Case report 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 Jakarta ,6 september t 27,2012 Period july 23th ,2012- September 29,30th

CONTENT

PREFACE CHAPTER 1:

PAGE 1

DEFINITION OF OSTEOMYELITIS . CHAPTER 2: CASE REPORT CHAPTER 3: CASE REVIEW (OSTEOMYELITIS) . CHAPTER 4: REFERENCES ..

PAGE 2

PAGE 3- 16

PAGE 18- 33

PAGE 34

PREFACE
Assalamualaikum Wr Wb

I would like to thank to the one supreme God, Allah S.W.T for all blessing so through my works I could finish this paper in time. This paper would not have been possible without encourage from my family, my groupmate and my lecturer whom I most grateful. Thank to our lecturer dr Arsanto triwidod, SpOT, FICS,K Spine,MHKes for his guidance and help me to finish this paper, without him, I belived that my work will facing some problem. This paper is all about chronic osteomyelitis of the right femur that I arranged in oder to completed my assignment for the department of surgery of koja hospital. The case in this paper actually very complicated case because the patient not only have been diagnosis suffered from bone infection but also having some fracture. So, because the title is about bone infection, so in this paper we will be discuss only about osteomyelitis and some part of fracture. To many other individuals who contributed while I was writing this paper. This paper is still not prefect. There are a lot of mistakes in the writing, grammar, medical term and also theory of illness. I hope, after reading this paper, readers could give some advices and critics that may develop my ability to write another better paper for the next time. Finally, I apologize for all mistake that I made in this paper. I hope this paper could be useful to the reader.
Wassalamualaikum Wr Wb

CHAPTER 1 DEFINITION Osteomyelitis is inflammation of the bone caused by an infecting organism. Although bone is normally resistant to bacterial colonization, events such as trauma, surgery, presence of foreign bodies, or prostheses may disrupt bony integrity and lead to the onset of bone infection. Osteomyelitis can also result from hematogenous spread after bacteremia. When prosthetic joints are associated with infection, microorganisms typically grow in biofilm, which protects bacteria from antimicrobial treatment and the host immune response. Early and specific treatment is important in osteomyelitis, and identification of the causative microorganisms is essential for antibiotic therapy. The major cause of bone infections is Staphylococcus aureus. Infections with an open fracture or associated with joint prostheses and trauma often require a combination of antimicrobial agents and surgery. When biofilm microorganisms are involved, as in joint prostheses, a combination of rifampicin with other antibiotics might be necessary for treatment

CHAPTER II CASE REPORT Name Age Sex Religion Ethnic Education Civil Status : Anggara sustina : 18 years old : men : islam : sundanese : SMA : single

Date of enter to hospital: 21.07.2012(from emergency room) Date of examination: 02.08.2012 History taken have been done on 02.08.2012, 10.30 am 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. Patient complaint he found one hole in the back of knee with discharge.the fluid that come out from the hole is yellow in color and thick. 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. 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 BMI: 17,77 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(-/-) Heart Inspection: no pulsation of ictus cordis appearance 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 Auscultation: sound of heart I-II reguler, gallop(-), murmur(-) 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 Extrimity: Right Muscle Tonnus Mass Joints Movement Strenght Edem atrophy normotony No abnormality No abnormality Not active Weak edema Left Eutrophy Normothony No abnormality No abnormality Active Normal No edema

Local status (right proximal femur) Right look - scar (+) - edema and redness in right distal femur (+) - sinus and discharge(+) - fistule(-) - no laceration - no ecchymosis - Deformity: Feel No Rotation No angulation - circumference 25cm deformity(discrepancy/shortening) True length: 67cm Apparent length: 55cm Anatomical length:25cm -Deformity: No rotation No angulation Left

-warmth -tenderness - circumference 31cm DEFORMITY(discrepancy/shortening) True length: 60 cm

Apparents length:50cm Anatomical length:25cm

-No fluctuation -no crepitation - pulse(+) Move Active( knee joint) Flextion : 40o ( normal range 0150o) Extention: -10o(normal 150-00) Flextion :60o Extention: -10
o

Active( knee joint) Flextion : 150o ( normal range 0-150o) Extention:00 (normal 15000) Passive(knee joint) Not examined

Passive(knee joint) -

Neurological status Sensory Pain upper part of the upper leg (L2) Feel the sensation symmetrical left and right Light touch Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right

lower-medial part of the upper Feel the sensation symmetrical leg (L3) medial lower leg (L4) 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

Motoric Right left

Hip joint

Normal power(5)

Normal power(5)

