March/April l LPN2008 45

OSTEOMYELITIS IS AN infectious process in the bone thatusually starts in the spongy medullary bone. Osteomyelitisliterally means inflammation of the bone and is usually causedby bacteria. The infection that causes osteomyelitis oftenstarts in another part of the body and spreads to the bonethrough the bloodstream. Affected bone is often vulnerableto infection because of recent trauma, such as a fracture orsurgery. Osteomyelitis is most common in children andadults over age 50, affecting men more often than women.It can be acute or chronic.

Bone can become infected in one of the following ways: as an extension of soft-tissue infection from an inci-sion or pressure ulcer by direct contamination from bone surgery, open frac-ture, or traumatic injury via the blood (hematogenous) from other sites of in-fection (tonsils, boils, teeth, upper respiratory tract).

Staphylococcus aureus causes between 70% and 80% ofosteomyelitis cases. Other frequent causes includePseudomonas and Escherichia coli. Some infections involvemultiple infectious agents.

Acute osteomyelitis usually occurs in children as aresult of infection with Gram-negative bacteria, and thelong bones (tibia, humerus, and femur) are commonlyaffected. Infection spreads quickly in children. It candamage bones and joints, impairing function, growth,and mobility.

Osteomyelitis in adults is most commonly a chroniccondition that can last several months to years and lead to

bone death. The development of sinus tracts betweenbone and skin is common in chronic cases. The pelvis andvertebrae are most often affected; about half of the cases ofvertebral osteomyelitis are due to S. aureus, and the otherhalf are due to tuberculosis. Chronic osteomyelitis of thespine is dangerous because it can damage the nerves. Sitesof chronic osteomyelitis can evolve into skin cancer organgrene, and possibly lead to limb amputation.

Risky business People who are at high risk for osteomyelitis includethose who are poorly nourished, elderly, or obese. Oth-ers at risk include those with impaired immune systems;those with chronic illnesses such as diabetes or rheuma-toid arthritis; and those receiving long-term cortico-steroid therapy or immunosuppressive agents. Peoplewith diabetes have an increased risk of getting osteo-myelitis for many reasons: They have impaired circulation, which causes woundsto heal slowly. If they have neuropathy, an injury may go undetectedfor a long time. Impaired vision or impaired mobility can lead to injuries.

Chronic diseases such as sickle-cell anemia, cancer,hemophilia, rheumatoid arthritis, and HIV also put peo-ple at high risk for infections. All these problems can leadto osteomyelitis. Weakness and impaired mobility fromthese diseases increase the potential for injuries. Thesepatients also have impaired ability to heal after an injury,

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JOYCE SEABOLT, LPNProgression Unit Brightwood Center Lutherville, Md.

The author has disclosed that she has no significant relationship with or financialinterest in any commercial companies that pertain to this educational activity.

Osteomyelitis is an inflammation of bonetissue that affects approximately 2 in10,000 people in the United States. Caringfor a patient with osteomyelitis can bechallenging because the signs and symp-toms often mimic other health problems.Find out what you can do to recognize thisserious condition and help guide yourpatient through diagnosis and recovery.

LPN2008 l Volume 4, Number 2

so their acute osteomyelitis is morelikely to evolve into chronicosteomyelitis.

Direct contaminationInfectious organisms can enter thebone directly through an open frac-ture, a traumatic injury such as agunshot wound, and during surgery.Postoperative surgical wound infec-tions occur within 30 days aftersurgery. They are classified as inci-sional (superficial, located above thedeep fascia layer) or deep (involvingtissue beneath the deep fascia).

If the patient received a boneimplant, a deep postoperative infec-tion may affect the site within a year.Deep sepsis after arthroplasty maybe classified as follows: Stage 1, acute fulminating: occur-ring during the first 3 months afterorthopedic surgery; frequently asso-ciated with hematoma, drainage, orsuperficial infection Stage 2, delayed onset: occurring be-tween 4 and 24 months after surgery Stage 3, late onset: occurring 2 ormore years after surgery, usually asa result of hematogenous spread.

Bone infections are more difficultto wipe out than soft tissue infectionsbecause blood vessels dont supplythe infected bone to provide accessto the bodys natural immuneresponse. Penetration by antibioticsis decreased as well, so osteomyelitismay become chronic and affect thepatients quality of life.

Before we get to what can be doneto treat osteomyelitis, its time totake a look at the common signs andsymptoms.

