CHRONIC OSTEOMYELITIS

OF LEFT TIBIA
BY:
NUR LYNA RIDZUAN
ADVISOR:
dr. ARIES FREDDY HUTABARAT
dr. ANGGA ANGGRIAWAN
SUPERVISOR:
dr NOTINAS HORAS, M. Kes. Sp OT

DEPARTMENT OF ORTOPAEDIC AND TRAUMATOLOGY

MEDICAL FACULTY
HASANUDDIN UNIVERSITY
MAKASSAR
2016

IDENTITY

Name
: Mr S
Age
: 39 years old
Sex
: Male
Date of Admission : February 29
2016
Medical Record
: 747167

th

HISTORY TAKING
Chief Complain : wound at left leg.
History of Illness :
Suffered since 6months ago and worsen this past 2months.
Patient complained about the discharged and smelly wound.
Patient has history of trauma and undergo for external
fixation at the left leg on September 2015
After the operation, patient never came back to the hospital
for medical check up and wound care because lack of
funds .
Patient has history of ups and down fever and pain at the
wound region for this past 2months and only took
paracetamol for reliever. History of tenderness (+)
No history of of DM , hypertension and cardiovascular
disease.

GENERAL STATUS
Conscious, Well-nourished
BP : 110/80 mmHg
HR : 80X/min
RR : 16X/min
Temp : 36,8oC

LOCAL STATUS
Look

Left Leg Region

External fixation is attached, open wound
size 1cm x 3cm x 1cm at 1/3 middle tibia
anterior aspect, area around wound is
darker than surrounding area, expose tibia
bone (+), deformity (-), scar (+), discharge
(+), swelling (-), hematoma (-)

Feel
Move

Tenderness (+)
Active and passive movement left knee
joint , flexion and extension 0- 90
Active and pasive movement of ankle joint
within normal limit

NVD

Sensibility is good
Pulsation of the dorsalis pedis and tibialis
posterior are palpable.
CRT <2

Leg Length
Discrepancy
Right
Left
ALL

82 cm

82 cm

TLL

72 cm

72 cm

LLD

0 cm

CLINICAL
FINDING

Anterior
View

Medial View

CLINICAL
FINDING

RADIOLOGIC FINDING

Tibia Sinistra AP/Lateral

LABORATORY
FINDINGS
WBC
5,35
4,00-10,0
RBC

4,59

4,00-5,50

HGB

12,5

12,0-16,0

LED

13/34

<10

PLT

349

150-400

CT

4-10

BT

1-7

HBsAg

Non

Non

Reactive

Reactive

RESUME
A 39 years old man admitted to the Wahidin Sudirohusodo
Hospital with chief complain of open wound at left leg, suffered
since 6 months ago and worsen this past 2 months. Patient has
history of trauma and undergo surgery for external fixation on
September 2015. After discharge, patient never came back for
medical check up and wound care. Patient has a history of ups
and down fever and pain at the wound region for pass 2 month
but only took paracetamol for reliever. History of tenderness (+)
On physical examination findings there is external fixation
attached and from anterior aspect there is open wound size 1cm
x 3cm x1cm at 1/3 middle tibia, area around the wound is darker
than surrounding area. Exposed tibial bone (+), discharge (+),
and movement of flexion extension of knee is 0- 90
From radiologic finding there is external fixation attached, signs of
osteomilitis at left tibial bone.

DIAGNOSIS
Chronic osteomyelitis left tibia

TREATMENT
IVFD RL 20TPM
Cefazoline 1gram/12jam/intravenous
Planning for debridement,
sequestrectomy and drainage
Bacteriology culture and sensitivity
test

DISCUSSION

INTRODUCTION
Osteomyelitis is an acute or
chronic inflammatory process of
the bone and its structures
secondary to infection.
When bone infection persists for
months, the resulting infection is
referred to as chronic osteomyelitis

Appleys system of orthopaedics and fractures, 9th ED.