Reflex Physiology reflex Knee reflex Achiles reflex Patalogical reflex Kerniq & laseq Barbinsky Not examined negative Negative Negative Right Not examined Positive normal Left Positive normal Positive normal

Laboratory finding On JULY 27th 2012 Haematology Hb : 10,2 g/dl (11,2-15,7 g/dl)

Leukocyte: 30. 100 /uL(3900-10 000/ul) Hematokrit: 32%(39-45%) Trombocyte: 430.000(140.000-440.000/ul) Kidney function: Creatine: 0,5 (0,4-0,7) Ureum: 25(17-43)

Second laboratory test on august 15, 2012 Haematology Hb : 11,4 g/dl (11,2-15,7 g/dl)

Leukocyte: 15.200/uL (3900-10 000/ul) Eritrocyte sedimention rate: 20mm/hour(< 10mm/hour) Hematokrit: 45%(39-45%) Trombocyte: 303.000/uL(182000-39.000/ul) Creatine: 0,5 (0,4-0,7) Ureum: 25(17-43)

Eletrolyte Na : 138 (135-247 mmol/L) K : 3,98 (3,5-5,0 mmol/L) Cl : 101 (9,6-108 mmol/L) X ray

1st x ray Identity: -anggara - 16 years old - no date Type : pelvic x ray (AP) Not good to interprate because its Difficult to differentiate between air And muscle Proximal displacement of the neck Femur Shaft

2nd x ray -type: tibia and fibule (AP) -good because can differentiate between air and bone - soft tissue swelling in fracture area

- completes transverse fracture Of fibular shaft \displaced

3RD X RAY Identity : anggara 16yr 3/08/2012 Type: Chest x ray(anterios posterior) - good photo - luscent in both right and left lung - no cardiomegaly with CTR<50% - no active or passive process of tuberculosis 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 shaft displaced

Working diagnosis 1) Post traumatic chronic osteomyelitis of the right distal femur 2) Neglected fracture of the right femur neck

Base of diagnosis 1. From anamneses 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 2. From physical examination Febrile tempreture ( 38oC) From local status look feel warmth tenderness circumference 31cm whereas the left side is 25cm scar (+) edema and redness in right proximal femur (+)

3. From laboratory finding Found the increasing of leukocyte to 30.000/ul and also ESR 20mm/hour Differential diagnosis 1) Septic Arthritis 2) osteosarcoma 3) Cellulitis

Management Operative(30/7/2012) Debridement Non operative Supportive

 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

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

Antimicrobials Hypobac 2x 500mg Sopirom 2x 1gr

Prognosis Ad vitam : bonam

Ad sanationam: dubia ad malam Ad fungsionam: dubia ad malam

CHAPTER IV CASE REVIEW

BONE A long bone consists of several sections:

Diaphysis: This is the long central shaft Epiphysis: Forms the larger rounded ends of long bones Metaphysis: Area betweent the diaphysis and epiphysis at both ends of the bone Epiphyseal Plates: Plates of cartilage, also known as growth plates which allow the long bones to grow in length during childhood. Once we stop growing, between 18 and 25 years of age the cartilage plates stop producing cartilage cells and are gradually replaced by bone.

Covering the ends of bones, where they form a joint with another bone, is a layer of hyaline cartiage. This is a firm but elastic type of cartilage which provides shock absorbtion to the joint and has no neural or vascular supply. Bone Anatomy If you were to cut a cross-section through a bone, you would first come across a thin layer of dense connective tissue known as Periosteum. This can be divided into two layers, an outer 'fibrous layer' containing mainly fibroblasts and an inner 'cambium layer', containing progenitor cells which develop into osteoblasts (the cells responsible for bone formation).

The periosteum provides a good blood supply to the bone and a point for musculaattachment.

Under the periosteum is a thin layer of compact bone (often called cortical bone), which provides the bones strength. It consists of tightly stacked layers of bone which appear to form a solid section, although do contain osteons, which like canals provide passageways through the hard bone matrix.

Epidemiology Approximately 20% of adult cases of osteomyelitis are hematogenous, which is more common in males for unknown reasons. The incidence of spinal osteomyelitis, as depicted in the image below, was estimated to be 1 in 450,000 in 2001. However, 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 The overall incidence of osteomyelitis is higher in developing countries. Etiology Posttraumatic osteomyelitis accounts for as many as 47% of cases of osteomyelitis. Other major causes of osteomyelitis include vascular insufficiency (mostly occurring in persons with diabetes; 34%) and hematogenous seeding (19%). Motor vehicle accidents, sports injuries, and the use of orthopedic hardware to manage trauma also contribute to the apparent increase in prevalence of posttraumatic osteomyelitis. Osteomyelitis may complicate puncture wounds of the foot, occurring in 1.8%-6.4% of patients following injury Causes Most cases of osteomyelitis are caused by staphylococcus bacteria, a type of germ commonly found on the skin or in the nose of even healthy individuals. Germs can enter a bone in a variety of ways, including:

Via the bloodstream. Germs in other parts of your body for example, from pneumonia or a urinary tract infection can travel through your bloodstream to a weakened spot in a bone. In children, osteomyelitis most commonly occurs in the softer areas, called growth plates, at either end of the long bones of the arms and legs.

