CHRONIC OSTEOMYELITIS

INTRODUCTION

Osteomyelitis is a local or generalized pyogenic disease of the bone, bone marrow and surrounding tissue. In children, the disease usually results from untreatedacute hematogenous osteomyelitis. Chronic osteomyelitis may also be seen after traumatic injuries, especially in times of civil unrest or war, or as a complication of surgical procedures such as open reduction and internal fixation of fractures. The long bones are affected most commonly, and the femur and tibia account for approximately half of the cases. Predisposing factors include poor hygiene, anemia, malnutrition, and a coexisting infectious disease burden (parasites, mycobacteria, acquired autoimmune deficiency syndrome), or any other factors that decrease immune function. Chronic osteomyelitis is defined by the presence of residual foci of infection (avascular bone and soft tissue debris), which give rise to recurrent episodes of clinical infection. 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. Osteomyelitis (Osteo derived from the Greek word osteon meaning bone, myelo meaning marrow and itis meaning inflammation) simply means an infection of the bone or bone marrow. It can usually subclassified on the basis of the causative organism (pyogenic bacteria or mycobacteria), the route, duration and anatomic location of the infection.

ANATOMY & PHYSIOLOGY

Human musculoskeletal system A musculoskeletal system (also known as the locomotor system) is an organ system that gives animals (including humans) the ability to move using the muscular and skeletal systems. The musculoskeletal system provides support form, support, stability and movement to the body. It is made up of the bodys bone (the skeleton), muscles, cartilage, tendons, ligaments, joints and other connective tissues (the tissue that supports and binds tissues and organs together). The musculoskeletal systems primary functions include supporting the body, allowing motion and protecting vital organs. The skeletal portion of the systems serves as the main storage system for calcium and phosphorous and contains critical components of the hematopoietic system. This system describes how bones are connected to other bones and muscle fibres via connective tissue such as tendons and ligaments. The bones provide the stability to a body in analogy to iron rods in concrete construction. Muscles keep bones in place and also play a role in movement of the bones. To allow motion different bones are connected by joints. Cartilage prevents the bone end from rubbing directly on to each other. Muscles contract (bunch up) to move the bone attached to the joint.

Tendons A tendon is a tough, flexible band of fibrous connective tissue that connects muscles to bones. Muscles gradually become tendon as the cells become closer to the origins and insertion on bones, eventually becoming solid bands of tendon that merges into the periosteum of individual bones. As muscles contract, tendons transmit the forces to the rigid bones, pulling on them and causing movement. Joints, ligaments and bursae Joints Joints are structures that connect individual bones and may allow bones to move against each other to cause movement. There are two divisions of joints, diarthroses which allow extensive mobility between two or more articular heads, and false joints or synarthroses, joints that are immovable, that allow little or no movement and predominantly fibrous. Synovial joints, joints that are not directly joined, are lubricated by a solution called synovial that is produced by the synovial membranes. This fluid lowers the friction between the articular surfaces and is kept within articular capsule, binding the joint with its taut tissue.

Ligaments A ligament is a small band of dense, white, fibrous elastic tissue. Ligaments connect the end of bone together in order to form a joint. Most ligaments limit dislocation, or prevent certain movements that may cause breaks. Since they are only elastic they increasingly lengthen when under pressure. When this occurs the ligament may be susceptible to break resulting in an unstable joint. Ligaments may also restrict some actions: movement such as hyperextension and hyperflexion are ligaments to an extent. Also ligaments prevent certain directional movement.

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.

PATHOPHYSIOLOGY

Direct entry osteomyelitis can occur at any age when there is an open wound(e.g. penetrating wounds, fractures) and microorganisms gai n 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, T he 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) Once formed, a sequestrum continues to be a infected island of bone surrounded by pus and difficult to reach by blood-borne antibiotics or white blood cells (WBCs).Sequestrum may enlarge and serve as a site for microorganisms that spread to other sites, including the lungs and the brain. The sequestrum can move out of the bone and into the soft tissue. Once outside the bone, the sequestrum may revascularize and then undergo removal by normal immune system process. Another possibility is that the sequestrum can be surgically removed through debridement of the necrotic bone. If the necrotic sequestrum is not resolved naturally or surgically, it may develop a sinus tract, resulting n a chronic purulent cutaneous drainage.(Lewis, 2004) Chronic osteomyelitis is either a continuous persistent problem (a r esult of inadequate acute treatment) or process of exacerbations and remission. Over time, granulation tissue turns to scar tissue. This vascular scar tissue provides an ideal site for continued microorganism growth in impenetrable to antibiotics. (Lewis, 2004)

History
PRESENT ILLNESS HISTORY: K.C a 7 years old, female had a small blister on the sole of the right foot. Patients mother ignored the lesion for she perceived it as a minor cut only. No treatment or consultation was done. after two weeks, patients mother noted swelling on the 3rd digit of the right foot; this was associated with on and off fever. On March 21, 2011, 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. PAST MEICAL HISTORY: The patient had a congenital heart defectpatent ductus arteriosus (PDA)and an inborn soft palpable mass on the upper right buttocks. 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.

stages

STAGE1: Acute fulminating-

occurring during the 1st 3months after orthopedic surgery; frequently associated with hematoma, drainage, or superficial infection.

