bahan osteomyelitis
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OSTEOMYELITIS
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Defnition o Osteomyelitis
The root words osteon (bone) and myelo(marrow) are combined with itis(inammation)
Osteomyelitis is an inectious process thatinvolves bone and its medullary cavity which
leads to a subsequent Inammatory process.
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lassifcation
Based on onset!cutehronic
Source of
infection"emato#enous
onta#enous
Direct Inection
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!cute Osteomyelitis
• !cute haemato#enous osteomyelitis is mainlya disease o children
•$tiolo#y% &taph. aureus' #ramne#ative bacili'#roup streptococcus
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In infant: There is still a ree anastomosis
between metaphyseal and epiphyseal
blood vessel' inection can *ust aseasly lod#e in epiphysis.
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• !cute Osteomyelitis in babies inection maysettle near the very end o bone% *ointinection and #rowth disturbance easly ollow.
• In older children' metaphyseal inection isusual+ the #rowth disc acts as a barrier tospread
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In children:
Or#anisme usuallysettle in the methaphysis
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Infection in the metaphysis may spreadtowards the surace' to orm a subperiostealabscess
Some of the bone may die, and is encasedin periosteal new bone as a sequestrum
The encasing involucrum is sometimesperorated by sinuses
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,
Inammation
athology
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-atholo#y o
acute ostemyelitisInfammation
acute inammatoryreaction' vascularcon#estion' eudation ouid' infltration o -/0'increase o intraosseuspressure
Suppuration&ubperiosteal abscess' endplate and intervertebraldisc inection
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-atholo#y o
acute ostemyelitisNecrosis
avascular necrosis o#rowth plate in inant.
acterial toins andleucocytic en1ymesalso may play theirpart in the advancin#
tissue destruction.reactive new bone
ormation
resolution and healing.
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NEW BONE FO!"#ION0ew bone orms rom the deep layers o
the stripped periosteum.
This is typical o pyo#enic inection and is
usually obvious by the end o the secondwee2. 3ith rime the new bone thic2ens toorm an involucrum enclosin# theinected tissue and sequestra.
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NEW BONE FO!"#IONI the inection persists' pus and tiny
sequestrated splcules o bone maycontinue to dischar#e throu#h
perorations (cloacae) in the involucrumand trac2 by sinuses to the s2in suraces+the condition is now established as achronic osteomyelitis.
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ESO$%#ION
Once common' chronic osteomyelitisollowin# on acute is nowadays seldomseen.
I inection is controlled and intraosseouspressure released at an early sta#e' thisdire pro#ress can be aborted.
The bone around the 1one o inection isat frst osteoporotic (probably due tohypcraemia).
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&i#n 4 &ymptoms&i#ns and symptoms can vary si#nifcantly.
The patient' usually a child' presents withsevere pain' malaise and a ever
In inants' elderly patients' orimmunocompromised patients' clinical fndin#smay be minimal.
-ain and local tenderness are common
fndin#s.
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5aboratory The most certain way to confrm the clinical
dia#nosis is to aspirate pus rom themetaphyseal subperiosteal abscess or the
ad*acent *oint. The 3 and 6- values are usually hi#h.
lood culture is positive in only about hal the
cases o proven inection.
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&ot tissue swellin# (early)' bone deminerali1ation(9:9< days)' sequestra (dead bone withsurroundin# #ranulation tissue)' and involucrum
(periosteal new bone) later.
/6I % etremely sensitive' even in the early phaseo bone inection' and can help to di=erentiate
between sottissue inection and osteomyelitis.
6adioscinti#raphy
&ensitive but not specifc.
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/ana#ement
&upportive treatment or pain anddehydration
&plinta#e o the a=ected part !ntibiotic therapy &ur#ical draina#e
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omplication
&uppurative arthritis -atholo#ical racture hronic osteomyelitis
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hronic Osteomyelitis
hronic osteomyelitis represents a continuation ounresolved acute inection
0ow days' it more requently ollows an openracture or operation.
>sual or#anisms are staphylococcus aureus'$scherichia coli' &treptococcus pyo#ens' -roteusand -seudomonas.
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&ta#in# ?or !dult hronic Osteomyelitis byierny et al. (;::@)
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-atholo#yone is destroyed or devitali1ed in a discrete area
at the ocus o inection.
avities containin# pus and pieces o dead bone(sequestra) are surrounded by vascular tissue'and beyond that by areas o sclerosis the result ochronic reactive new bone ormation.
The histolo#ical picture is one o chronicinammatory cell infltration around areas oacellular bone or microscopic sequestra.
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linical eatures-ain' pyreia' redness and tenderness have
recurred' or with a dischar#in# sinus.
There may be a seropurulent dischar#e andecoriation o the surroundin# s2in.
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5aboratory$&6 and white blood cell count may be
increased
Or#anisms cultured rom dischar#in# sinuses
should be tested repeatedly or antibioticsensitivity.
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Ima#in#7ray eaminationone resorption with thic2enin#
and sclerosis o surroundin# bone
"owever' there are mar2ed variation%there may be no more than
locali1ed loss o trabecculation'
or a area osteoporosis'
periosteal thic2enin#' sequestrashow up as unnaturally dense ra#ments.
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adioscintigrapb) with AAm Tc"D-reveals increased activity in boththe perusion phase and the bonephase.. It has relatively low
specifcity and other inammatorylesions can show similar chan#es.
In doubtul cases' scannin# with
Bacitrate or In labelledleucocytes may be morerevealin#.
