OSTEOMYELITIS

The root words osteon (bone) and myelo (marrow) are combined with itis (inflammation) to define the clinical state in which bone is infected with microorganisms.

Osteomyelitis is an inflammation of bone caused by an infecting organism.

1. OSTEOMYELITIS Prepare by: RN Arpana Bhusal BNS

2. Introduction The root words osteon (bone) and myelo ( marrow ) are combined with itis ( inflammation ) to define the clinical state in which bone is infected with microorganisms. Osteomyelitis is an inflammation of bone caused by an infecting organism. It may remain localized, or it may spread through the bone to involve the marrow, cortex, periosteum , and soft tissue surrounding the bone. T he original site of infection is elsewhere in the body, and spreads to the bone by the blood. Bacteria or fungus may sometimes be responsible for osteomyelitis . Infection of the bone, most often of the cortex or medullary portion.

3. Classification Attempts to classify are based on (1)the duration and type of symptoms (2)the mechanism of infection Classification Duration Acute <2weeks Early acute - Late acute(4-5 days) Sub acute 2weeks—6weeks - Less virulent- more immune Chronic >6 weeks

4. Contd ……. ( 2)the mechanism of infection a. Exogenous : ( Trauma, Surgery, Iatrogenic) is caused by a pathogen from outside the body or the by the spread of infection from adjacent soft tissues. _ The organism is Staph aureus . _ Example- pathogens from open fracture. _ The onset is insidious: initially cellulites progressing to underlying bone . . Hematogenous :   caused by blood borne pathogens originating from infectious sites within the body . _ Ex: sinus, ear, dental, respiratory & GU infections. _ The infection spreads from the bone to the soft tissues & can eventually break through the skin , becoming a draining fistula. _ Again, Staph aureus is the most common causative organism.  

5. Causes _ Bone infection can be caused by bacteria (more common) or fungi (less common). _ Infection may spread to a bone from infected skin, muscles, or tendons next to the bone, as in osteomyelitis that occurs under a chronic skin ulcer (sore). The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood. _ A current or past injury may have made the affected bone more likely to develop the infection. A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone. _ children - long bones usually affected. _ Adults -- feet, vertebrae, and pelvis are most commonly affected.

6. Single pathogenic organism hematogenous osteomyelitis, Multiple organisms direct inoculation or contiguous focus infection. Staphylococcus aureus ---most commonly isolated pathogen. gram-negative bacilli and anaerobic organisms are also frequently isolated In infants: Staphylococcus aureus Streptococcus agalactiae Escherichia coli In children over one year of age: Staphylococcus aureus , Streptococcus pyogenes Haemophilus influenzae 1 Staphylococcus aureus is common organism isolated. 2 Etiology

7. Risk Factors - Diabetes Hemodylisis Injected drug use Poor supply of blood Recent trauma Spleenectomy

8. Acute Osteomylitis It can be primary ( hematogenous ) or secondary. Hematogenous osteomyelitis is the commonest and most often seen in children. Involvement of metaphysis of the long bones. Inseretion of blood vessels through diaphysis and reach up to growth plate.

9. Aetiopathogenesis Staphylococcus aureus is the commonest causative organism. Others, Streptococcus, Pneumococcus . It goes to the bone via the blood circulation. Primary focus of the infection is generally not detectable. Organism pass through the bone and get lodged in the metaphysis . Lower femoral metaphysis is the commonest site and others are, upper tibial , upper femoral and upper humeral metaphysis are also involved.

10. Pathogenesis: Direct inoculation of microorganisms into bone penetrating injuries and surgical contamination are most common causes Hematogenous spread usually involves the metaphysis of long bones in children or the vertebral bodies in adults Osteomyelitis Microorganisms in bone Contiguous focus of infection seen in patients with severe vascular disease . -Bone destruction. -Production of exudate and pus. -Accumulation of exudate in medullary cavity & spread out of it

11. Clinical Pictures Acute onset of pain and swelling at the end of a bone. Fever Infection of skin, tonsil O/E: Redness, heat Later stage abscess in the muscles or subcutaneous plane. arthritis

12. Diagnosis Blood: Polymorphonuclear leukocytosis , Elevated ESR & C/S. X-Ray: Periostal new bone deposition. Bone Scan

