Case report based on patient found in Hasan Sadikin Hospital Bandung. Patient is diagnosed with Osteomyelitis on right humerus

1. Case Report Session
Osteomyelitis
Pembimbing:
Dr. Yoyos Dias Ismiranto, dr. SpOT., M.Kes FICS
Penyusun: Devyashini Prabhakaran
Bagian Orthopedi dan Traumatologi
Fakultas Kedokteran
Universitas Padjadjaran
Bandung
2014

2. 1. Identitas Pasien
• Nama :Tn. DA
• Umur :30 thn
• Jenis kelamin : Laki-laki
• Agama : Islam
• Alamat : Kg. Babakan,RT 01, RW
06,Citapen, Cihampelas,
Bandung
• Status Pernikahan : Bernikah
• Pekerjaan : Buruh

3. • Anamnesa
KU: Keluar nanah dari lengan atas kanan
• Anamnesa khusus:
– 2 tahun SMRS, os mengeluh timbul bisul di
lengan atas kanan. Bisul pecah dengan
mengeluarkan nanah. 1 bulan yang lalu, os
dilakukan operasi pembersihan tulang dan
pemasangan selang antibiotik. Sekarang nanah
berkurang dan selang antibiotik nyeri
dilepaskan.

4. • Riwayat penyakit dahulu: Post op
debridement + sequestrectomy + AB beads
• Riwayat penyakit pada keluarga: tidak ada.

5. Pemeriksaan Fisik
Keadaan umum : Compos Mentis
Tanda vital
 Tensi : 100/70 mmHg
 Nadi : 80 x/menit
 Respirasi : 20 x/menit
 Suhu : 36,6 oC
Status Generalis
Kepala : Konjungtiva tidak anemis, Sklera tidak ikterik
Leher : KGB tidak teraba membesar
Dada : Bentuk dan gerak simetris, VBS ki=ka, rhonki (-/-)
wheezing (-/-),Bunyi jantung murni reguler
Abdomen : Datar dan lembut, Bising usus (+) normal, Hepar dan
lien tidak teraba, Ruang traube kosong
Ekstremitas : Lihat status lokalis

6. Status Lokalis:
a/r humerus
L : Scar (+),Swelling (+), pus (+), fistel (+)
F : NT (+), sensitibilitas dalam batas normal,
kapiler refil (+ <2 detik)
M : elbow stiffness 90°

7. Pemeriksaan Penunjang
• Lab Darah
• X-ray

8. • Tampak lesi litik dan
sklerotik pada 1/3 distal os
humerus dan 1/3 proximal
os radius.
• Tampak lesi periosteal pada
1/3 distal os humerus
kanan dan 1/3 proksimal os
radius kanan
• Kesan: menyokong suatu
osteomielitis kronis
Foto elbow

10. Foto Thorax
•Kesan: Cor dan pulmo tidak
tampak kelainan

11. Diagnosis kerja
• Post debridement + sequestrectomy + AB
beads due to chronis ostemomyelitis a/r
Humerus
Treatment
• Removal of AB beads and debridement

12. Prognosis
• Ad vitam : Bonam
• Ad fungtionam : Dubia ad bonam

13. Pembahasan Osteomyelitis

14. Definisi
• Suatu proses inflamasi akut ataupun kronis
daritulang dan struktur-struktur disekitarnya
akibatinfeksi dari kuman-kuman piogenik

15. Patogenesis
• Infeksi dapat berkembang melalui
beberapacara, yaitu :
– Penyebaran hematogen dari infeksi di bagian
tubuh lain (osteomielitis hematogen)
– Pembedahan jaringan tubuh terpapar
denganlingkungan sekitarnya (osteomielitis
esogenik)
– Luka penetrasi langsung (osteomielitis esogenik)

16. Insiden
• Osteomielitis akut hematogen : anak-anak
• Osteomielitis dari trauma direk /contiguous:
usiaremaja dan dewasa muda
• Spinal osteomielitis : usia > 45 tahun
• dapat pula ditemukan pada bayi dan ‘infant’
• Anak laki-laki > anak perempuan (4:1)
• Lokasi yang tersering : tulang-tulang panjang