STAGE2: Delayed onset-

occurring between 4 and 24months after surgery.

STAGE3: Late onset-

occurring 2 or more years after surgery, usually as a result of hematogenous spread

Clinical manifestation
Chronic Osteomyelitis refers to a bone infection that persists for longer than 1month or an infection that has failed to respond to the initial course of antibiotictherapy. 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.

LABORATORY EXAMINATION
composition March 23,11 Urinalysis: Color Light yellow Hazy 18-20 20-22 Amber to yellowish Clear 0-4 hpf Actual infection Pus cells March 23, 11 Blood Chemistry: leukocyte 22.2 4.5-10 x 10^ g/L 0-5 hpf

result

Normal result

interpretation

Nsg. responsibility

Transparency RBC

Monitor laboratory studies. Monitor the ff. for signs of infection. -Elevated temp. -Color of respiratory secretions -Appearance of urine Administer or teach use of antimicrobial drugs. Teach patient to wash hands often, especially after toileting, before meal sand after administering selfcare. Teach patient or caregiver thesigns & symptoms of infectionand when to report these tothe physician. Encourage to eat foods highin Vitamin C like citrus fruits.

NURSING CARE PLAN

ASSESSMENT
Subjective: Namamaga yung paa ng anak ko. as verbalized by the mother Objective: T: 36.3 CR: 79bpm RR:35bpm slow healing of lesion swelling of theright foot presence of abscess on theright foot weak pulse onthe right foo

diagnosis
Risk for peripheral neurovascular dysfunction Related to interruption of blood flow secondary to disease condition.

planning
At the end of the nursing interventions, the client will be able to maintain issue perfusion as evidenced by palpable pulses, skin warm, normal sensation and stable vital signs.

intervention

rationale
Provide basis for understandi ng general, current situation of client. absent pulse may reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Return of color should be rapid (3-5 secs.)White, cool skin indicates arterial impairment. Cyanosis suggests venousimpairme nt. Promotes venousdrainage/ decreases edema

evaluation

Assess general condition of and contributing factors to patient.

Evaluate presence of peripheral pulse distal to injury via palpation.

Assess capillary return, skin color, and warmth distal to inflammation.

Maintain elevation of inflamed extremity unless contrain dicated by confirmed presence of compartment al syndrome. Investigate sudden signs of limb ischemia, e.g., decreased skin temperature, pallor, and increased pain. Encourage patient to routinely exercise joints distal to inflammation. Investigate reports of pain, noting location and intensity (scale of 0-10), .

Promotes venous drainage/ decreases edema

Osteomyelitis may cause damage to adjacent arteries, with resulting loss of distal blood flow. Enhances circulation and reduces pooling of blood, especially in the lower extremities. Helpful in determining pain management and effectiveness of interventions.

Maintain bed rest or chair rest when indicated. Place pillows on affected area. Encourage frequent changes of position to move in bed, supporting affected joints above and below, avoiding jerky movt

Bed rest may benecessary to limitpain/injury to joints. Rests painful andmaintains neutralposition

Prevents generalfatigue and jointstiffness, stabilizes joint, decreasing jointmovements andassociated pain

MEDICAL MANAGEMENT

The objective of treating osteomyelitis is to eliminate the infection and prevent the development of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture, and chronic problems, so it is important to treat the disease the disease as soon as possible. Drainage: if there is an open wound or abscess, it may be drained through a procedure called needle aspiration. Medications: prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics help the body get rid of bacteria in the bloodstream that may otherwise reinfect the bone. Splinting or cast immobilization: this may be necessary to immobilize the affected bone and nearby joints in order to avoid further trauma and to help the area heal adequately and as quickly as possible. Surgery: most well-established bone infections are managed through open surgical procedures during which the destroyed bone is scraped out.

DRUG STUDIES
A.) Generic Name: Cefuroximem Brand Name: kefuroxs Specific Action: ANTIINFECTIVE;ANTIBIOTIC; SECOND-GENERATIONCEPHALOSPORIN Pharmacologic Action: Preferentially binds to one or more of the penicillin-binding proteins (PBP)located on cell walls of susceptible organisms. This inhibits 3rd and final stage of bacterial cell wall synthesis, thus killing the bacteria. Indication: It is effective for the treatment of penicillinase-producing Neisseria gonorrhoea (PPNG).Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitismedia, pharyngitis/tonsillitis,sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection. Contraindication: Hypersensitivity to cephalosporins and related antibiotics; pregnancy (categoryB), lactation. Adverse effect:

Body as a Whole: Thrombophlebitis(IV site); pain, burning, cellulitis (IM site); super infections, positive Coombs'test.

