I. INTRODUCTION DEFINITION Osteomyelitis is an infection of the bone.

The bone becomes infected by one of three modes: Extension of soft tissue infection Direct bone contamination from bone surgery, open fracture, or traumatic injury Hematogenous (blood borne) spread from other sites of infection. Osteomyelitis resulting from hematogenous spread typically occurs in a bone area or lowered resistance, possibly from subclinical trauma.

Postoperative surgical wound infections occur within 30 days after surgery. They are classified as incisional or deep. If an implant has been used, deep postoperative infections may occur within a year. Deep sepsis after arthroplasty may be classified as follows: Stage 1, acute fulminating: occurring during the first 3 months after orthopaedic surgery; frequently associated with hematoma, drainage, or superficial infection Stage 2, delayed onset: occurring between 4 and 24 months after surgery Stage 3, late onset: occurring 2 or more years after surgery, usually as a result of hematogenous spread Bone infections are more difficult to eradicate than soft tissue infections because the infected bone becomes walled off. Natural body immune responses are blocked, and there is less penetration by antibiotics. Osteomyelitis may become chronic and may affect the patients quality of life.

ETIOLOGY Staphylococcus aureus causes 70% to 80% of bone infections. Other pathogenic organisms frequently found in the osteomyelitis include Proteus and Pseudomonas species and Escherichia coli. The incidence of penicillin-resistant, nosocomial, gramnegative, and anaerobic infections is increasing.

PATHOPHYSIOLOGY

The initial response to infection is inflammation, increased vascularity, and edema. After 2 to 3 days, thrombosis of the blood vessels occurs in the area, resulting in ischemia with bone necrosis. The infection extends into the medullary cavity and under the periosteum and may spread into adjacent soft tissues and joints. Unless the infective process is treated promptly, a bone abscess forms. The resulting abscess cavity contains dead bone tissue (the sequestrum), which does not easily liquefy and drain. Therefore, the cavity cannot collapse and heal, as occurs in soft tissue abscess. New bone growth (the involucrum) forms and surrounds the sequestrum. Although healingappears to take place, a chronically infected sequestrum remains and produces recurring abscess throughout the patients life. This referred to as chronic osteomyelitis.

CLINICAL MANIFESTATIONS 1. Localized bone pain 2. Tenderness, heat and edema in the affected area. 3. Guarding of the affected area 4. Restricted movement in the affected area 5. Systemic symptoms High fever and chills acute osteomyelitis Low grade fever and general weakness chronic osteomyelitis

6. Necrosis of bone tissue (sequestrum) and drainage from wound site may be present 7. WBC and ESR are elevated

RISK FACTORS Poorly nourished Elderly Obese Impaired immune systems With chronic illness (diabetes, rheumatoid arthritis)

Receiving long-term corticosteroid therapy

II. DIAGNOSTIC PROCEDURES Test WBC count plain radiograph of affected area blood cultures ESR CRP cultures from aspiration of joint/abscess cultures from bone after debridement Tests to consider Test sinus-tract cultures MRI of joint CT of joint radionuclide scans Result positive infected areas typically appear with decreased signal intensity on T1-weighted images and increased signal intensity on T2weighted images axial scans demonstrate abnormal thickening of affected cortical bone, sclerotic change, encroachment of the medullary cavity, and abnormal chronic sinus drainage increased flow activity, blood pool activity, and positive signs of uptake on images taken 3 hours after injection of methylene diphosphonate Result may be elevated infected areas typically appear dark; soft tissue swelling, periosteal thickening, and focal osteopenia may be apparent; lytic changes are late changes positive elevated (>70 mm/hour) elevated (>95.2 nanomols/L [>10 mg/L]) positive positive

III. MEDICAL MANAGEMENT 1. Analgesics (narcotic and non-narcotic) 2. Antibiotics 3. Dressing change sterile technique 4. Maintain proper body alignment and change position frequently to prevent deformities 5. Immobilization of affected part 6. Provide a diet high in CHON

IV. SURGICAL MANAGEMENT Incision and drainage of bone abscess Sequestrectomy removal of dead, infected bone and cartilage Bone grafting after repeated infections involves placement of bone tissue for healing, stabilization of placement Amputation

V. NURSING MANAGEMENT RELIEVNG PAIN The affected part may be immobilized with a splint to decrease pain and muscle spasm. Monitor for neurovascular status of affected extremity. Affected extremity should be handled with great care and gentleness. Elevation reduces swelling and associated discomfort. Give/administer prescribed analgesics and other pain reducing techniques. IMPROVING PHYSICAL MOBILITY Explain the rationale for the activity restrictions.
Encourage full participation in ADLs within the physical

limitations to promote general well-being. CONTROLLING THE INFECTIOUS PROCESS The nurse monitors the patients response to antibiotic therapy and observes the IV access site for evidence of phlebitis, infection, or infiltration.

 With long-term, intensive antibiotic therapy, the nurse monitors the patient for signs of superinfection (ex. Oral or vaginal candidiasis, loose or foul-smelling stools). Change the dressings using aseptic technique. If surgery is necessary, the nurse takes measures to ensure adequate circulation, to maintain needed immobility, and to comply with weight bearing restrictions. Encourage to eat food rich in protein and vitamin C. Encourage adequate hydration.

OSTEOMYELITI