1. Osteomyelitis

2. Def – osteomyelitis is a severe pyogenic infection and inflammation of bone and surrounding tissues

3. Etiology Bacteria Viruses Fungi and parasites
Common microorganisms are S.aureus, streptococcus, hemophilus influenzae enterobacteria, salmonella
Entry of organism from an open wound or hematogenous spread

4. Risk factors
Soft tissue infections and direct bone contamination (surgery, gunshot)
Chronic illness
Diabetes or vascular disease
Alcohol or drug abuse
Immunosuppression
Elderly
Poorly nourished
Obese patients

5. Classification Based on mode of entry – classified in to
Exogenous osteomyelitis
Endogenous or hematogenous osteomyelitis
Based on the duration
Acute and chronic ostoemyelitis

6. Exogenous osteomyelitis
Onset is insidious
Caused by a pathogen outside the body or by the spread of infection from adjacent soft tissues.
Example – from an open fracture or a surgical procedure
can also caused by human and animal bites
The infection spreads from soft tissues to the bone

7. Hematogenous osteomyelitis
Caused by blood borne pathogens originating from infectious sites within the body
Example –from sinus, ear, dental, respiratory and genitourinary infections
In this the infection spreads from the bone to the soft tissues and eventually break through the skin becoming draining fistula
More common in children's and older adults

8. Pathophysiology In hematogenous osteomyelitis
Organisms reach the bone through the circulatory and lymphatic systems
Bacteria lodge in the small vessels of the bone
Inflammation
Blockage of the vessel causes thrombosis, ischemia and necrosis of bone
(femur, tibia, humerus and radius are commonly affected)

9. Bacteria and inflammation spread within the shaft of the bone and spread throughout the haversian systems and reach the periosteum
Subperiosteal abscess
Segmental bone necrosis sequestrum (dead piece of bone)
new bone laid down over the infected bone by osteoblasts is called as involucrum- opening in the involucrum allow infected material to escape into soft tissue

11. In exogenous osteomyelitis
Infection begins in soft tissues, disrupting muscle and connective tissue and eventually forming abscess

13. Clinical features
Acute osteomyelitis – less than one month in duration
CM of acute osteomyelitis are both systemic and local
Systemic – fever, night sweats, chills, restlessness, nausea and malaise
Local – severe bone pain unrelieved by rest and worse with activity, swelling, tenderness, warmth at the site
Later signs include drainage from sinus tracts to the skin and fracture site

14. Bone infection persists for longer than 4 weeks and also failed to respond to the initial treatment

15. Clenched fist
osteomyelitis

17. Complicaitons Sepsis Pathologic fracture and non union
Draining fistula
Shortening of the extremity
Amputation
Brodie’s abscesses – isolated encapsulated pockets of microorganisms surrounded by bone matrix –capable of reinfection at any time

18. Diagnostic measures
lab studies - elevated WBC, c-reactive protein (CRP) and erythrocyte sedimentation rate
BLOOD CULTURE – to find out the organisms
CT scan and radionuclide bone scan
X ray ,MRI, Bone biopsy
History collection
Physical examination

19. Management
Goals
Complete removal of dead bone and affected soft tissue
Control of infection
Elimination of dead space

20. Surgical management Debridement surgery To remove necrotic tissue
Removal of sequestrum and surrounding granulation tissue (sequestrectomy)
The dead space is later filled with, antibiotic beads (polymethylmethacrylate beads with either vancomycin, tobramysin or gentamicin),tissue flaps and bone grafts
Beads are usually removed after 2 to 4 weeks and reconstruction is performed

21. Osteomyelitis with fracture
Bone graft and internal or external fixation together
Ilizarov technique – helps in bone lengthening and reshaping.
Papineau technique - type of open bone grafting technique in which wounds are packed with cancellous bone with no attempt at soft tissue coverage.

27. Medical management Antipyretics and analgesics
Antibiotic therapy – penicillin, cephalosporin, clindamycin
Depends on the causative organism
2 to 4 weeks IV followed by 4 weeks oral medication
3 to 6 weeks in case of orthopedic implants
Hyperbaric oxygen therapy may be used

28. Nurisng management Maintain aseptic technique during dressing
Observes for signs and symptoms of complications
Timely medication – for effective action of antibiotics
Complete rest for early healing
Fracture prevention
Use splints and other assistive devices
ROM exercises to prevent contractures and functional deformities
Provide diet high in vitamins and proteins

29. Nsg diagnosis Acute pain Activity intolerance
Impaired physical mobility
Risk for fracture
Deficient knowledge

30. Relieving pain Restrict activity
Immobilize affected part – use splints
Handle affected part with care
Elevate affected part to reduce swelling and discomfort
Administer prescribed analgesic
Monitor neurovascular status of affected extremity

31. Controlling infectious process
Monitor response of treatment
Observe IV sites for phlebitis or infiltration
If surgery is planned, ensure adequate circulation
Maintain aseptic technique
Avoid pressure on grafted area
Monitor general health
Provide a balanced diet high in protein and vitamin C to promote healing

32. Home and community based care
Self care
Strict therapeutic regimen of antibiotics
Prevention of falls
Teach patient how to maintain and manage the IV access site and equipment it there
Provide medical education (drug name, dose, frequency and administration)
Instruct patient to observe for elevated temp, drainage, adverse reactions
Teach patient and family how to perform aseptic dressing
Explain the importance of follow up