Case Report

Chronic Osteomyelitis Left Leg

Nursyimaa Bt Md. Ibrahimc111 10 850

Advisor :

dr.Padlan

dr.Luthfi

Supervisor:dr. Notinas Horas, M.Kes,Sp.OT

Orthopaedic and Traumatology Department

Patient identity

• Name : Mr.A

• Age : 29 years old

• Sex : male

• Date of admittance : 20 April 2015

• MR : 709126

History taking

Chief complaint : Wound at the left leg

Suffered since 7 years ago. At first, patient got neddle injury and size of the wound is as the size of the neddle. He noticed that the wound getting bigger and bigger from day to day and starts to secrete pus. Patient claimed that he used to clean the wound using betadine and also had consume anti-inflamation which he bought himself. He also complain of pain especially at the ankle. There is no fever, history of fever (+). There is no history of DM

General status• Moderate illness/ malnourished / conscious

BW=43kg, BH=160, BMI=16.8kgm2

• BP : 120/70 mmHg

• Pulse : 84x/m, regular

• RR : 18x /m, regular

• T : 36.50 C (axillar)

Local statusRegio Cruris Sinistra

• Look : scar at the lateral aspect as high as proximal cruris: sinus at the lateral aspect at 1/3 distal cruris: deformity (+), hematom (-), edema (-)

• Feel : pain on palpable• Move : active and passive gerakan knee joint : 130-170

: active and passive ankle joint cannot be evaluated because of pain• NVD : sensibility is good, pulsation of arteri dorsalis pedis is palpable,

CRT <2 seconds

Regio Ankle Sinistra

• Look : wound at the lateral aspect extending to posterior, size 10x6cm, base of the wound is muscle, pus (+)

: wound at the medial aspect, size 2x1cm : deformity (+), hematom (+), edema (+)

• Feel : pain on palpable• Move : active and passive ankle joint cannot be evaluated because of pain

on movement• NVD : sensibility is good, pulsation of arteri dorsalis pedis is palpable,

CRT <2 seconds

Clinical picture

Laboratory findings

WBC 11.7/mm3 4.00-10.0 mm3

RBC 4,01 x 106 /mm3 4.00-6.00 mm3

HGB 9,4 g/dL 12.0-16.0 g’dL

HCT 30,7 % 37.0-48.0 %

PLT 358 x 10 3 /mm3 150-400mm3

GDS 76 mg/dl 140mg/dl

BT 2’30 menit 1-7 menit

CT 8’30 menit 4-10 menit

ESR 116/124mm <10mm

HbsAg Non Reactive Non Reactive

IMAGING Cruris sinistra AP / Lateral (20/04/2015)

• Alignment of cruris is not intact• Bone contour is not smooth• Destruction of distal tibia et

fibula and os calcaneus sinistra plus multiple lytic lesion and sclerotic

Pedis sinistra AP / Lateral (20/04/2015)• Bone alignment is not intact• Lytic and sclerotic lesion at os

metatarsal• Sclerotic lesion and destruction

at os calcaneus and os talus sinistra• Soft tissue swelling

• Alignment of pedis is not intact• Lytic lesion at os metatarsalis • Sclerotic lesion and destruction

at os calcaneus pedis and os talus• Soft tissue swelling

Resume• A male 29 years old with wound of the left leg since 7 years ago. At first, patient got neddle

injury and size of the wound is as needle-size. He noticed that the wound getting bigger and bigger from day to day and starts to secrete pus. He also complain of pain especially at the ankle. History of fever (+).

• On physical examination at regio cruris sinistra, deformity (+), scar at the lateral aspect as high as proximal cruris, sinus at the lateral aspect at 1/3 distal cruris, pain on palpable, active and passive ankle joint cannot be evaluated because of pain.

At regio pedis sinistra, deformity (+), wound at the lateral aspect extending to posterior, size

10x6cm, base of the wound is muscle, pus (+). Wound at the medial aspect, size 2x1cm.