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!I is etremely sensitive' evenin the early phase o boneinection' and can help todi=erentiate between sottissue
inection and osteomyelitis. The most typical eature is a
reduced intensity si#nal in T9
wei#hted ima#es.
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In!estigations
#he most certain wa) to con&rm theclinical diagnosis is to aspirate pus romthe metaph)seal subperiosteal abscess orthe ad1acent 1oint.
The white cell count and reactiveprotein values are usually hi#h and the
haemo#lobin concentration diminished+
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In!estigations
The $&6 also rises but it may ta2e severaldays to do so and it oten remainselevated even ater the inectionsubsides.
lood culture is positive in only about halthe cases o proven inection.
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"i#erential diagnosis
ellulitis
&treptococcal necroti1in# myositis
!cute suppurative arthritis
!cute rheumatism&ic2lecell crisis
BaucherCs disease
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Treatment
&upportive treatment or pain anddehydration+
&plinta#e o the a=ected part+
!ntibiotic therapy @ E wee2s+ and
&ur#ical draina#e
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$%TIBIOTI& T'E$TME%TOlder children and ft adult %
Staph)lococcus group?lucloacillin and usidic acid i.v 9 ;
wee2sOrally antibiotics @ E wee2s
hildren F < years - 2aemophilus groupand gram negatie organisms3ephalosporins 4ceuro'ime or ceota'ime5
i.v or orall) "mo'icillin(clavulanic acid combination
4co(amo'iclav* a 6(lactamase inhibitor5
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/ana#ement!ntibiotics
5ocal Treatment
Operation %
DebridementDealin# with the dead space&ot tissue cover
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omplication! patholo#ic racture
0on union or se#mental bone loss
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S(B$)(TE OSTEOMYELITIS
6elative mildness
The or#anism bein#less virulent(Staph)lococcus
aureusor ) and thepatient moreresistance (or both)+
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S(B$)(TE OSTEOMYELITIS
/ore variable ins2eletal distributionthan acuteosteomyelitis
The Distal emur andthe proimal anddistal tibia areavorite sites.
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$T*OLO+Y 3ell defned cavity in cancellous bone
#lairy seropurulent uid (rare pus)
avity is lined by #ranulation tissue o
miture o acute and chronicinammatory cells.
The surroundin# bone trabeculae areoten thic2ened
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)linical features The patient % child or adolescent
-ain near one o the lar#er *oints orseveral wee2s or even months
! limp or sli#ht swellin#' muscle wastin#and local tenderness
0ormal temperature to sli#ht hi#her
3hite cell count may be normal but $&6
is raised
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IM$+I%+-lain 76ay! circumscribed' oval or round cavity 9 ;
cm in diameter on tibia or emoralmetaphysis or in epiphysis or in cuboidal
bone (calcaneus)avity surrounded by halo o sclerosis (the
classic rodieGs abscess)/etaphysis lesion little or no periosteal
reactionDiaphysial lesion periosteal new bone
ormation and cortical thic2enin#
6adioisotope scan
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"I$+%OSISDi=erential dia#nosis % Osteoid osteoma
with appearance as mali#nant bonetumour
ertain eamination by iopsy orbacteriolo#ical culture.
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T'E$TME%Tonservative
Immobili1ation and antibiotics(ucloacillin and usidic acid) or E
wee2s than thereater or E 9; monthsurreta#e+ indicate or lesion ater biopsyand also or the case with no healin# withconservative treatment. !ntibiotics
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)*'O%I) OSTEOMYELITIS
The usual or#anisms (and with time thereis always a mied inection) are Staph.aureus* E. coti* S. p)ogenes* 7roteus and7seudomonas-
In the presence o orei#n implantsStaph. cpidermidis* which is normallynonpatho#enic' is the commonest o all.
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Pathology one is destroyed or devitali1ed in a
discrete area at the ocus o inection ormore di=usely alon# the surace o aorei#n implant.
avities containin# pus and pieces odead bone (sequestra) are surrounded byvascular tissue' and beyond that by areas
o sclerosis the result o chronic reactivenew bone ormation.
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Pathology The sequestra act as substrates
The histolo#ical picture is one o chronicinammatory cell infltration around areas
o acellular bone or microscopicsequestra.
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)hronic osteomyelitis chronic bone inection' with a persistentsequestrum' may be a sequel to acute osteomyelitis (a). /oreoften it ollows an open racture or operation (b). Occasionally itpresents as a brodieCs abscess (c).
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Clinical features
There may be a seropurulent dischar#eand ecoriation o the surroundin# s2in.
In posttraumatic osteomyelitis the bonemay be deormed or nonunited.
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Imaging
7ray eaminationBone resorption with thicening andsclerosis o surrounding bone* loss otrabeculation* area osteoporosis*
periosteal thicening* se8uestra* or thebone crudel) thicened and misshapen
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Imagingadioisotope scintigraph)
Sensitive but not speci&c. %sing 99m #c(2:7
or showing increased activit) o perusionand bone phase and ;
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Investigations
$&6 and blood white cellcount may beincreased+ are helpul
in assessin# the pro#resso bone inection but theyare not or dia#nostic.
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Investigations
Or#anisms cultured romdischar#in# sinusesshould be testedrepeatedly or antibiotic
sensitivity+ with time'they oten chan#e theircharacteristics andbecome resistant to
treatment.
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T*$%&S
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Breene'3. 0etterGs Orthopaedic 9st ed
!pley' !pleyGs &ystem O Orthopaedics !nd?ractures Hth $dition
&alter' 6obert ' /D' Tetboo2 o Disordersand In*uries o the /usculos2eletal system