17. Klasifikasi
• Menurut durasi (tradisional)
– Akut (7-14 hari)
– Subakut (14 hari -3 bulan)
– Kronik (> 3 bulan)
• Menurut etiologi dan kronisitas (Waldvogel)
– Hematogen
– Contiguous
– Kronik
• Menurut penyebaran anatomis (Cierny-Mader )
– Stadium I -Medular
– Stadium II -Cortex superfisial
– Stadium III- medular dan korteks terlokalisasi
– Stadium IV- Medular dan korteks difus

18. Presentasi klinis
• Osteomielitis hematogen
• Sesuai gejala dan tanda inflamasi akut
• Nyeri terlokalisasi
• Penderita menghindari menggunakan bagian
tubuhyang sakit
• PF : nyeri tekan lokal, pergerakan sendi terbatas,oedem
dan kemerahan jarang ditemukan
• Gejala sistemik : demam, malaise, menggigil, nafsu
makan menurun
• Lab : peningkatan CRP ,LED, dan leukosit

19. Presentasi klinis
• Osteomyelitis subakut
• Sering pada anak-anak
• Akibat kuman bervirulensi rendah tanpa gejala
• Gambaran radiologis :
– Seperti osteomielitis akut osteolisis dan elevasi
periosteal
– Seperti osteomielitis kronik zona sirkumferensial
tulangyang sklerotik

20. Presentasi klinis
• Osteomielitis kronik
• Akibat infeksi akut atau subakut yang tidak
diobati
• Ulkus persisten
• Fistel atau drainase pus
• Fatigue
• Malaise

21. Pemeriksaan Penunjang
• Pemeriksaan darah lengkap
• Kultur
• Fotopolos
• Ultrasound
• Radionuklir
• CT Scan
• MRI

22. Pemeriksaan radiologis
• Foto polos
– Osteomielitis awal : tidak ada kelainan radiologis
– 7-10 hari: area osteopeni yang mengarah ke destruksi tulang, tampak
reaksi periosteal
• Osteomielitis kronik
– Destruksi tulang yang masif
– Involukrum (new bone formation)
– Sequestrum (dead bone)
• Gas gangrene radiolusen
• USG
– Berguna untuk mengidentifikasi efusi sendi
– Baik digunakan utk osteomielitis akut pada pediatrik dapat
mendeteksi dalam 1-2 hari awal penyakit
– Soft tissue abses dan reaksi periosteal
– Tidak dapat mendeteksi infeksi korteks

23. Pemeriksaan radiologis
• CT Scan
– Digunakan pada tulang-tulang dengan anatomi
kompleks pelvis, calcaneum, sternum, vertebra
– Dapat mendeteksi kalsifikasi, osifikasi,
danabnormalitas intrakortikal
• Radionuklir
– Menggunakan technetium 99m
– Sangat sensitif namun tidak spesifik untuk infeksI
tulang

24. Diagnosis Banding
• Osteomielitis:
– Jaringan lunak terjadi pembengkakan yang difus
– 4-6 mingguuntukmenghancurkantulang
• Histiocytosis sel Langerhans:
– Tidak terlihatsecara signifikan
pembengkakan jaringan lunak atau massa
– 7-10 hari untukmenghancurkantulang
• Ewing Sarkoma
– Jaringan lunaknya terlihat sebuah massa
– 4-6 bulan untuk menghancurkan tulang

25. Penatalaksanaan
• Tirah baring
• Pertahankan keseimbangan cairan, elektrolit dan
status gizi
• Antipiretik bila demam, analgesik bila nyeri
• Antibiotika diteruskan hingga 6 minggu
– Ciprofloksasin, Ceftriaxone
– Ceftazidime, Ceftazolin, Nafcillin
• Evaluasi hasil terapi dengan pemeriksaan CRP dan
LED setiap minggu

26. Penatalaksanaan
• Intervensi bedah
– Menghilangkan semua jaringan mati dan benda
asing
– Sequestrum dibuang dengan meninggalkan
involukrum
– Debridemen kulit, subkutan, dan otot

27. Komplikasi
• Abses tulang
• Bakteremia
• Fraktur
• Selulitis
• Fistel

28. Surgical treatment

29. Bone Debridement:
• The goal of debridement is to leave healthy, viable
tissue.
• Débridement of bone is done until punctate bleeding
is noted, giving rise to the term the paprika sign.
• Copious irrigation with 10 to 14 L of normal saline.
• Pulsatile lavage using fluid pressures 50-70 pounds
per square inch and 800 pulses per min.
• The extent of resection is important in B hosts as B
hosts treated with marginal resection (i.e., with a
clearance margin of <5 mm) found to have a higher
rate of recurrence than normal hosts.
• Repeated debridements may be required.

