion: vocal fremitus left and right symmetric, no compresive pain(-/-) Percusion: sonor in both side of lung Auscultation: sound of breathing right and left vesikuler, ronchi(-/-), wheezing(-/-) Inspection: no pulsation of ictus cordis appearance

Heart

Palpation: ictus cordis palpable on intercostal space v, 1cm media from left midclavicle
Percusion: right border: intercosta space v right parasterna line Left border: intercosta space v, 1cm media from left midclavicula

Upper broder: intercosta space ii from lef parasternal line

Stomach:

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

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

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

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

Percusion: tympani, shiffting dullness(-) Genital : no lession, no pain

Analysis: 1) From general examination didnt find any abnormality sign

Extrimity
right

Left Eutrophy

atrophy Muscle Tonnus Mass Joints Movement Strenght Edem normotony No abnormality No abnormality Not active weak edema

Normothony No abnormality No abnormality Active Normal No edema

RIGHT
warmth -tenderness - circumference 31cm DEFORMITY(discrepancy/shortening) True length: 60 cm Apparents length:50cm Anatomical length:25cm -No fluctuation

LEFT
circumference 25cm deformity(discrepancy/shortening) True length: 67cm Apparent length: 55cm Anatomical length:25cm

RIGHT Active( knee joint) Flextion : 40o ( normal range 0150o) Extention: 10o(normal 15000) Passive(knee joint) Flextion :60o Extention: -10o

LEFT Active( knee joint) Flextion : 150o ( normal range 0150o) Extention:00 (normal 150-00) Passive(knee joint) Not examined

SENSORY
Pain upper part of the upper leg (L2) lower-medial part of the upper leg (L3) medial lower leg (L4) Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation Light touch Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation

symmetrical left and right

lateral lower leg (L5) Feel the sensation symmetrical left and right sole of foot (S1) Feel the sensation symmetrical left and right

symmetrical left and right

Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right

Right Hip joint Normal power(5)

left Normal power(5)

Physiology reflex

Left

Knee reflex Achiles reflex Patalogical reflex Kerniq & laseq Barbinsky

Not examined Positive normal

Positive normal Positive normal

Not examined negative

negative negative

Physiology reflex

Right

Left

Analysis: 1) From examination of extremity, local status ,sensory, motoric and reflexs, we can conclude that the problem for this patient is occurs in the right lower extremity. It might be some of fracture in the neck of the right femur because from deformity examination anatomical length is remain the same between right and left but the length of apperents and true length having sliding shortening. From pubic
From SIAS

From great trochanter

R=50 L=55

Side of fracture
R=L=25cm R=60 L=65

2) The sign like warmth, tendernes, sweeling and discharge In the right distal femur shows us that some inflamation process occur there. It might be because of infection of bacteria that enter to the pattients body from hematogenous or contigous pathway. But from this case, the probability port of d entry of the bacteria is Direct Inoculation pathway is more than hematogenous because of the localized open wound. The sinus tract is form because of some perforated process inside the body. In this case because of involocrum peforated by openings through which purulence may track into the surrounding soft tissue and eventually drain to the skin surface 3) Because of the sweeling and tenderness, range of movement include active and pasive is decreasing. 4) From sensory examination didnt found any abnormality of neurologic.

LABORATORY FINDING
Haematology Hb Leukocyte Hematokrit Trombocyte Eritrocyte sedimention rate Kidney function: Creatine: 0,5 0,5 (0,4-0,7) 27/7/2012 10,2 g/dl 30. 100 /uL 32% 430.000 15/08/2012 11,4 g/dl 15.200/uL 45% 303.000/uL 20mm/hour Normal value (11,2-15,7 g/dl) (3900-10 000/ul) (39-45%) (140.000440.000/ul) (< 10mm/hour)

Ureum

25

25

(17-43)

electrolyte Na K Cl

27/7/2012 --

15/08/2012 138 3,98 101

Normql value 135-247 mmol/L 3,5-5,0 mmol/L 9,6-108 mmol/L

Identity : anggara

16yrs 3/08/2012

Type: chest x ray(anterior posterior) Good photo Luscent in both right and left lung No cardiomegaly with CTR< 50% No active or inactive process of tuberculosis

