OSTEOMYELITIS

Osteomyelitis is a bone infection usually caused by bacteria but sometimes by a fungus. When a bone is infected, the soft, inner part often swells. As the swollen tissue presses against the rigid outer wall of the bone, the blood vessels in the marrow may be compressed, reducing or cutting off the blood supply to the bone. Without an adequate blood supply, parts of the bone may die. The infection also can spread outward from the bone to form collections of pus in adjacent soft tissues, such as the muscles. The bone becomes infected by one of these three modes: 1. Extension of soft tissue infection 2. Direct bone contamination from bone surgery, open fracture, or traumatic injury 3. Hematogenous spread from other sites of infection Patients who are at high risk for osteomyelitis include those who are poorly nourished, elderly or obese. Also at risk are those patients with impaired immune system, or those with chronic illness, and those receiving long term corticosteroid therapy.

SYMPTOMS When the infection is bloodborne, the onset is usually sudden, occurring often with the clinical manifestations of septicemia such as; chills, high fever, rapid pulse and general malaise. The systemic symptoms at first may overshadow the local signs. As the infection extends through the cortex of the bone, it involves the periosteum and the soft tissues. The infected area becomes painful, swollen, and extremely tender. The patient may describe a constant, pulsating pain that intensifies with movement as a result of the collecting pus. When osteomyelitis occurs from spread of adjacent infection or from direct contamination, there are no signs of septicemia. The area is swollen, warm, painful and tender to touch. The patient with chronic osteomyelitis presents with a continuously draining sinus or experiences recurrent periods of pain, inflammation, swelling and drainage. The low-grade infection thrives in scar tissue, because it has reduced blood supply.

ANATOMY AND PHYSIOLOGY The health and proper functioning of the musculoskeletal system is interdependent with that of the other body systems. The bony structure provides protection to the vital organs, including the brain, heart and the lungs. The bony skeleton provides a sturdy framework to support body structures. The bone matrix also stores calcium, phosphorus, magnesium, and fluoride. In addition, the red bone marrow located within the bone cavities produces red and white blood cells in a process called hematopoiesis. Joints hold the bones together and allow the bone to move. The muscles attached to the skeleton contract, moving the bones and producing heat, which help to maintain body temperature. There are 206 bones in the human body, divided into four categories: Long bones (femur) Short bones (metacarpals) Flat bones (sternum) Irregular bones (vertebrae)

The shape and construction of the bone are determined by its function and the forces exerted on it. Bones are constructed of cancellous or cortical bone tissue. Bone is composed of cells, protein matrix, and mineral deposits. The cells are of three basic types--- the osteoblasts, osteocytes, and osteoclasts. Osteoblasts function in bone formation by secreting bone matrix. The matrix, which consists of collagen and ground substances, provides a framework in which inorganic mineral salts are deposited. Osteocytes are matured bone cells involved in bone maintenance functions; they are located in lacunae (bone matrix unit). Osteoclasts, located in the shallow Howships lacunae (small pits in the bone), are multinuclear cells involved in the destruction, resorption and remodeling of bone. Osteon is the microscopic functional unit of the bone. Covering the bone is a dense, fibrous membrane known as the periosteum. It nourishes bone and allows for its growth. It also provides for the attachment of tendons and ligaments. It contains nerves, blood vessels and lymphatics. The layer closer to the bone contains osteoblasts, which are bone forming cells. The endosteum is a thin, vascular membrane that covers the marrow cavity of long bones and the spaces in the cancellous bone. Bone marrow is a vascular tissue located in the medullary cavity of the long bones and in the flat bones. Red bone marrow, located mainly in the sternum, ilium, vertebrae, and in the ribs of adults is responsible for producing red and white blood cells. In adults, the long bone is filled with fatty, yellow marrow.

Bone begins to form long before birth. Ossification is the process by which the bone matrix is formed and hardening minerals are deposited on the collagen fibers. The collagen fibers give tensile strength to the bone, the calcium gives compressional strength.

ASSESSMENT FINDINGS Activity/ rest: weakness, fatigue, mobility problem Circulation: anemia, rapid pulse, delayed capillary refill on affected extremity, tissue swelling at the site, Integument:

DIAGNOSIS Symptoms and findings during assessment may suggest osteomyelitis. In acute osteomyelitis, early x-ray findings demonstrate soft tissue swelling. In about 2 weeks, areas of irregular decalcification, bone necrosis, periosteal elevation, and new bone formation are evident. Radioisotope bone scans, particularly the isotope labeled white blood cell scan, and magnetic resonance imaging help with early definitive diagnosis. Blood studies reveal an elevated leukocyte levels and an elevated sedimentation rate. Wound and blood culture studies are performed to identify appropriate antibiotic therapy. With chronic osteomyelitis, large, irregular cavities, raised periosteum, sequestra, or densed bone formations are seen on x-ray. Bone scans may be performed to identify areas of infection. The

sedimentation rate and the WBC count are usually normal. Anemia, associated with chronic infection may be evident. The abscess is cultured to determine the infective organism and the appropriate antibiotic therapy.