Signs and symptomsChildren under the age of 3 arecommon targets for osteomyelitisbecause they fall frequently andtheir immune systems are not yetdeveloped. Instruct parents to moni-tor a childs injury site (especially

fractures and puncture wounds)long after they seem to be healed.Osteomyelitis is one complicationthey can help prevent.

Signs and symptoms of acuteosteomyelitis include: pain in the affected area redness, swelling, and warmthover the area of infection fever irritability malaise.

In children, many of these symp-toms may mistakenly be attributed toother causes, such as the flu. Childrenfrequently have scrapes, falls, punc-tures, and fractures and experiencepain, swelling, redness, or drainageafter those injuries, and a diagnosis ofosteomyelitis can be overlooked.

Signs and symptoms of chronicosteomyelitis include: redness, swelling, and warmth overthe area of infection pain or tenderness in the affectedarea drainage from an open wound inthe area of infection fever (in some cases).

Because bone infections in adultscommonly follow an injury orsurgery, the symptoms may erro-neously be attributed to the injury or

surgery and osteomyelitis can beoverlooked.

Once osteomyelitis is suspected,its time to perform some tests tomake a definitive diagnosis. Hereswhat you need to know about thecurrent tests available.

Testing, testingBecause diagnosing osteomyelitiscan be difficult, assessment requiresa complete medical history, physicalexamination, and diagnostic testing.This testing may include bloodwork, bone biopsy, X-rays, bonescans, computed tomography (CT)scans, and magnetic resonanceimaging (MRI).

Blood work typically includes acomplete blood cell (CBC) count,erythrocyte sedimentation rate(ESR), blood cultures, and C-reactive protein (CRP) level. TheCBC count will show an elevatedwhite blood cell count when infec-tion is present. The ESR is almostalways elevated in the presence ofinflammation. The CRP helps detectinflammation and infection.

A bone biopsy is the gold standardfor diagnosing osteomyelitis. It willidentify the infection and can be per-formed through surgery (an open

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What osteomyelitis looks like

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biopsy) or by deep needle aspiration. X-rays can detect osteomyelitis

only after it has reached an advancedstage, but common findings in chron-ic osteomyelitis include bone sclerosisand periosteal new bone formation.

Bone scans are done after dye hasbeen injected and absorbed by bonetissue. They can detect areas ofincreased or decreased bone metabo-lism, even in the early stages ofinfection.

CT scans can show abnormal cal-cification (the buildup of calcium inbody tissues) and ossification (whencartilage is turned into bone).

MRIs are most useful to evaluatevertebral lesions and can distinguishbetween soft tissue infection andbone infection.

Treatment optionsOnce your patient has been diag-nosed with osteomyelitis, his treat-ment will depend on the bacteriainvolved, the site of infection, andthe type of osteomyelitis (acute orchronic). Antibiotic therapy, bedrest and opioid analgesia, nutritionalsupport, and surgery are options;lets take a look at what each can doto help your patient.

Intravenous antibiotic therapy isadministered after blood cultures oraspiration cultures identify the causeof the infection. Bacterial infectionsusually require 2 to 6 weeks ofantibiotic therapy (unless vertebraeare infected, when treatment lasts 6

to 8 weeks). Fungal infections mayrequire several months of treatment,and chronic infections may requiretreatment indefinitely.

Antibiotic therapy usually beginsin the hospital and continues athome, either intravenously (I.V.) ororally. Common antibiotics usedinclude ciprofloxacin (Cipro), naf-cillin (Unipen), clindamycin(Cleocin), vancomycin, flucloxacillin(Floxapen), and gentamicin(Genoptic). Remind your patient totake his antibiotics exactly as pre-scribed and to call his health careprovider if any problems occur.

Bed rest and opioid analgesia maybe indicated to manage pain. Bedrest is especially important whenosteomyelitis affects weight-bearingbones (those in the spine, hip, knees,and foot) because standing puts pres-sure on the infection site.

Nutritional support, whichincludes a high-protein diet unlessits contraindicated, can help aidwound healing.

Surgery is considered when: antibiotic therapy fails the patient develops neurologicdeficits the bone becomes deformed.

Surgery may be as simple as drain-ing a bone abscess. Abscesses mustbe drained because they can impairthe blood supply to the affected areaand cause bone death (osteonecro-sis). Sometimes, the surgery may beas complicated as a spinal recon-

struction. It all depends on the infec-tion, the site, the symptoms, and thesurgeon. Many surgeries involvebone scraping. Once the infectedarea is debrided, the bone shouldregenerate rapidly.