GI: Diarrhea, nausea, antibiotic-associated colitis. Skin: Rash, pruritus, urticaria. Urogenital :Increased serumcreatinine and BUN, decreased creatinine clearance

Nursing responsibility:

Determine history of hypersensitivityre actions tocephalosporins ,penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Inspect IM and IV injection site s frequently for signs of phlebitis. Report onset of loose stools or diarrhea .Although pseudomembranous colitis. Monitor I&O rates and pattern :Especially important in severely ill patients receiving high doses. Report any significant changes.

B.) Generic Name: Paracetamol Brand Name: Gandol Specific Action: NON-OPIOIDANALGESIC Pharmacologic Action: Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces anti pyresis by inhibiting the hypothalamic heat-regulating centre. Its weak antiinflammatory activity is related to inhibition of prostaglandin synthesis in the CNS. Indication: To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring down a high temperature. For this reason, paracetamol can be given to children after vaccinations to prevent post-immunisation pyrexia(high temperature).Paracetamol is often included in cough, cold and fluremedies. Contraindication: Hypersensitivity to acetaminophen or phenacetin; use with alcohol. Adverse effect: Side effects are rare with paracetamol when it is taken at there commended doses. Skin rashes, blood disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for along time. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs. Nursing Responsibility:

Assessment & DrugEffects - Monitor for S&S of:hepatotoxicity,even withmoderateacetaminophendoses, especiallyin individuals withpoor nutrition.

Patient & FamilyEducation - Do not takeother medications(e.g., coldpreparations)containingacetaminophenwithout medicaladvice;overdosing andchronic use cancause liver damage andother toxiceffects. - Do not self-medicate childrenfor pain morethan 5 d withoutconsulting aphysician.

COMPLICATION
When the bone is infected, pus is produced in the bone, which may result in an abscess. The abscess steals the bone's blood supply. The lost blood supply can result in a complication called chronic osteomyelitis. This chronic infection can cause symptoms that come and go for years. Other complications include: Need for amputation Reduced limb or joint function Spread of infection to surrounding tissues or the bloodstream

PROGNOSIS
Prognosis varies depending on how quickly an infection is identified, and what underlying conditions exist to complicate the infection. With quick, response treatment, only about 5% of all cases of acute osteomyelitis will eventually become chronic osteomyelitis. Patients with chronic osteomyelitis may require antibiotics periodically for the rest of their lives

NURSING MANAGEMENT

Protect the affected extremity from further injury and pain by supporting the limb above and below the affected area. Prepare the client for surgical treatment , such as debridement, bone grafting or amputation, as appropriate. Administer prescribed medications, which may include opioid and non-opioid analgesics and antibiotics. Promote healing and tissue growth. - Provide local treatments as prescribed (e.g. warm saline soaks, wet to dry dressings) - Provide a diet high in CHON and vitamin C and D.

PREVENTION
Elective orthopedic surgery should be postponed if the patient has a recent history of infection (eg, UTI, sore throat) or a recent history of infection. During orthopedic surgery, careful attention is paid to the surgical environment and to techniques to direct bone contamination. Prophylactic antibiotics, administered to achieve adequate tissue levels at the time of surgery and for 24hrs aft r surgery, are helpful. Urinary catheter and drains are removed as soon as possible to the incidence of hematogenous spread of infection.

recommendation
Monitoring a client should typically be monitored for recurrence of infection. Follow-up should be: Weekly (1st month after treatment), Every 2wks (2nd & 3rd months), every 2-3mos (month 6-24; can be reduced to annual follow-up after 13mos on physicians judgment. Client should be advised to practice good hygiene, avoid smoking, IV drug use, and in general, to be aware of signs of recurrence infection, such as renewed swelling, redness, fever, and pain.

REFERENCES

Classification of chronic osteomyelitis , Bogdan Maciuceanu1, Lucian P. Jiga1, Alexandru Nistor1, Jenel Patrascu2, Mihai Ionac (year 2005) http://www.tmj.ro/article.php?art=96594685124485 Anatomy an physiology, Elennor F. abrigo, Genesis Job, Monique S. olaivar. Summer affiliation 2010. http://www.scribd.com/doc/32119459/Chronic-Osteomyelitis Clinical manifestation, by lori newell (january 25, 2010)

http://www.livestrong.com/article/76453-chronic-osteomyelitis-symptoms/ http://www.peoples-health.com/osteomyelitis.htm
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Brunner text book 10th edition volume 2, Unit 15 (musculoskeletal Function) page 2064-2067

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Jordan, Floyd Louie Puchero, joana Marie Siruet, CrystHal Solano, hannah ruth

BSN 3A2-7

GROUP 27