OSTEOMYELITIS

DEFINITION
Osteomyelitis is an infection and inflammation of the bone and bone marrow, a rare but serious condition. Bones
can become infected in a number of ways: Infection in one part of the body may spread through the bloodstream into
the bone, or an open fracture or surgery may expose the bone to infection.

RISK FACTORS

 Causative organisms: it can be caused by a variety of microbial agents staphylococcus aureus, E.coli,
pseudomonas, Klebsiella, salmonella and proteus.
 Age above 50 years adults
 Obese and malnourished patients.
 Diabetes (most cases of osteomyelitis stem from diabetes)
 Sickle cell disease
 HIV or AIDS
 Rheumatoid arthritis
 Intravenous drug use
 Alcoholism
 Long-term use of steroids
 Haemodialysis
 Poor blood supply
 Recent injury
 Post-operative surgical infections.
 Prolonged use of corticosteroid therapy or immuno suppressive drugs

CLASSIFICATION
It is classified on the basis of
↣ The causative organism
↣ Onset of infection
↣ Anatomic location of the bone
↣ Pyrogenic bacteria
↣ Route
↣ Duration

According to the onset of disease

1 Acute infection
2. Chronic condition
Chronic OM is often defined as OM that has been present for more than one month. In reality, there are no distinct
subtypes; instead there is a spectrum of pathologic features that reflect balance between the type and severity of the
cause of the inflammation, the immune system and local and systemic predisposing factors.
 Suppurative osteomyelitis.
 Acute osteomyelitis
 Chronic suppurative osteomyelitis
 Primary [ no preceding phase]
 Secondary [follows an acute phase]
 Non suppurative osteomyelitis
 Diffuse sclerosing
1
 Focal sclerosing [condensing osteitis]
 Proliferative periostitis [periostitis ossificans, Garre’s sclerosing osteomyelitis]
 Osteoradionecrosis

According to the involvement of bones or anatomical location

 Vertebral osteomyelitis
 Sternal osteomyelitis
 Tibia
 Femur
 Humerus
 Vertebra
 Maxilla
 Mandibular bodies

According to the organisms

 S. Aureus
 Enterobacter species
 Group A and B streptococcus species
 Haemophilus influenza
 Enterobacter species

PATHOPHYSIOLOGY

Bacteria contaminate the bone and multiply

initiate inflammatory and immune response

pus formation occur which followed by edema and vascular

congestion

infection travels from haversian canal in medullary cavity of bone

marrow to other segments of bone

periosteum of bone raised and distrupts blood vessels that enter

bone

ischemia of bone occurs which lead to bone tissue necrosis

bone abscess forms abcess cavity called sequestrum which doesnot

heal and collapse due to compromised vascualar system

new bone surrounds the sequestrum and it remains present

throughout the life of patient

chronic osteomylitis

2
CLINICAL MANIFESTATION

 Fever, irritability, fatigue

 Nausea
 Tenderness, redness, and warmth in the area of the infection
 Swelling around the affected bone
 Lost range of motion
 Pain in the area of the infection
 Drainage of pus through skin
 General discomfort, uneasiness, or ill feeling[malaise]
 Excessive sweating
 Change in gait
 Constant, pulsating pain present which increases during movement.

DIAGNOSITIC EVALUATION

 History collection
 Physical examination
 Blood tests [high wbc count]
 X-rays.
 MRI.
 Ct scan
 Culture of blood
 Needle aspiration
 Biopsy
 Bone scan

MANAGEMENT
Figuring out if a person has osteomyelitis is the first step in treatment. A bone biopsy is necessary to confirm a
diagnosis of osteomyelitis. This also helps determine the type of organism, typically bacteria, causing the infection
so the right medication can be prescribed.
Antibiotics help bring the infection under control and often make it possible to avoid surgery. People with
osteomyelitis usually get antibiotics for several weeks through an IV, and then switch to a pill form.
More serious or chronic osteomyelitis requires surgery to remove the infected tissue and bone. Osteomyelitis surgery
prevents the infection from spreading further or getting so bad that amputation is the only remaining option.
Treatment
 Antibiotics
 Surgery for abscess, constitutional symptoms, potential spinal instability, or much necrotic bone

Antibiotics
Antibiotics effective against both gram-positive and gram-negative organisms are given until culture results and
sensitivities are available.

