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Osteomyelitis
- 1. Case conference 30/1/2017 Extern Chittranootliwluck Maharat Nakhon Ratchasima hospital
- 2. Patient profile • Male,15 year-old • CC :ปวดเข่าข้างขวา 1 เดือนก่อนมาโรงพยาบาล • PI : 1 เดือนก่อนมาโรงพยาบาล มีอาการปวดเข่าข้างขวา ปวดมาก ขึ้นเรื่อยๆ ไม่มีปวดร้าวไปไหน เข่าขวาบวม ไม่แดงหรือร้อน สังเกตว่ามี หนองไหล จากบาดแผลเดิม ไม่มีไข้ ไม่มีปวดตอนกลางคืน ไม่มีเบื่อ อาหารน้าหนักลด ไม่มีปวดข้ออื่นหรือปวดย้ายข้อ ไม่มีข้อติดตอนเช้า
- 3. • Past history: 1 ปีก่อนมาโรงพยาบาลเคยได้รับอุบัติเหตุมีกระดูก ต้นขาขวาหักร่วมกับกระดูกหน้าแข้ง ได้รับการใส่เหล็ก6 เดือน (DX:Open fracture right distal femur and right proximal tibia) • Last admit 13-19 /10/2016 remove plate and screw • Medication – None – No use herb or steroid, no drug allergy • Personal history – No smoking ,no alcohol drinking
- 4. Physical examination • GA: A Thai man, good conscious ,well co- operate • V/S BP 120/80 PR 128 RR 20 BT 37.5 • HEENT: not pale conjunctivae, anicteric sclerae • HEART: normal s1,s2 no murmur • Lung : clear both lung ,no adventitious sound • Abdomen : soft ,not tenderness
- 5. • Neurology :alert ,well co-operative ,motor grade 5 all extremity ,sensory intact , reflex 2+ all extremity • Musculoskeletal : – surgical wound along right anterior of femur to anterior of tibia, there are pus from sinus tract at right lower part of femur ,right knee swelling ,no redness , no warm, – tender around sinus tract ,limit ROM due to pain, not tenderness along joint line, ballottement test negative
- 6. • Differential diagnosis –Infection : cellulitis , pyomyositis , osteomyelitis ,bursitis , septic arthritis – Inflammation : gout, Charcot arthropathy
- 7. Investigation • CBC • ESR •CRP • Film X-ray • Anti-HIV • FBS • Blood culture and pus culture
- 8. • CBC – WBC13,400 /ul HGB 13.6g/dl – HCT 41.6% MCV 77.7fl – Platelet 357,000/ul NE 62.4% – LYM 19% MO 8.9% – EO 9.2% BA 0.5% • ESR 74mm/hr • CRP 49.5 mg/dl • Anti-HIV neg • FBS 86 mg/dl • Blood culture negative, pus culture negative
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- 14. treatment • Medication – Antibiotic: cefazolin 1 g IV q 6 hour – Pain control : morphine , paracetamol • Surgery – Sequestrectomy – Debridement
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- 16. Osteomyelitis • Osteomyelitis isan infectious process that involves bone and its medullary cavity. Bacteria are the usual causes of osteomyelitis • Infecting organisms may enter bones or joints in the following ways – hematogenous spread – external inoculation – extension from an adjacent structure that is infected
- 17. osteomyelitis • Osteomyelitis maybe classified as age , duration of symptoms , route of infection, causative organism
- 19. pathophysiology • Hematogenous – brushingour teeth ,impetigo, otitis media, pharyngitis, or pneumonia. Reticulo-endothelial defense mechanisms fail, however, bacteria may gain access to bone. In experimental studies, previous trauma – In children, the growth plate (transient bacteremia)
- 20. Osteoblast cell death Phagocytosis celland endothelial cell secrete osteoclast activating factor>>sinus day3 Purulent exudate extend to cortex, periosteum ( sub periosteal abscess) and subcutaneous tissue Involucum and sequestrum Joint capsule (hip,ankle,elbow ,shoulder)
- 24. Acute osteomyelitis • osteomyelitisis an infection that is diagnosed within 2 weeks of the onset of symptoms. • It is more common in males (2:1 ratio), is most often monostotic (>90%), and usually • involves the lower extremity (90%). Parents of children with this condition commonly • report that their children walk with a limp, or that they refuse to walk.
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- 26. investigation • CBC • ESR(48-72hr,3-5day),CRP(6hr,1week) • Film antero-posterior and lateral radiographs of the affected area • blood culture(30%) • aspiration of the affected area.(30-50%) • Urine analysis • Other : CT ,MRI, bone scan
- 29. Differential diagnosis • Softtissue infection • Charcot arthropathy • Osteonecrosis • Gout • Fracture • Bursitis • Malignancy • Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO)
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- 31. Age group pathogenantibiotics Neonate-6 month Group B streptococci, Gram-negative organisms flucloxacillin plus a third- generation cephalosporin like cefotaxime +- gentamycin 6month-6 years Haemophilus influenzae flucloxacillin and cefotaxime or cefuroxime. Older children and previously fit adult Staphylococcal infections intravenous flucloxacillin and fusidic acid. Elderly and previously unfit patients Gram-negative infections flucloxacillin and a second- or third-generation cephalosporin Patients with sickle-cell disease salmonella and/or other Gram- negative organisms third-generation cephalosporin or a fluoroquinolone like ciprofloxacin. Heroin addicts and immunocompromised patients Pseudomonas aeruginosa, Proteus mirabilis or anaerobic Bacteroides species) third-generation cephalosporins or a fluoroquinolone
- 32. Management • ATB3-6 weekor ESR<25mm/hr 3 week • IV ATB until the patient’s condition begins to improve and the CRP values return to normal levels which usually takes 2–4 weeks
- 34. complication • Epiphyseal damage •Suppurative arthritis • Metastatic infection • Pathological fracture • Chronic osteomyelitis
- 35. Subacute osteomyelitis • Clinical:fever , pain • ESR , CRP สูงไม่มาก H/C neg • Film lytic ,sclerotic border • IV ATB 1 week then oral high dose4-6 week
- 38. Chronic osteomyelitis • Sequestrum, involucum , chronic sinus drainage • Surgery: debridement sequestrectomy ,saucerization • IV ATB pre-op,post-op 7days then high does oral ATB untill 6 weeks or ESR<25
- 41. Take home message •Osteomyelitis , involucum , sequestrum • Early detection, prevention • Clinical fever, sign of inflammation (septic arthritis, juvenile rheumatoid arthritis , cellulitis, pyomyositis ) • ATB 3-6 week (IV 2-4 week then high dose oral form) broad-spectrum empiric therapy
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