From a nearby infection. Severe puncture wounds can carry germs deep inside your body. If such an injury becomes infected, the germs can spread into a nearby bone.

Direct contamination. This may occur if you have broken a bone so severely that part of it is sticking out through your skin. Direct contamination also can occur during surgeries to replace joints or repair fractures. 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 There are two ways that acute osteomyelitis can occur:

Contiguous osteomyelitis is where an infection spreads directly into the bone as a result of an injury, such as a fractured bone or animal bite, during surgery, or as a result of another condition such as diabetes or vascular disease.

Haematogenous osteomyelitis is where an infection spreads into a bone from the bloodstream.

Contiguous osteomyelitis is the most common type of acute osteomyelitis, accounting for four out of five cases. It mainly affects adults. People who have a condition that affects the blood supply to certain parts of their body, such as type 2 diabetes, have an increased risk of developing contiguous osteomyelitis. Any surgical procedure on the skeleton may introduce infection into bone. Haematogenous osteomyelitis mostly affects younger children, although adult cases may occur in anyone with a weakened immune system, such as those with rheumatoid arthritis or HIV.

People who regularly inject drugs, such as heroin, also have an increased risk of developing haematogenous osteomyelitis.

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 osteomyelitis

Acute osteomyelitis Most cases of acute osteomyelitis involve one of the long bones in the legs. However, sometimes the bones in the arm or the vertebrae (in the back) can be affected. The symptoms of acute osteomyelitis include:

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

Young children who cannot talk may be unable to report their painful sym

ptoms to you. You should look out for the following signs and symptoms:

irritability eating much less than usual reluctance to use the affected body part

Chronic osteomyelitis Once chronic osteomyelitis is established, the person affected may have periods of almost no symptoms. However, symptoms can flare up at any time. For example, you may experience:

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

Pathophysiology Acute osteomyelitis presents as a suppurative infection accompanied by oedema, vascular congestion, and small-vessel thrombosis. In early acute disease, the vascular supply to the bone is decreased by infection extending into the surrounding soft tissue. Large areas of dead bone (sequestra) may be formed when the medullary and periosteal blood supplies are compromised. Acute osteomyelitis can be arrested before dead bone develops if treated promptly and aggressively with antibiotics and surgery (if necessary). In an established infection, fibrous tissue and chronic inflammatory cells form around the granulation tissue and dead bone.

Pathological features of chronic osteomyelitis are the presence of necrotic bone, the formation of new bone, and the exudation of polymorphonuclear leukocytes. New bone forms from the surviving fragments of periosteum and endosteum in the region of the infection. An encasing sheath of live bone, an involucrum, surrounds the dead bone under the periosteum. The involucrum is irregular and is often perforated by openings through which purulence may track into the surrounding soft tissue and eventually drain to the skin surface, forming a chronic sinus. Most infections in orthopaedics, including osteomyelitis, are caused by biofilm-forming bacteria. A biofilm is a highly structured community of bacterial cells that adopt a distinct phenotype, communicate through cell-cell signals, and adhere to an inert or living surface. Biofilm-forming bacteria exist in 1 of 2 states - the planktonic state or the stationary state. Planktonic bacteria are free-floating; the bodys host defences can easily eradicate the organism through the usual immunological mechanisms. In contrast, stationary bacteria within the biofilm appear to be phenotypically different from their planktonic types. They have a slower rate of growth and are less metabolically active, and are thereby less susceptible to the effects of chemotherapeutic agents. In chronic osteomyelitis and implantassociated infections, bacteria grow within biofilms attached to the surface of the dead bone or foreign material. This protective mode of growth shields bacteria from antibiotic agents and host defence mechanisms, and enables the infection to persist. The concept of biofilm science must be applied to the diagnosis, treatment, and prevention of chronic orthopaedic infection

Predisposing factors: -Vascular insufficiency -disordersgenitourinary infections -respiratory infections -IV drug use -immunocompromising diseases -history of blood- stream infections -Indwelling prosthetic devices