Identity: anggara

16yrs No date

Type: pelvix x ray(AP) Not good to interprate because its difficult to differentiate between air, muscle and bone Proximal displacement of the neck femur shaft

No identity Tibia and fibule (AP) Good because can differentiate between air, muscle and bone Soft tissue swelling in fracture area Complete transverse fracture of fibular shaft displaced

Additional examination Femur X ray( AP) Biopsy

RESUME
Men, 18 years old came to RSUD Kojas emergency unit with complain pain in right tigh . The patient confessed that 9 months ago he get involved in accident on october 2011. Wound on his leg with size around 5 cmx 2cm, dirty and not sutured. He went to bonesetter, and was treating with some kind of herbal ointment and also apply the maneuver of traction. A weeks after using the ointment the pain in the thigh of the right leg started to becoming worsen. The distal femur started to swelling , redness and also felt limited movement of his knee. In 3 months prior admission patient complaint of the episodic febrile fever with chill and also malaise. From physical examination, the tempreture is febrile 38oC and from local status in right femur , look some lession on knee, edem and redness in knee. From feel, found out, warm , compresive pain(+) and the size of knee convolution is 15cm, no active movement, range of scope limited, pain on movement from Pasive movement positive but still imited From laboratry finding, increasing of leucoyte(30. 100 /uL) and eritrosit sedimention rate(20mm/hour). Decreasing of Hb (10,2 g/dl) From thoraxs x ray photo didnt find any problem, no active or passive process of tuberculosis and CTR<50%. For pelvic x ray, found Proximal displacement of the femur shaft and for X ray photo of tibia and fibula found the complete transverse fracture of fibular

Working diagnosis

Base of dx

From history taking

Patient involved an accident 9 month ago Open wound around 5cmx2cm, dirty and not sutured History of alternative treatment which is increasing the factor of infection( applay some herbal ointment) Felt Sharp pain on his knee which is spread to his hip , but day by day the intensity of pain became less Ferbrile fever with chill and malaise

From physical examination

Febrile tempreture ( 38oC) From local status

look

scar (+) edema and redness in right proximal femur (+) Sinus with discharge fistel

feel

warmth tenderness circumference 31cm whereas the left side is 25cm

From laboratory finding

Found the increasing of leukocyte to 30.000/ul and also ESR 20mm/hour

Septic Arthritis

osteosarcoma

Cellulitis

Differential diagnosis

MANAGEMENT
Supportive IVFD asering Na + diklofenat 2x 50 mg Omeprazole 2x1 Ketopain 3xl Bedrest Normal diet Mobilisation( after operation) Non operative

Antimicrobials Hypobac 2x 500mg Sopirom 2x 1gr

Debridement Lay position with spinal anasthesis Sepsis in operation area (medioposterior distal femur) Capsul was opened, move out the pus and collect the pus to sent to lab. Curated and pair of drainase Operative(30/7/2012)

Prognosis Ad vitam : bonam Ad sanationam: dubia ad malam Ad fungsionam: dubia ad malam

Defining Osteomyelitis

Whats in a Name?
Osteomyelitis (Osteo- bone, Myelo- Marrow, and itis Inflammation)
It is an infection of the of the bone or bone marrow which leads to a subsequent Inflammatory

CASE REVIEW

Epidemiology
20%

of adult cases of osteomyelitis are hematogenous, which is more common in males for unknown reasons.

The overall incidence of vertebral osteomyelitis is believed to have increased in recent years because of intravenous drug use, increasing age of the population, and higher rates of nosocomial infection due to intravascular devices and other instrumentation Higher in developing countries.

Causes
1. Positive gram:

Staphylococus aureus (most common) Streptococus pyogen Streptococus pneumoniae

Haemophilus influenzae (50% < 4 years old) E. coli Pseudomonas aeruginosa Proteus mirabilis

1.

Negative gram:

Types of osteomyelitis

There are two main types of osteomyelitis: Acute osteomyelitis is where the bone infection develops within two weeks of an initial infection, injury or underlying disease and may respond to antibiotic treatment. Chronic osteomyelitis is where the bone infection has produced irreversible bony changes that cannot be treated by antibiotics alone

Acute Osteomyelitis

Types of Acute Osteomyelitis

I.

