Acute Osteomyelitis And Nursing Care Plan

Osteomyelitis

Organisms can reach a bone by one of three routes:

• Blood stream (Haematogenous).

• From without (open fractures).

• Direct spread. e.g. chronic ulcer leg.

Acute Haematogenous Osteomyelitis

• Bacteria:  Most commonly staplylococcus.

• Source of infection: Septic focus especially tonsillitis, upper respiratory infection.

• Predisposing factors:

  • General: Lower vitality.
  • Local : Trauma.

• Bone affected: Long bones especially lower limb bones.

• Site of initial lesion. (Metaphysis):

  • Immature bone.
  • Vascular arrangement.
  • Liable to trauma.

Local pathological changes:

• Stage of suppuration.

• Stage of sequestration.

• Stage of Involucrum formation.

 

Pattern in Various Age

Infants Child Adult
Epiphysis affection Frequent Rare
Adjacent Joint Frequent ? Intra capsular May Occur
Subperiosteal abscess Occur Frequent Rare
Sequestrum Massive Massive Small
Involucrum Occur Massive Not marked

 

Complications of Acute Haematogenous Osteomyelitis:

  • Septic arthritis.
  • Chronicity
  • Pathological fracture.
  • Pyaemia.

 

Diagnosis Acute Haematogenous Osteomyelitis

• Age:

Children, infants predominate.

• History:

Mild trauma may be obtained. Followed in one to three days by fever, severe pain, general malaise.

 

Examination:

General: Fever, rapid pulse, toxaemia.

Local: Local swelling, aedema, local tenderness, warmth, redness of the skin. Effusion of the near by joint.

Radiography: Normal x-ray during the first 3 weeks, later rarefied the bone and periosteal new bone formation.

Investigation:

• Leucocytosis.

• E.S.R ↑.

• Blood culture may be +ve.

Differential diagnosis:

• Rheumatic arthritis.

• Pyogenic septic arthritis.

• Cellulitis.

 

Treatment of acute osteomyelitis

  • Morbidity is Lowered if acute osteomyelitis is treated shortly after its onset.
  • Rest in bed. (General)
  • Systemic Antibiotics
  • An antibiotic is effective before this pus forms.
  • An antibiotics cannot sterilize avascular tissues and pus that should be removed.

 

  • Local splintage
  • Drainge (Bone Drilling).

 

Indication for surgery:

• Clinical diagnosis of abscess formation.

• Severely ill child (Toxaemia).

• Failure of I.V. antibiotic treatment.

• Surgery should not further damage of already ischaemic bone.

• If pus removal, then antibiotics can prevent reformation and primary closure is safe.

• Antibiotics should be continued after surgery.

 

Osteomyelitis after open fracture

• At the fracture site.

• Usually subacute.

• Union of the fracture is delayed.

Treatment:

  • Preventive
  • External fixator for immobilization of the fracture.
  • Drainge & dressing.
  • Local antibiotics.

 

Bone Infection Resulting From Adjacent Inflammation (Periosteitis)

Chronic Osteomyelitis

I. as a sequel to acute osteomyelitis

Factors of choronicity:

  • History of acute osteomyelitis, bone is thickened, tender, discharging sinus.
  • Bone cavity
  • Sequestrum
  • Bacteria
  • Sinuses

Radiographs:

• The bone is thickened with patchy and irregular scelerosis surrounding the bone cavity.

• A sequestrum shows as a dense loose fragment.

sequestrum

Complication:

• Pathological fracture.

• Irregular growth.

• Amyeloid disease is rare.

 

Treatment

Antibiotics alone are of little value

1. Operative Drainge:

2. Excision of certain bone

3. Amputation:

Indications:

• Carcinoma of the sinus.

• Amyloid disease.

• Complete bed ridden patient.

 

II. Brodie’s Abcess

• A chronic bone abscess usually of small size & situated in metaphysis of long bone, the abscess may be sterile. There is dense sclerosis around the cavity.

 

III.Chronic sclerosing (Garre’s type)

• A non suppurative type. There is diffuse thickening of bone with encroachment on medullary canal (no sequestration or sinus formation).

 

IV. Salmonella Osteomylitis

• A positive Widal test

 

V. Brucellosis

• A positive culture of blood

• A high agglutination titre reaction of 1/80.

 

Pyogenic infection of joints

Organisms:

Staphylococci route of infection

• Haematogenous.

• Direct extension.

• From without (open injury).

• Intra-articular injection.

Site:

Any joint may be infected (knee, hip).

 

Local Changes:

1. Synovitis: It becomes Red, Swollen, Exudate forms

2. Chondrolysis: Articular cartilage by:

• Digestive action of proteolytic enzymes released from dead polymorphic leucocytes.

• Excessive plasmin.

• Direct action of bacterial toxins.

3. Bone involvement.

4. Ligaments: Are softened and stretched.

5. Capsule: Rupture

 

Complications:

  • Choronicity.
  • Pathological dislocation.
  • Pyaemia

Pathological dislocation due to:

• Muscle spasm.

• ↑ intra-articular pressure.

• Laxity ligaments.

• Destruction of joint surfaces.

Course:

• Recovery of joint mobility.

• Ankylosis

 

Diagnosis:

Patient: Childhood.

History: Rapid onset with rigors, fever,

 

Examination:

• Inability to walk.

• Swelling, deformity, pain tenderness, local signs of inflammation, limitation of joint movments, muscle spasm.

 

Radiography:

After one month à Rarefaction of bone ends diminshed joint space, irregular joint surfaces and subchondral sclerosis.

 

Investigations:

• Leucocytosis

• ↑ E.S.R.

• Aspiration of the joint.

 

D.D.

• Acute osteomyelitis.

• Rheumatic arthritis.

• Haemoarthrosis.

• T.B arthritis (muscle atrophy is marked)

 

Treatment:

• General: Rest, fluid, antibiotics.

Aspiration:

  • Diagnostic
  • Therapeutic
  • Prognostic

Arthrotomy

 

Nursing care plan for Osteomyelitis

 

  • Examination of body areas that reveal infection such as redness and increased warmth or swelling
  • Assess the level of patient anxiety and an the potential of acute Osteomyelitis to become chronic
  • Assess the patient gait or any presence of abnormal gait
  • Prevent any direct infection
  • Early debridement of necrotic tissue after surgery to lessen the possibility of any infection
  • Administration of prophylactic antibiotics for patients with open fracture
  • Provide heat application to lessen discomfort
  • Provide oral fluids to prevent dehydration
  • Proper positioning to decrease discomfort
  • Use sterile dressing to prevent infection
  • The involved extremity should be handled very carefully to prevent fractures
  • Patient, family education

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