Open wounds/fractures

Microorganisms gain entryby way of blood

Microorganisms lodge intoan area where circulation slows 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 Involcrum

Separation of devitalized bone from living bone

Continues to be an infected island drainage from sinus tracts Difficulty to reach by blood borne antibiotics Chronic stage

Enlarged sequestrum

Development of sinus tract

Sequestrum move out to the soft tissue

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

Turns to scar tissue

revascularized

Site for continued microorganism growth

Removal by the normali mmune process healing

Remission and exacerbation

amputation

Pain Fever HA Erythema Sinus Tract Limp

Tenderness Nausea/Vomiting Swelling Drainage Fluctuence

Diagnosing osteomyelitis Physical examination To confirm a diagnosis of suspected osteomyelitis, your GP will first carry out a physical examination of your affected body part to check for signs of redness, swelling and tenderness. They will want to know about your recent medical history, such as whether you have recently had an injury, surgery or a previous infection. Blood test Your GP may refer you for a blood test. This cannot confirm osteomyelitis, but it can indicate whether you have a high number of white blood cells in your blood, which may suggest that

you have an infection. Also, if the osteomyelitis was caused by bacteria spreading in your blood, a blood test may be useful for detecting the bacteria. Imaging tests If osteomyelitis is suspected, it is likely that you will be referred for further imaging testing. There are several imaging tests that may be able to detect bone damage caused by osteomyelitis. They include:

X-rays, in which low levels of radiation are used to create an image of the affected bone

magnetic resonance imaging (MRI) scan, which is where a strong magnetic field and radio waves are used to build up a picture of the inside of the affected bone

computerised tomography (CT) scan, which is where a series of X-rays of your affected bone are taken and a computer is used to assemble them into a more detailed three-dimensional image

ultrasound scan, which is where high-frequency sound waves are used to create an image of the affected bone to highlight any abnormalities

Biopsy If earlier testing suggests that you have osteomyelitis, it is usually necessary to remove a small sample of bone for further testing. This is known as a biopsy. A biopsy is usually necessary to confirm a diagnosis of osteomyelitis and it can help to establish the exact type of bacteria or fungus that is causing your infection. This can be very useful when deciding on the most effective treatment. A biopsy is usually combined with surgery in chronic cases

Diferential diagnosis 1. 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. 2. 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). 3. 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. 4. 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 Two classification systems are commonly used for osteomyelitis. Waldvogel et al (1970) classified bone infections based on pathogenesis and proposed the original osteomyelitis staging system. This system groups bone infections as either

hematogenous or osteomyelitis secondary to a contiguous focus of infection. Contiguousfocus osteomyelitis is further classified based on the presence or absence of vascular insufficiency. Both hematogenous and contiguous focus may then be classified as either acute or chronic.[23] The staging system designed by Cierny-Mader et al (2003) is more recent and more commonly used. It considers host immunocompetence in addition to anatomic osseous involvement and histologic features of osteomyelitis.[24, 1]

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 therapy.

The second part of the Cierny-Mader classification system describes the physiologic status of the host.
o o

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.

In 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. Other classification systems for long bone osteomyelitis Gordon classification classifies long bone osteomyelitis based on osseous defects. The system uses infected tibial nonunions and segmental defects.

Type A includes tibial defects and nonunions without significant segmental loss Type B includes tibial defects greater than 3 cm with an intact fibula Type C includes tibial defects of greater than 3 cm in patients without an intact fibula The Ger classification is used to address the physiology of the wound in osteomyelitis, which is categorized as simple sinus, chronic superficial ulcer, multiple sinuses, or multiple skinlined sinuses. Bone infection persists if appropriate wound management is not undertaken. It is important to cover open tibial fractures with soft tissue early in the disease to prevent infection and ulceration. The Weiland classification categorizes chronic osteomyelitis as a wound with exposed bone, positive bone culture results, and drainage for more than 6 months. This system also considers soft tissue and location of affected bone. It does not recognize chronic infection if wound drainage lasts less than 6 months.

Type I osteomyelitis was defined as open exposed bone without evidence of osseous infection but with evidence of soft-tissue infection.

