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Submitted by: Ma. Kay Bernadette T. Lumbab, RN
Fulminating Osteomyelitis
I. INTRODUCTION
DEFINITION
Osteomyelitis is an infection of the bone. The bone becomes infected by one of
three modes:
Extension of soft tissue infection
Direct bone contamination from bone surgery, open fracture, or traumatic
injury
Hematogenous (blood borne) spread from other sites of infection.
Osteomyelitis resulting from hematogenous spread typically occurs in a bone
area or lowered resistance, possibly from subclinical trauma.
Postoperative surgical wound infections occur within 30 days after surgery. They
are classified as incisional or deep. If an implant has been used, deep postoperative
infections may occur within a year. Deep sepsis after arthroplasty may be classified
as follows:
Stage 1, acute fulminating: occurring during the first 3 months after
orthopaedic surgery; frequently associated with hematoma, drainage, or
superficial infection
Stage 2, delayed onset: occurring between 4 and 24 months after surgery
Stage 3, late onset: occurring 2 or more years after surgery, usually as a
result of hematogenous spread
Bone infections are more difficult to eradicate than soft tissue infections
because the infected bone becomes walled off. Natural body immune responses are
blocked, and there is less penetration by antibiotics. Osteomyelitis may become
chronic and may affect the patients quality of life.
ETIOLOGY
Staphylococcus aureus causes 70% to 80% of bone infections. Other
pathogenic organisms frequently found in the osteomyelitis include Proteus and
Pseudomonas species and Escherichia coli. The incidence of penicillin-resistant,
nosocomial, gram-negative, and anaerobic infections is increasing.
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PATHOPHYSIOLOGY
The initial response to infection is inflammation, increased vascularity, and
edema. After 2 to 3 days, thrombosis of the blood vessels occurs in the area,
resulting in ischemia with bone necrosis. The infection extends into the medullary
cavity and under the periosteum and may spread into adjacent soft tissues andjoints. Unless the infective process is treated promptly, a bone abscess forms. The
resulting abscess cavity contains dead bone tissue (the sequestrum), which does
not easily liquefy and drain. Therefore, the cavity cannot collapse and heal, as
occurs in soft tissue abscess. New bone growth (the involucrum) forms and
surrounds the sequestrum. Although healingappears to take place, a chronically
infected sequestrum remains and produces recurring abscess throughout the
patients life. This referred to as chronic osteomyelitis.
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CLINICAL MANIFESTATIONS
1. Localized bone pain
2. Tenderness, heat and edema in the affected area.
3. Guarding of the affected area
4. Restricted movement in the affected area
5. Systemic symptoms
High fever and chills acute osteomyelitis
Low grade fever and general weakness chronic osteomyelitis
6. Necrosis of bone tissue (sequestrum) and drainage from wound site may
be present
7. WBC and ESR are elevated
RISK FACTORS
Poorly nourished
Elderly
Obese
Impaired immune systems
With chronic illness (diabetes, rheumatoid arthritis)
Receiving long-term corticosteroid therapy
II. DIAGNOSTIC PROCEDURES
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Tests to consider
Test Result
sinus-tract cultures positive
MRI of joint infected areas typically appear withdecreased signal intensity on T1-weightedimages and increased signal intensity on T2-weighted images
CT of joint axial scans demonstrate abnormal thickeningof affected cortical bone, sclerotic change,encroachment of the medullary cavity, andabnormal chronic sinus drainage
radionuclide scans increased flow activity, blood pool activity,and positive signs of uptake on images taken3 hours after injection of methylenediphosphonate
III. MEDICAL MANAGEMENT
1. Analgesics (narcotic and non-narcotic)
2. Antibiotics
3. Dressing change sterile technique
4. Maintain proper body alignment and change position frequently to prevent
deformities
5. Immobilization of affected part
Test Result
WBC count may be elevated
plain radiograph of affected area infected areas typically appear dark; softtissue swelling, periosteal thickening, andfocal osteopenia may be apparent; lytic
changes are late changesblood cultures positive
ESR elevated (>70 mm/hour)
CRP elevated (>95.2 nanomols/L [>10 mg/L])
cultures from aspiration of joint/abscess
positive
cultures from bone after debridement positive
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6. Provide a diet high in CHON
IV. SURGICAL MANAGEMENT
Incision and drainage of bone abscess
Sequestrectomy removal of dead, infected bone and cartilage
Bone grafting after repeated infections involves placement of bone
tissue for healing, stabilization of placement
Amputation
V. NURSING MANAGEMENT
RELIEVNG PAIN
The affected part may be immobilized with a splint to decrease
pain and muscle spasm.
Monitor for neurovascular status of affected extremity.
Affected extremity should be handled with great care and
gentleness.
Elevation reduces swelling and associated discomfort.
Give/administer prescribed analgesics and other pain reducing
techniques.
IMPROVING PHYSICAL MOBILITY
Explain the rationale for the activity restrictions.
Encourage full participation in ADLs within the physical
limitations to promote general well-being.
CONTROLLING THE INFECTIOUS PROCESS
The nurse monitors the patients response to antibiotic therapy
and observes the IV access site for evidence of phlebitis,
infection, or infiltration.
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With long-term, intensive antibiotic therapy, the nurse monitors
the patient for signs of superinfection (ex. Oral or vaginal
candidiasis, loose or foul-smelling stools).
Change the dressings using aseptic technique.
If surgery is necessary, the nurse takes measures to ensure
adequate circulation, to maintain needed immobility, and to
comply with weight bearing restrictions.
Encourage to eat food rich in protein and vitamin C.
Encourage adequate hydration.