If a prosthesis (such as a total kneereplacement) is the site of osteo-myelitis, it is removed. Sometimes,the empty space is packed withantibiotic-impregnated materials.Other times, a new prosthesis isimplanted immediately and I.V.antibiotics are given.

Unless there is nerve damage,surgery isnt recommended forpatients with spinal osteomyelitis.

Other approaches for treatingosteomyelitis include: splinting and cast immobilization toprevent further trauma or to helpthe bone and joint heal (usuallyused in children) two different types of external fixa-tors: static fixators hold bones inplace; dynamic fixators adjust tocompress, angle, or lengthen bones free tissue transfers, in which tissue(with its blood supply) is attached tonew vessels in the wound bone grafts to replace infected bonecells with healthy bone (usuallyfrom the patients pelvis) hyperbaric oxygen therapy, alongwith antibiotics, to inhibit thegrowth of anaerobic organisms amputation when a new prosthesiswill function better than the chroni-cally infected limb.

Chronic osteomyelitis resiststreatment, especially if multiplemicrobes or a fungus are the cause.Chronic types usually require a com-bination of antibiotics and surgery.

Caring for your patientCaring for a patient with osteo-myelitis includes managing immedi-ate problems and making sure hisongoing treatment is safe and effec-tive. Your goals should be to:

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Teaching factsPatients with osteomyelitis need to take care of themselves to improve theirchances of fighting infection. Teach your patients to: Eat a variety of fruits and vegetables, which can provide the body with the nutri-tional support it needs to fight infection and stay healthy. Stop smoking. Smoking slows blood flow to the hands and feet, making it moredifficult for the body to fight infection. Provide your patient with smoking cessationmaterials if he needs help. Continue antibiotic treatment as prescribed. Advise him to call his health careprovider to report any adverse effects before discontinuing the drug on his own. Thesuccess of antibiotic treatment depends on following the complete regimen.

control the patients pain withprescribed analgesics and nonphar-macologic techniques monitor his response to antibiotictherapy observe the patients I.V. site forsigns of complications monitor the area of infection andneurovascular status (if an extremityis involved) apply gentle range-of-motionexercises to the joints above andbelow the affected site unless contraindicated, providenutritional support in the form of ahigh-protein diet teach your patient how to takeprescribed antibiotics and how torecognize possible adverse reac-

tions. See Teaching facts for moreinformation.

It can be preventedBecause osteomyelitis is a prevent-able disease, inform all your patients,especially those with risk factors,about the causes of osteomyelitis andhow preventive measures can help(see An ounce of prevention). Educatedpatients may succeed in preventingor minimizing the pain that accom-panies osteomyelitis. LPN

Selected referencesAmerican Academy of Orthopaedic Surgeons. In-fections. http://orthoinfo.aaos.org/topic.cfm?topic=A00197. Accessed December 10, 2007.

Cierny III G. Guest editorial. http://www.osteomyelitis.com Accessed January 1, 2007.

The Cleveland Clinic. Osteomyelitis. http://www.clevelandclinic.org/health/health-info/docs/2700/2702.asp?index=9495. Accessed January 17, 2007.The Mayo Clinic. Osteomyelitis. http://www.mayoclinic.com/health/osteomyelitis/DS00759.Accessed November 29, 2006.

The Merck Manual of Geriatrics. Osteomyelitis.http://www.merck.com/mrkshared/mmg/sec7/ch50/ch50a.jsp. Accessed February 11, 2007.National Institutes of Health. Malignant otitis ex-terna. http://www.nlm.nih.gov/medlineplus/ency/article/000672.htm. Accessed February 17,2007.

Sheff EK. Solving the mystery of osteomyelitis.Nursing2005. 35(7):32hn1-32hn3, July 2005.

Smeltzer SC, et al. Brunner and Suddarths Textbookof Medical-Surgical Nursing, 11th edition. Philadel-phia, Pa., Lippincott Williams & Wilkins, 2007.

LPN2008 l Volume 4, Number 248

hyaline cartilage

cancellous bone

epiphyseal plate

medullary cavity

compact bone

epiphysis

epiphysis

epiphysis

diaphysis

Earn CE credit online: Go to http://www.nursingcenter.com/ce/lpn and receive acertificate within minutes.