13. Treatment 1.General treatment: Nutritional therapy or general supportive treatment by intaking enough caloric, protein, vitamin etc. 2 . Antibiotic therapy 3. Surgical treatment 4. Immobilization Nade’s indications for surgery Abscess formation Severely ill & child with features of acute osteomyelitis Failure to respond to IV antibiotics for >48 hrs

14. Complications Septicemia, Pyaemia Chronic Osteomyelitis Acute pyogenic arthritis Pathological fracture Growth plate disturbance

15. Nursing Diagnosis Acute Pain related to inflammation and edema. Impaired physical mobility related to pain. Deficit knowledge related to the treatment regimen. Nursing Intervention Relieving Pain Improving physical mobility Controlling infectious process Educate patient about self care.

16. CHRONIC OSTEOMYELITIS Mr Yogendra Mehta BSN, MN(BPKIHS, TU,IOM) Lecturer

17. CHRONIC OSTEOMYELITIS The bone infection starts at least two months after an injury, initial infection, or the start of an underlying disease. It is infected dead bone within a compromised soft tissue envelope. The infected foci within the bone are surrounded by sclerotic, relatively avascular bone covered by a thickened periosteum and scarred muscle and subcutaneous tissue. Sinus track may be formed. Organisms in COM - staphylococcus aureus

18. Pathology End-artery branches of the nutrient artery are affected by etilogy Obstruction Avascular necrosis of bone tissue necrosis, breakdown of bone acute inflammatory response due to infection Squestra formation Chronic osteomyelitis

19. Clinical Features Skin and soft tissue integrity Red &Tenderness Affected bone deformed Neurovascular status of limb Presence of sinus Bone pain in affected area Chronic Fatigue Loss of movement of affected area

20. Diagnosis COM Based on Clinical features laboratory Imaging studies Laboratory COM Erythrocyte sedimentation rate C reactive protein WBC count only elevated in 35% Biopsy for histological and microbiological evaluation Staphyloccocus species Anaerobes and gram negative bacilli

21. Contd...... Plain X rays Cortical destruction Periosteal reaction Sequestra CT Scan Identifying sequestra Definition of cortical bone and surrounding soft tissues MRI Shows margins of bone and soft tissue oedema Evaluate recurrence of infection after 1 year Sinus tracks and cellulitis

22. Treatment of COM Surgical treatment Sequestrectomy Resection of scarred and infected bone and soft tissue Radical debridement Debridement I & D Stabilizing of affected bone by using metal , rods Adequate debridement leaves a dead space that needs to be managed to avoid recurrence, or bony instability Skin grafts, Muscle flaps Free bone transfer Hyperbaric oxygen therapy

23. Contd...... Antibiotics Resection of a segment of affected bone may be necessary to control infection Resection or excision for COM

24. Amputation for osteomyelitis Amputation indications include Arterial insufficiency Major nerve paralysis Non functional limb-stiffness, contracture Malignant change

25. Prevention Avoiding Infection Improving your health Stop Smoking Healthy diet Avoid Alcohol Daily Exercise

26. Nursing Management Nursing Diagnosis: Acute pain related to inflammation & swelling. Impaired physical immobility related to pain. Impaired skin integrity related to the effect of immobilization. Risk for infection related to abscess formation of bone, skin damage.

27. Contd ….. Nursing Intervention: Maintain immobilization on the pain part, with bed rest. Elevate limb experiencing pain. Avoid the use of sheets, plastic or pillow under extremity pain. Evaluation of pain or discomfort. Note the location and characteristics, including intensity. Encourage patients to discuss issues in relation to infection in the bone. 6. Perform range of motion exercises and watch passively or actively. 7. Give alternative comfort measures such as massage, back or change in position.

28. Contd ….. Nursing Intervention: 8. Encourage use of stress management techniques, such as progressive relaxation, breath exercises, visualizations imagination, and therapeutic touch. 9. Investigate any unusual pain or a sudden, progressive or bad location unrelieved by analgesics. 10. Explain the procedure before performing nursing care 11. Perform a cold compress first 24-48 hours and as needed. 12.Give analgesics as indicated. Pain scale 1-10). Note the hint of pain and changes in vital signs of emotion or behavior.

29. THANK YOU