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Lucban, Quezon
CHRONIC OSTEOMYELITIS
A Case Study
Submitted by:
Abrigo, Ellennor F.
Job, Genesis
Olaivar, Monique S.
Submitted to:
Prof. Caroline Murallon
A. GENERAL OBJECTIVES:
B. SPECIFIC OBJECTIVES:
CHAPTER II
Introduction of the Disease
Do what you love. Know your own bone; gnaw at it, bury it, unearth it, and gnaw it still.
-Henry David Thoreau
Eradication of the infection is difficult, and complications associated with both the
infection and their treatments are frequent. Our goals are to review the pathophysiology,
natural history, and management for children with chronic osteomyelitis within the
context of a developing world setting.
CHAPTER III
Anatomy and Physiology
There are, however, diseases and disorders that may adversely affect the
function and overall effectiveness of the system. These diseases can be difficult
to diagnose due to the close relation of the musculoskeletal system to other internal
systems. The musculoskeletal system refers to the system having its muscles attached
to an internal skeletal system and is necessary for humans to move to a more favorable
position.
Subsystems
Skeletal
Function
The Skeletal System serves as a framework for tissues and organs to attach
themselves to. This system acts as a protective structure for vital organs. Major
examples of this are thebrain being protected by the skull and the lungs being protected
by the rib cage.
Located in long bones are two distinctions of bone marrow (yellow and red). The
yellow marrow has fatty connective tissue and is found in the marrow cavity. During
starvation, the body uses the fat in yellow marrow for energy. The red marrow of some
bones is an important site for blood cell production, approximately 2.6 million red blood
cells per second in order to replace existing cells that have been destroyed by the liver.
[4]
Here all erythrocytes, platelets, and most leukocytes form in adults. From the red
marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their special
tasks.
Muscular
Tendons
Joints
Bursa
A bursa is a small fluid-filled sac made of white fibrous tissue and lined with
synovial membrane. Bursa may also be formed by a synovial membrane that extends
outside of the join capsule. It provides a cushion between bones and tendons and/or
muscles around a joint; bursa are filled with synovial fluid and are found around almost
every major joint of the body.
CHAPTER IV
Overview of the Disease
Definition
Causes
• An open injury to
the bone, such as an
open fracture with the
bone ends piercing the
skin.
• An infection from
elsewhere in the body,
such as pneumonia or a
urinary tract infection that has spread to the bone through the blood
(bacteremia, sepsis).
• A minor trauma, which can lead to a blood clot around the bone
and then a secondary infection from seeding of bacteria.
• Bacteria in the bloodstream bacteremia (poor dentition), which is
deposited in a focal (localized) area of the bone. This bacterial site in the
bone then grows, resulting in destruction of the bone. However, new bone
often forms around the site.
• A chronic open wound or soft tissue infection can eventually extend
down to the bone surface, leading to a secondary bone infection. (Black
and Hawks, 2005)
Risk Factors
Males are affected more often than females, often as a result of trauma.
Susceptibility to infection increases with IV drug use, diabetes,
immunocompromising diseases or a history of blood- stream infections. (Black
and Hawks, 2005)
Prognosis
Mortality/Morbidity
Chronic myelitis refers to a bone infection that persists for longer than 1
month or an infection that has failed to respond to the initial course of antibiotic
therapy. Systemic signs may be diminished, with local signs of infection more
common, including constant bone pain and swelling, tenderness and warmth at
the infection site. (Lewis, 2004)
Laboratory Studies
Laboratory
studies and X-rays or
bone scans are
important in the
definitive diagnosis of
osteomyelitis. Elevated
WBC and ESR, an
elevated level of C-
reactive protein (a protein that circulates in the blood and dramatically increases
in level when there is inflammation) usually occur. Along with clinical
manifestations, usually allow initial diagnosis and early treatment while the
physician waits for further evidence from blood cultures or needle aspirate
analysis. To diagnose a bone infection and identify the organisms causing it,
doctors may take samples of blood, pus, joint fluid, or the bone itself to test.
Usually, for vertebral osteomyelitis, samples of bone tissue are removed with a
needle or during surgery.
Elimination of the infecting organisms, both locally from the bone and
systemically from the body, is the major treatment goal for osteomyelitis. Prompt
treatment also prevents further bone deformity and injury, increases client
comfort, and avoids complications of impaired mobility. Surgery is initially
performed on the adult client with osteomyelitis to ensure effective debridement
and drainage, elimination if dead space, and adequate soft tissue coverage.