INSTRUCTIONS

Overcoming osteomyelitis

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An ounce of preventionWhen patients have an increased risk of infection, educate them about ways to pre-vent infections and help prevent osteomyelitis. If they do get cuts and scrapes, theAmerican Association of Orthopaedic Surgeons recommends these simple steps toprevent infections in skin wounds: First, control the bleeding, then clean the wound with soap and water. Keep all foreign matter out of the wound but dont try to remove matter embeddedin the wound. Use sterile materials for the first dressing. See your primary care provider for a final, definitive cleaning of the wound.

Normal bone

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Overcoming osteomyelitisGENERAL PURPOSE: To provide the nurse with a comprehensive review of the diagnosis, management, and treatment of osteomyelitis.LEARNING OBJECTIVES: After reading the preceding article and taking this test, you should be able to: 1. Discuss the infectious process caus-ing osteomyelitis. 2. Identify the symptoms and tests used in diagnosing osteomyelitis. 3. Explain the options for treatment and prevention of osteomyelitis.

1. Each of the following statements aboutosteomyelitis is true excepta. it can be an acute or chronic infectious

process.b. it affects men more than women.c. it usually starts in the bone and spreads to

other parts of the body.d. it usually starts in the spongy medullary

bone.

2. Which bacteria cause 70% to 80% ofosteomyelitis cases?a. Pseudomonasb. Escherichia colic. multiple infectious agentsd. Staphylococcus aureus

3. Half the cases of vertebral osteomyelitisin adults are caused bya. tuberculosis. c. Pseudomonas.b. fungi. d. E. coli.

4. People with diabetes are at increasedrisk for osteomyelitis because of impairedcirculation anda. impaired immune system.b. poor nutrition.c. neuropathy.d. corticosteroid therapy.

5. A patient with deep sepsis 3 months af-ter arthroplasty and a history of a postoper-ative hematoma would be classified asa. stage 1. c. stage 3.b. stage 2. d. stage 4.

6. What should parents of injured childrenbe taught about osteomyelitis?a. Check for fever often.b. Their active immune systems are an effec-

tive barrier against osteomyelitis.c. Monitor the injury site even after apparent

healing.

d. Osteomyelitis is rare in children.

7. Which of the following symptoms is pre-sent in acute osteomyelitis but may not bepresent in chronic osteomyelitis?a. redness and swellingb. feverc. warmthd. pain

8. A C-reactive protein test helps detecta. increased white blood cells.b. low hemoglobin levels.c. inflammation and infection.d. an elevated sedimentation rate.

9. The gold standard for diagnosing osteomyelitis isa. bone biopsy.b. magnetic resonance imaging (MRI).c. computed tomography (CT) scan.d. bone scan.

10. Which test can detect osteomyelitis onlyafter its reached an advanced stage?a. MRI c. X-rayb. bone scan d. CT scan

11. A patient with suspected vertebral os-teomyelitis is best evaluated bya. a CT scan. c. an X-ray.b. a bone scan. d. an MRI.

12. A patient with fungal osteomyelitis mayrequire antibiotic therapy fora. 2 to 4 weeks. b. 6 to 8 weeks. c. several months.d. an indefinite amount of time.

13. Which antibiotic is not commonly usedfor treatment of osteomyelitis? a. ciprofloxacin (Cipro)

b. vancomycinc. levaquind. gentamicin (Genoptic)

14. What level of activity is most likely to beordered for a patient with osteomyelitis ofthe hip?a. bed restb. standing with assistancec. chair onlyd. ambulation

15. Which treatment is usually used in chil-dren with osteomyelitis to prevent furthertrauma? a. surgeryb. external fixatorsc. bone graftsd. splinting and cast immobilization

16. Which treatment is used to inhibit thegrowth of anaerobic organisms?a. a bone graftb. hyperbaric oxygen therapyc. free tissue transfersd. external fixators

17. Chronic osteomyelitis usually requirestreatment witha. free tissue transfers and bone grafts.b. hyperbaric oxygen therapy.c. amputation.d. a combination of antibiotics and surgery.

18. To prevent infections in skin wounds,you should advise a patient with a cut orscrape toa. dress the wound with sterile materials.b. clean the wound with soap and water.c. remove any embedded matter from the

wound.d. see his primary care provider for final

cleaning.

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ENROLLMENT FORM LPN2008, March/April, Overcoming osteomyelitis$ $