Hematogenous Osteomyelitis Direct inoculation Osteomyelitis

II.

Acute Osteomyelitis
Hematogenous Osteomyelitis:

Bacterial seeding from the blood. Seen primarily in Children. The most common site is the Metaphysis at the growing end of Long Bones in Children, and The Vertebrae and pelvic in Adults.

Acute Osteomyelitis
Direct Inoculation Osteomyelitis

Direct contact of the tissue and bacteria as a result of an Open Fracture or Trauma. Tend to involve multiple organisms.

Acute Osteomyelitis Causative Organisms:

Staphylococcus aureus (Mainly)

Streptoccous pyogens or pneumoniae. (Less)

H.Influenzae (Young Children) Salmonella (Sickle-Cell)

Symptoms of Acute osteomyelitis

a sudden high temperature (fever) of 38C (100.4F) or above, although this symptom is often absent in children under one year old bone pain, which can often be severe swelling, redness and warmth at the site of the infection a general sense of feeling unwell the affected body part is tender to touch the range of movement in the affected body part is restricted lymph nodes (glands) near the affected body part may be swollen

Chronic osteomyelitis

Chronic osteomyelitis can sometimes start as acute osteomyelitis. If acute osteomyelitis is not treated properly it can become established and produce permanent, destructive changes to bone, resulting in pain, discharge and loss of function. As with acute osteomyelitis, the infection can be spread through the blood or directly into the bone as a result of injury or other trauma. Chronic osteomyelitis can also develop as a complication of a pre-existing infection such as tuberculosis (a bacterial infection) or syphilis (a sexually transmitted infection), although this is uncommon in the UK today.

Symptoms of chronic osteomyelitis

bone pain feeling persistently tired pus draining from the sinus tract (a passageway that develops near the infected bone) local swelling skin changes excessive sweating chills

Open wounds/fractures Microorganisms gain entryby way of blood Microorganisms lodge intoan area where circulation slows Predisposing factors: -Vascular insufficiency -disorders genitourinary infections -respiratory infections -IV drug use -immunocompromising diseases -history of blood- stream infections -Indwelling prosthetic devices Microorganisms grow increase pressure

ischemi

Vascular compromiseof the periosteum Infection through the boned cortex and marrow

fever, night sweats,chills, restlessness,nausea and malaiseconstant bone pain,swelling, tenderness,warmth at the infection site,restricted movementof the affected part

cortical devascularization

necrosis

Debridement

Formation of new bone

Separation of devitalized bone from living bone Continues to be an infected island Difficulty to reach by blood borne antibiotics drainage from sinus tracts

Involcrum

Chronic stage Systemic signs maybe diminished withconstant bone pain,Swelling, tenderness,warmth at the infection site of organ function

Enlarged sequestrum

Development of sinus tract

revascularized

Turns to scar tissue Site for continued microorganism growth Remission and exacerbation

Removal by the normali mmune process Sequestrum move out to the soft tissue

amputation

healing

Physical examination

Blood test Imaging tests Biopsy

Blood test
Leucocytosis ESR

usually is elevated

ESR usually is elevated (90%) nonspecific

protein level usually is elevated
The

C-reactive

C-reactive protein level usually is elevated (nonspecific but more useful than ESR).

Aspiration of the pus from the subperiosteal abscess and culture, and test sensitivity for antibiotics Blood culture results are positive in only 50% of patients with hematogenous osteomyelitis.

Imaging:

First 10 days X-Rays Show No Abnormality. By the end of the 2nd Week signs of rarefaction of Metaphysis and New Bone Formation. With Healing there is Sclerosis and thickening of Cortex. MRI may help to distinguish between Bone and Soft-Tissue Infection. Form the squestrum and involucrum

BIOPSY
From: Soft tissue collection Subperiosteal abscess Intraosseos lesions For: Smear Culture Pathology
Neddle Aspiration or Open biopsy:

DIFERENTIAL DIAGNOSIS
Inflammatory Arthritis Inflammatory arthritis is an umbrella term which covers all types of arthritis which are connected with your immune system. This includes rheumatoid arthritis (autoimmune disease which attacks the membrane around your joints); ankylosing spondylitis (characterized by inflammation of the large joints and spine); lupus (affects your organs and connective tissue); Reiter's syndrome (affects tendons, skeleton, mucous membranes and joints); and psoriatic arthritis (your joints and skin become inflamed). Bone Cancer The types of bone cancer which must be ruled out include osteosarcoma and Ewing sarcoma. According to the American Cancer Society, osteosarcoma is the most common form of bone cancer and can metastasize (spread) beyond the bone. Ewing sarcoma is a tumor which is more common in children than adults and is more responsive to radiation treatment than osteosarcoma.