Neurovascular distal in normal limits.

• From laboratorium examination :increase WBC , increase ESR, decrease Hb 9.4 g/dL

• From radiology examination there is multiple lytic lesion and destruction at distal tibia et fibula sinistra, and sclerotic lesion at pedis sinistra.

Diagnosis

• Chronic Osteomyelitis Left Leg

ManagementMedicamentosa:

IVFD RL 20 drop per minutesAnalgeticAntibiotic

Surgery : Disarticulation of genu sinistra

DISCUSSION

Anatomy

Long bone vascularization

Definition

• Osteomyelitis inflammation of the bone caused by an infecting organism.

• The infection may be limited to a single portion of the bone or may involve numerous regions, such as the marrow, cortex, periosteum, and the surrounding soft tissue

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed.

Port D’ entry

Vascular insufficiency

Hematogenous

Contagious focus of infection

CLASSIFICATION• Based on onset

Acute Chronic

• Mechanism of infectionExogenous Contagious focus of infection

Hematogenous

Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed

Chronic osteomyelitis• Sequel to acute hematogenous osteomyelitis

• Usual organisms are staphylococcus aureus, Escherichia coli, Streptococcus pyogens, Proteus and Pseudomonas.

• In the presence of foreign implants : Staph. Epidermidis is the commonest pathogen.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Pathology• Bone is destroyed or devitalized in a discrete area

at the focus of infection.

• Cavities containing pus and pieces of dead bone (sequestra) are surrounded by vascular tissue, and beyond that by areas of sclerosis the result of chronic reactive new bone formation.

• Sequestra, foreign implants act as substrates for bacterial adhesion, ensuring the persistence of infection and sinus drainage.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Extension into joint

cavity

Extension into subperiosteal

location

New bone

formation

Sinus tract

Dead bone (sequestrum) and abscess

Cierny and Mader staging system of chronic osteomyelitis based on anatomical & physiological

Classification Description

Anatomical Stage

1 Medullary osteomyelitis

2 Superficial osteomyelitis

3 Localized osteomyelitis

4 Diffuse osteomyelitis

Physiological Host Status

A Normal host

B Systemic compromise or

Local compromise

C Severely compromised by local and systemic

Cierny and Mader staging system of chronic osteomyelitis based on anatomical

I Medullary Endosteal disease

II Superficial Cortical surface infected because of coverage defect

III Localized Cortical sequestrum that can be excised without compromising stability

IV Diffuse Features of I, II, and III plus mechanical instability before or after débridement

Staging System based on physiological class

A host Normal Immunocompetent with good local vascularity

B host Compromised Local (L) or systemic (S) factors that compromise immunity or healing

C host Prohibitive Minimal disability, prohibitive morbidity anticipated, or poor prognosis for cure

DIAGNOSIS

IMAGING

LABORATORYCLINICAL

MANIFESTATION

Clinical manifestation • Pain, fever, malaise, redness and tenderness

have recurred, or with a discharging sinus.• There may be a sero-purulent discharge and

excoriation of the surrounding skin.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Laboratory• ESR and white blood cell count may be increased not diagnostic• Organisms cultured from discharging sinuses

should be tested repeatedly for antibiotic sensitivity sample taken from aspiration more accurate

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Imaging

• X-ray examination Bone resorption with thickening and

sclerosis of surrounding bone periosteal thickening, sequestra, or the

bone crudely thickened and misshapen.

• CT and MRIShow the extent of bone destruction and reactive edema, hidden abscess and sequestra.

APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Management• Antibiotics• Local treatment wound dressing• Operation :

Thorough debridement of necrotic tissue and boneSequestrectomyDead space management bone and soft tissue

reconstrustionSoft tissue coverage

COMPLICATION

• A pathologic fracture may develop if the bone is excessively loaded before healing and remodeling.• Joint stiffness• Bacteremia • Bone abscess • Cancer

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