Antibiotics alone rarely resolve infection in adults, but they do work more
efficiently after surgical preparation of the treatment area. High doses of
parenteral antibiotics are frequently administered for 4 to 8 weeks to achieve a
bactericidal level in the bone tissue. Oral antibiotics are continued for another 4
to 8 weeks, with serial bone scans and ESR measurements performed to
evaluate the effectiveness of drug therapy. Open drainage wounds are packed
with gauze to promote drainage. If initial treatment is delayed or inadequate, the
necrotic bone separates from the living bone to form sequestra, which serves as
a medium for additional microorganism growth. Chronic osteomyelitis can result.
(Black and Hawks, 2005)
In the study, Jan Fritz, MD, from the department of radiology and
radiological science at Johns Hopkins University School of Medicine in Baltimore,
and colleagues reviewed two-plane radiographs, clinical findings and lab data for
13 children (median age, 13 years) with CRMO. They evaluated lesion depiction,
location and characterization and extraskeletal abnormalities, and compared MRI
findings with clinical and lab data and radiographic results.
VITAL INFORMATION
NAME: K.C.
ADDRESS: Caloocan City
AGE: 7 years old
SEX: Female
WEIGHT: 15.9 kg
NATIONALITY: Filipino
RELIGION: Roman Catholic
BIRTHDAY: April 03, 2002
STATUS: Child
ADMISSION DATE: March 22, 2010; 4:30 pm
WARD: Children’s ward
ATTENDING PHYSICIAN: Dr. Caltila
DIAGNOSIS: Chronic osteomyelitis: 3rd digit, right foot
A. GENERAL STUDY
General Appearance
Patient appears her stated age. She is awake sitting on bed with ongoing
IVF of D50.3NaCl 500cc to run for KVO @ 100cc level, inserted @ right basilic
vein. Patient is active and playful. Her right foot is slightly bigger than her left due
to inflammation process secondary to chronic osteomyelitis.
Body Structure
Other body parts look equal bilaterally and are in relative proportion to
each other.
Behavior
She has good eye to eye contact. She does attend and responds to
questions appropriately.
Initial V/S
Temperature: 36.3oC
Cardiac Rate: 79bpm
Respiratory Rate: 35bpm
B. PHYSICAL ASSESSMENT
Method Actual
Area Assessed Normal Findings Remarks
Used Findings
Skin
• Shape
Inspection >Convex to curvature >Convex to >Normal
curvature
Auricle
• Position Inspection >At the level of the >At the level of >Normal
external cantus of the the external
eyes cantus of the
eyes
Nose
Lips
Tongue
Neck
Thyroid glands
Heart
• Rate Auscultation >Regular rate(60-100) >Regular >Normal
rate(80bpm)
Abdomen
• Contour Inspection >Flat, rounded >Flat, rounded >Normal
Musculoskeletal
Two years PTA, patient had a small blister on the sole of the right foot.
Patient’s mother ignored the lesion for she perceived it as a minor cut only. No
treatment or consultation was done.
Two weeks PTA, patient’s mother noted swelling on the 3rd digit of the
right foot; this was associated with on and off fever.
On March 21, 2010, patient had high grade fever. They consult at a local
hospital and urinalysis was done. The patient was diagnosed of UTI, and was
given antibiotics and pain medications. They were referred to the Philippine
Orthopedic Center (POC) for chronic osteomyelitis.
On August 16, 2002, the patient was admitted to the Philippine Heart
Center after experiencing cyanosis and loss of breath PTA. On admission, she
was given oxygen and other unrecalled management according to her mother.
She was operated on October of the same year regarding her PDA condition.
Patient also had urinary tract infection (UTI) a year ago. She consulted to
a local doctor and was given antibiotics.
G. LABORATORY ANALYSIS
Direct entry osteomyelitis can occur at any age when there is an open wound
(e.g. penetrating wounds, fractures) and microorganisms gain entry to the body.
Osteomyelitis may also occur in the presence of a foreign body such as an implant or
an orthopedic prosthetic device (e.g. plate, total joint prosthesis ). After gaining entrance
to the bone by way of the blood, the microorganisms then lodge in an area of the bone
in which circulation slows, usually the metaphysis. The microorganisms grow, resulting
in an increase in pressure because of the nonexpanding nature of most bones. This
increasing pressure eventually leads to ischemia and vascular compromise of the
periosteum. Eventually the infection passes through the bone cortex and marrow cavity,
ultimately resulting in cortical devascularization and necrosis. Once ischemia occurs,
the bone dies. The area of devitalized bone eventually separates from the surrounding
living bone forming sequestra. The part of the periosteum that continues to have blood
supply forms new bone called involucrum. (Lewis, 2004)
Bacterial invasion
Neutrophil invasion/
Inflammatory response
Pain
Ischemic necrosis
Sequestra
Osteoblastic response
Involucrum
Osteomyelitis
I. NURSING CARE PLAN
Subjective: Risk for peripheral At the end of the nursing • Assess general • Provide basis for
neurovascular interventions, the patient condition of and understanding
• “Namamaga
dysfunction related will be able to maintain contributing factors to general, current
‘yung paa ko.” as
tointerruption of blood tissue perfusion as patient. situation of client.