For acute hematogenous osteomyelitis, initial antibiotic treatment should include a penicillinase-resistant
semisynthetic penicillin (eg, nafcillin or oxacillin 2 g IV q 4 h) or vancomycin 1 g IV q 12 h (when MRSA is
prevalent in a community) and a 3rd- or 4th-generation cephalosporin (such as ceftazidime 2 g IV q 8 h
or cefepime 2 g IV q 12 h).
3
For chronic osteomyelitis arising from a contiguous soft-tissue focus, particularly in patients with diabetes,
empiric treatment must be effective against anaerobic organisms in addition to gram-positive and gram-
negative aerobes. Ampicillin/sulbactam 3 g IV q 6 h or piperacillin/tazobactam 3.375 g IV q 6 h is commonly
used; vancomycin 1 g IV q 12 h is added when infection is severe or MRSA is prevalent. Antibiotics must be
given parenterally for 4 to 8 wk and tailored to results of appropriate cultures.

SURGICAL MANAGEMENT

If any constitutional findings (eg, fever, malaise, weight loss) persist or if large areas of bone are destroyed,
necrotic tissue is debrided surgically. Surgery may also be needed to drain coexisting paravertebral or epidural
abscesses or to stabilize the spine to prevent injury. Skin or pedicle grafts may be needed to close large surgical
defects. Broad-spectrum antibiotics should be continued for > 3 wk after surgery. Long-term antibiotic therapy
may be needed.

↣ Skin grafts
↣ Muscle and myocutaneous flaps
↣ Free bone transfer
↣ Papineau technique
↣ Hyperbaric oxygen therapy
↣ Vaccum dressing
↣ Sequestrectomy
 Resection of scarred and infection bone and soft tissue
 Radical debridement

Open surgery is needed for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is
removed or sometimes saucerization

 The objectives of the surgery are to drain any abscess cavity and remove all non-viable or necrotic tissue
 Subperiosteal abscess in an infant- several small holes drilled through the cortex into the medullary canal
 If intramedullary pus is found, a small window bone is removed
 Skin is closed loosely over drains and the limb splinted.
 Prior to the widespread availability and the use of antibiotics, blow fly larvae were sometimes deliberately
introduced to the wounds to feed on the infected material.

NURSING MANAGEMENT

 Maintain immobilization on the pain part, with bed rest.

 Elevate extremities experiencing pain
 Avoid use of sheets, plastic or pillow under extremity pain
 Evaluation of pain or discomfort. Note the location and characteristics, including intensity [ pain scale 1-10].
Noe the hint of pain and changes in vital signs of emotion or behaviour.
 Encourage patients to discuss issues in relation to infection in the bone.
 Perform range of motion exercises and watch passively or actively.
 Give alternative comfort measures such as massage, back or change in position.
 Encourage use of stress management techniques, such as progressive relaxation, breath excercises,
visualizations imagination, and therapeutic touch.
 Investigate any unusual pain or a sudden, progressive or bad location unrelieved by analgesics.
 Explain the procedure before performing nursing.
 Perform a cold compress first 24- 48 hours and as needed.
 Give analgesics as indicated.

4
COMPLICATIONS

 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 surgically removed (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.

CONCLUSION
Osteomyelitis is an infective process that encompasses all of the bone components, including the bone marrow.
The key to successful management is early diagnosis and appropriate surgical and antimicrobial treatment. A
multi-disciplinary approach is required, involving an orthopaedic surgeon, an infectious disease specialist, and a
plastic surgeon in complex cases with significant soft tissue loss.