Type II osteomyelitis showed circumferential, cortical, and endosteal infection, demonstrated on radiographs as a diffuse inflammatory response, increased bone density, and spindle-shaped sclerotic thickening of the cortex. Other radiographic findings included areas of bony resorption and often a sequestrum with a surrounding involucrum. Type III osteomyelitis revealed cortical and endosteal infection associated with a segmental bone defect

Therapy Treating acute osteomyelitis Acute osteomyelitis can usually be successfully treated using antibiotics

These medicines are usually given as a six-week course. For part of the treatment course you will need to take the medicine intravenously (directly into a vein). Depending on your general state of health, you may need to stay in hospital during this time. Otherwise, you may be able to receive the injections as an outpatient (where you go home the same day). You will usually be able to switch to tablets for the rest of the treatment course once you are well. In cases of osteomyelitis, there is usually a choice of antibiotics available to treat the infection and often two antibiotics are used in combination. This is known as dual therapy. Occasionally, the bacteria causing the infection are resistant to standard antibiotics and lessfrequently-used antibiotics are needed. A much less common cause of osteomyelitis is a fungal infection. In cases of fungal osteomyelitis, an antifungal medication called voriconazole is usually the treatment of choice. Treating chronic osteomyelitis People with chronic osteomyelitis will usually require a combination of antibiotics medication and surgery to remove any damaged bone. A surgeon may need to make an incision (cut) near the site of the infection to drain away any pus. If there is extensive bone damage, it will be necessary to surgically remove any diseased bone and tissue. This procedure is known as debridement. Debridement can often leave an empty space in the bone, which is sometimes packed with antibiotic-loaded cement. If the surgeon does this, a second operation will be required to remove the cement within a few weeks of the first. Not all centres use cement and no difference is found in the clearance of infection. In some cases, it may also be necessary to transfer muscle and skin from another part of the body to repair the tissue surrounding the affected bone. Hyperbaric oxygen therapy Some researchers have argued that a type of non-surgical treatment called hyperbaric oxygen therapy may be useful in treating cases of both acute and chronic osteomyelitis that do not respond to conventional treatment. During hyperbaric oxygen therapy, you are placed in a specially designed chamber that is similar to a decompression chamber used by divers.

The chamber is filled with oxygen, which is administered at a much higher pressure (hyperbaric) than the normal level of oxygen in the atmosphere. The high levels of oxygen are thought to speed up the healing process and slow the spread of infection. There is currently only limited evidence supporting the effectiveness of hyperbaric oxygen therapy for treating osteomyelitis. From the evidence available, it would appear that it is most effective in treating osteomyelitis associated with a diabetic foot ulcer.

The most common treatments for osteomyelitis are antibiotics and surgery to remove portions of bone that are infected or dead.

Medications A bone biopsy will reveal what type of germ is causing your infection, so your doctor can choose an antibiotic that works particularly well for that type of infection. The antibiotics are usually administered through a vein in your arm for at least six weeks. Side effects may include nausea, vomiting and diarrhea.

Surgery Depending on the severity of the infection, osteomyelitis surgery may include one or more of the following procedures:

Drain the infected area. Opening up the area around your infected bone allows your surgeon to drain any pus or fluid that has accumulated in response to the infection.

Remove diseased bone and tissue. In a procedure called debridement, the surgeon removes as much of the diseased bone as possible, taking a small margin of healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that shows signs of infection also may be removed.

Restore blood flow to the bone. Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your body. Sometimes temporary fillers are placed in the pocket until you're healthy enough to undergo a bone graft or tissue graft. The graft helps your body repair damaged blood vessels and form new bone.

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

The underlying factors that often cause osteomyelitis, such as poor circulation or a weakened immune system, can be difficult to treat, particularly if you have severe diabetes or HIV. Therefore, if you have had a previous episode of osteomyelitis, there is a chance that it could return. The risk factors for recurring osteomyelitis vary depending on your circumstances. It may be possible to reduce your risk by making lifestyle changes, such as lowering the amount of saturated fat in your diet and by taking precautions against infection.

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.

Septic arthritis. In some cases, infection within bones can spread into a nearby joint. Impaired growth. 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.

Skin cancer. 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

REFERENCES 1) Reksoprodjo S, kumpulan ilmu bedah bahagian kedokteraan FKUI 1st edition Jakarta;binarupa aksara Pub sept 2002 2) Apley, A. Graham et al. Buku Ajar Ortopedi dan Fraktur Sistem Apley edisi ke-7. Widya Medika. Jakarta : 1995 3) Advanced Trauma Life Support 6th ed. American College of Surgeons Committee on Trauma. USA: 1997. 4) medscape, osteomyelitis(online), 2012 july 30 available from URL: http://emedicine.medscape.com/article/1348767-overview#a0112 5) NHS.UK: different between acute and chronic osteomyelitis, 2012 july 30 available from URL: http:// www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspx 6) Mayoclinic, Osteomyelitis, 2012 Agust 1 available from URL: http://www.mayoclinic.com/health/osteomyelitis/DS00759/ 7) Orthopedic examination 2012 Agust 1 available from URL: http://www.netterimages.com/image/8246.htm