ETIOLOGY
Posttraumatic osteomyelitis accounts
for as many as 47% of cases of
osteomyelitis.
Other major causes of osteomyelitis
include vascular insufficiency (mostly
occurring in persons with diabetes;
34%)
hematogenous seeding (19%).

STUCTURE OF BONE

EVIDANCE LEADING TO
DIAGNOSIS

 Open wound with

pus since
6months
History of trauma
(+)
History of fever
(+) HISTORY

TAKING

PHYSICAL
EXAMINATI
ON
Open wound (+)
Tenderness (+)
Expose tibia
bone (+)

Elevated ESR

LABORATOR
Y

RADIOLOGY FINDING

PHYSICAL
EXAMINATI
ON

HISTORY
TAKING

RADIOLOGY
FINDING +
LABORATOR
Y FINDINGS

CHRONIC
OSTEOMYELITIS

PATHOPHYSIOLOGY
Direct
inoculation of
bacteria via
trauma, surgical
reduction and
internal fixation
of fractures,
prosthetic
devices, spread
from soft-tissue
infection

infection begins
outside the
bony cortex and
works its way in
toward the
medullary
canal.

A progression
through
inflammation >
suppuration >
necrosis > new
bone formation
> to resolution
or intractable
chronicity.

CLINICAL MANIFESTATION
ACUTE

CHRONIC

Pain
Fever
Refusal to bear weight
Elevated white cell count
Elevated ESR
Elevated CRP

decreased sensation
poor capillary refill
decreased dorsalis pedis and posterior tibial
pulses.
Classic signs are healed and discharging
sinuses and x-ray features of bone
rarefaction surrounded by dense sclerosis
and cortical thickening; within that area
there may be an obvious sequestrum.

RADIOLOGY

TREATMENT
The principles of treatment are:
to provide analgesia and general supportive
measures
to rest the affected part
to identify the infecting organism and administer
effective antibiotic treatment or chemotherapy
to release pus as soon as it is detected
to stabilize the bone if it has fractured
to eradicate avascular and necrotic tissue
to restore continuity if there is a gap in the bone
to maintain soft-tissue and skin cover.

ANTIBIOTICS :
to suppress the infection and prevent its spread
to healthy bone and to control acute flares.
The choice of antibiotic depends on
microbiological studies, but the drug must be
capable of penetrating sclerotic bone and
should be non-toxic with long-term use.
administered for 46 weeks (starting from the
beginning of treatment or the last debridement)
before considering operative treatment.

OPERATIVE
1. DEBRIDEMENT :
. At operation all infected soft tissue and
dead or devitalized bone, as well as
any infected implant, must be excised.
. After three or four days the wound is
inspected and if there are renewed
signs of tissue death the debridement
may have to be repeated several
times if necessary.

2. DRAINAGE :
If pus is found and released there is little to
be gained by drilling into the medullary cavity.
If there is no obvious abscess, it is reasonable
to drill a few holes into the bone in various
directions.
If there is an extensive intramedullary abscess,
drainage can be better achieved by cutting a
small window in the cortex. The wound is
closed without a drain and the splint (or
traction) is reapplied

3. SOFT TISSUE COVER

The bone must be adequately
covered with skin. For small defects
splitthickness skin grafts may suffice
for larger wounds local
musculocutaneous flaps, or free
vascularized flaps, are needed.

AFTER CARE
Once the signs of infection subside,
movements are allowed - walk with
the aid of crutches. Full
weightbearing is usually possible
after 34 weeks.
Local trauma must be avoided and
any recurrence of symptoms,
however slight, should be taken
seriously and investigated.

COMPLICATION
Osteonecrosis
Arthritis septic
Skin cancer (squamous carcinoma )

PROGNOSIS

Staging the condition helps in riskbenefit assessment and has some predictive
value concerning the outcome of treatment. The system popularized by Cierny et
al. (2003) is based on both the local pathological anatomy and the host
background (Table 2.2).

THANK YOU