Gout According to the Mayo Clinic, gout is a treatable yet complex disorder characterized by symptoms like extreme arthralgia (joint pain) and inflammation. The condition usually affects your big toe's joint but it can also affect ankles, wrists, hands, knees and feet. Without treatment, it usually lasts between 5 and 10 days and then subsides. It is diagnosed with a blood test and a test of your joint fluid

Traumatic Fractures and Stress Fractures Fractures caused by trauma are relatively easily diagnosed using X-ray technology. Stress fractures, however, are slightly more complicated. These tiny cracks in your bone are created by repetitive force and overuse (like long-distance running) or from normally using a bone which has been weakened. Anyone who has broken a bone can recognize symptoms of a traumatic fracture (swelling and pain with use). According to the Mayo Clinic, stress fractures may be characterized by swelling, pain which increases as time goes by, pain occurring earlier in each consecutive workout session and pain which decreases while resting and increases while active. These types of fractures usually do not appear on an X-ray for 3 to 4 weeks after you develop symptoms.

Staging(Cierny-Mader et al (2003) )

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 open fracture. Stage 3 osteomyelitis often responds well to limited surgical intervention that preserves bony stability. Stage 4 osteomyelitis represents extensive disease involving multiple bony and soft tissue layers. Stage 4 disease is complex and requires a combination of medical and surgical therapies, with postsurgical stabilization as an essential part of thera

The second part of the CiernyMader classification

Class

A hosts have normal physiologic, metabolic, and immune functions. Class B hosts are systemically (Bs) or locally (Bl) immunocompromised. Individuals with local and systemic immune deficiencies are labeled as Bls. Class C hosts, treatment poses a greater risk of harm than osteomyelitis itself. The state of the host is the strongest predictor of osteomyelitis treatment failure, so the physiologic class of the infected individual is often more important than the anatomic stage.

Treatment
Principles of treatment:
1.

Analgesia an general supportive measures. Rest of the affected part Antibiotic treatment.

2.

3.

4.

Surgical eradication of pus and necrotic tissue(debridement).

Therapy
Treating acute osteomyelitis Antibiotics These medicines are usually given as a sixweek course In cases of osteomyelitis, there is usually a choice of antibiotics available to treat the infection and often two antibiotics are used in combination In cases of fungal osteomyelitis, an antifungal medication called voriconazole is usually the treatment of choice

Treating chronic osteomyelitis

The combination of antibiotics medication and surgery to remove any damaged bone. For surgery, will make an incision (cut) near the site of the infection to drain away any pus. The extensive bone damage remove any diseased bone and tissue This procedure is known as debridement sometimes packed with antibiotic-loaded cement

Debridement

Remove any foreign objects. In some cases, foreign objects, such as surgical plates or screws placed during a previous surgery, may have to be removed. Amputate the limb. As a last resort, surgeons may amputate the affected limb to stop the infection from spreading further

Complications of osteomyelitis

Recurring osteomyelitis

as poor circulation or a weakened immune system

Bone death (osteonecrosis)

An infection in your bone can impede blood circulation within the bone, leading to bone death. Your bone can heal after surgery to remove small sections of dead bone. If a large section of your bone has died, however, you may need to have that limb amputated to prevent spread of the infection.
In some cases, infection within bones can spread into a nearby joint. In children, the most common location for osteomyelitis is in the softer areas, called growth plates, at either end of the long bones of the arms and legs. Normal growth may be interrupted in infected bones. If your osteomyelitis has resulted in an open sore that is draining pus, the surrounding skin is at higher risk of developing squamous cell cancer

Septic arthritis.

Impaired growth.

Skin cancer