30. Sequestrectomy and curettage. A, Affected bone is exposed, and sequestrum is
removed. B, All infected matter is removed. C, Wound is either packed open or closed
loosely over drains.

31. When to do sequestrectomy?
Early sequestrectomy
- Eradicate infection
-Better environment for periosteum to respond
Delayed sequestrectomy
-Wait till sufficient involucrum has formed before
doing a sequestrectomy to mimimize the risk of
fracture, deformity & segmental loss

32. Prerequisites for Sequestrectomy
Radiological
• Well formed
involucrum
surrounding the
discretely visible
sequestrum
adequately at least
2/3rd diameter of
bone (3 intact walls
on two views ensure
3/4th intact walls)
Clinical
• Symptomatic patient
with pus discharge or
chronic unreleaved
disabling pain due to
osteomyelitis per se
and type A/B host.

33. Management of Dead Space:
Antibiotic Beads
 May be used to sterilize and temporarily maintain a
dead space.
 Beads are made with PMMA+ab
 Cement -40 gm.
 Genta- 1-2 gm. or vanco 1-2 gm.
 Other antibiotics that can be used are Tobramycin,
Penicillin, cephalosporins, amikacin, vancomycin.
 The gentamycin concentration remain for 30 days
after implantation.
 The shape and type of methylmethacrylate has a
significant effect on the amount of antibiotic
delivery, as well as duration.
 The best delivery profile was with PMMA beads
impregnated with gentamicin.
 Usually removed within two to four weeks and are
replaced with a cancellous bone graft.

34. Antibiotic beads:
• Can act as a biomaterial surface to which bacteria
preferentially adhere.
• To avoid such a problem, biodegradable antibiotic-impregnated
(calcium sulfate) beads have been
employed recently and have shown favorable antibiotic
release kinetics
– Elution testing of 4% by weight loaded calcium
sulfate pellets revealed a maximum concentration
of 828 μg/ml and undetectable levels by day 15.
• Antibiotic-impregnated cancellous bone grafts were
recently used in a clinical trial of forty-six patients, and
the osteomyelitis was arrested in 95% of them

35. Management of Dead Space:
• Antibiotics (clindamycin and amikacin) have
also been delivered directly into dead spaces
with an implantable pump.
• Very high local and low systemic levels of
antibiotics have been achieved.

36. Soft-Tissue Coverage:
• Three methods commonly used:
– Primary closure- if no infection
– Let tissue heal by secondary intention
– Small soft-tissue defects may be covered with a split-thickness
skin graft.
– Local muscle flaps and free vascularized muscle flaps in
the presence of a large soft-tissue defect or an
inadequate soft-tissue envelope.
• Healing by so-called secondary intention should be
discouraged, since the scar tissue that fills the defect may
later become avascular.

37. Bone Stabilization:
• If skeletal instability is present at the site of an infection,
measures must be taken to achieve stability with
– Plates
– Screws
– Rods
– An external fixator
• External fixation is preferred over internal fixation because
– of the tendency of the sites of medullary rods to become
secondarily infected and to spread the extent of the
infection.
• Rigid fixation helpful in union of fracture sites.

38. Limb reconstruction:
• Ilizarov external fixation
– Is used for reconstruction of segmental defects and difficult infected
nonunions.
– Based on the technique of distraction osteogenesis whereby an
osteotomy created in the metaphyseal region of the bone is gradually
distracted to fill in the defect.
– Used for difficult cases of osteomyelitis when stabilization and bone-lengthening
are necessary.
– May also be used to compress nonunions and to correct malunions.

39. AMPUTATION:
• Infrequently performed
• INDICATIONS
1. Malignancy
2. Arterial insufficiency
3. Nerve paralysis
4. Jt. Contracture & stiffness making limb
nonfunctional