verbalized
flow secondsary to evidenced by palpable • Evaluate • Decreased/absent
disease condition pulses, skin warm, presence/quality of pulse may reflect
Objective:
normal sensation and peripheral pulse distal vascular injury and
• slow healing of
stable vital signs. to injury via palpation. necessitates
lesion
immediate medical
• swelling of the
evaluation of
right foot
circulatory status.
• presence of
• Assess capillary • Return of color should
abscess on the
return, skin color, and be rapid (3-5 secs.).
right foot
warmth distal to White, cool skin
• weak pulse on
inflammation. indicates arterial
the right foot
impairment. Cyanosis
suggests venous
impairment.
• Maintain elevation of • Promotes venous
inflamed extremity drainage/decreases
unless contraindicated edema.
by confirmed
presence of
compartmental
syndrome.
• Investigate sudden • Osteomyelitis may
signs of limb cause damage to
ischemia, e.g., adjacent arteries, with
decreased skin resulting loss of distal
temperature, pallor, blood flow.
and increased pain. • Enhances circulation
• Encourage patient to and reduces pooling
routinely exercise of blood, especially in
digits/joints distal to the lower extremities.
inflammation.
Subjective: Impaired skin integrity • Examine the skin for • Provides information
• “May sugat po related to inflammatory At the end of the nursing open wounds, foreign regarding skin
ako sa paa” as response secondary to interventions, the patient bodies and circulation and
verbalized. disease condition will demonstrate discoloration. problems that may be
behaviors/techniques to caused by edema
Objective: prevent skin formation that may
breakdown/facilitate
• disruption of skin require further
healing as indicated. medical intervention.
surface of the
lower extremity • Demonstrate good • Maintaining a clean,
• destruction of skin hygiene, e.g., dry skin provides a
skin wash thoroughly and barrier to infection.
layers/tissues of pat dry carefully. Patting skin dry
the right foot instead of rubbing
• reports of pain, reduces risk of dermal
pressure in trauma to fragile skin.
affected/ • Discuss importance of • These provide patient
surrounding area adequate nutrition information how
• invasion of body especially fluids, nutrition could elevate
structures proteins, vitamins B her chances of a
• with purulent and C, iron and faster recovery and
discharge on the calories. wound healing.
right foot • Establish a turning or • This provides the
repositioning patient’s guide
schedule. towards a proper skin
management
technique minimizing
more skin trauma.
• Emphasize principles • To avoid possible
of asepsis especially infection thus
hand washing and hindering the wound
avoidance of touching healing process.
wound with bare
hands.
• Demonstrate wound • To provide the patient
care technique such or patient’s SO on the
as wound cleansing. correct procedures
and techniques of
wound caring.
The doctor ordered for her CBC, ESR, CRP, CT, BT, PT, PTT and UA. The
patient also underwent x-ray of her right foot.
On March 29, 2010, the patient was for repeat UA, CBC, ESR, and CRP.
Her antibiotic medication was continued; and IVF was the same. She was prescribed
paracetamol 250mg/5mL q4 and for temp. >=38.0oC.
CHAPTER VI
Evaluation
She does not experience any pain, fever and/or malaise though there is an
obvious swelling of her right foot and respiratory discharges scanty in amount, greenish
in color.
Patient was scheduled for surgery of her foot on March 31, 2010 but her doctor
delayed because of her intermittent condition of the heart as revealed by her x-rays, and
her lesion needs to be drained first. Her operation is still pending.
Bibliography
Radiology: Whole-body MR useful in detecting rare bone disease. Molecular Imaging. 10 September
2009. 03 April 2010 <http://www.molecularimaging.net/index.php?option=comarticles&view
=article&id=18689:radiology-whole-body-mr-useful-in-detecting-rare-bone-disease>
Human musculoskeletal system. Wikipedia, The Free Encyclopedia. 26 March 2010. 03 April 2010.
< http://en.wikipedia.org/wiki/Human_musculoskeletal_system>
Chronic Osteomyelitis In Children. Global Help. June 2005. 03 April 2010 < http://www.global-
help.org/publications/articles/article_chronicosteomyelitis.html