CHRONIC OSTEOMYELITIS FEMUR

PATIENT IDENTITY
Name
: MAR
Age
: 12 years old
Sex
: Male
MR
: 708750
Date of admission : June 6th 2015

HISTORY TAKING
Chief complaint : pain and swelling at the right tight
Suffered since 1 year prior to admission, worsened since
last 2 months. The patient experienced on and off pain
and swelling at the right thigh and worsened when
walking. The pain felt like squeeze and did not radiate.
Theres no history of trauma. He went to Selayar Hospital
for sought consult and then referred to our hospital.

GENERAL STATUS
Consciousness/ well-nourished
BP = 110/70 mmHg
Pulse = 92 x/min, regular
Respiratory rate = 18 x/min
Temperature = 36,6 0C

LOCAL STATUS
Right Thigh Region
Inspection : Swelling (+), deformity (-), hematome (-),
wound (-)
Palpation : Tenderness (+)
ROM
: Active and passive movement of hip
Active and passive movement of the knee
NVD : Sensibility is good, dorsalis pedis artery and
tibialis posterior are palpable, CRT<2

LABORATORY FINDINGS
WBC

11.49 x
10 /mm

4.0-10.0 x
103/mm3

RBC

4.94 x 10
/mm

4.0-6.00
x106 /mm3

HGB

11.6 g/dL

12-16.0 g/dL

HCT

36.5 %

37.0-48.0 %

PLT

365

150-400x
10 /mm

CT

730

4-10

BT

200

1-7

HbsAg

Non reactive

RESUME
Male, 12 years old, suffered since 1 year prior to admission, worsened
since last 2 months. The patient experienced on and off pain and
swelling at the right thigh and worsened when walking. The pain felt
like squeeze and did not radiate. Theres no history of trauma. He
went to Selayar Hospital for sought consult and then referred to our
hospital.
From Physical Examination
Inspection : Swelling (+), Palpation: Tenderness (+)
From MRI Examination
Patient diagnosed with osteomyelitis kronik regio proximal femur
dextra with soft tissue abcess.

DIAGNOSIS
Chronic Osteomyelitis Right Femur

MANAGEMENT
Antibiotic
Debridement

DISCUSSION

Definition of Osteomyelitis
The root words osteon (bone) and myelo (marrow) are
combined with itis (inflammation)
Osteomyelitis is an infectious process that involves
bone and its medullary cavity which leads to a
subsequent Inflammatory process.
Greene,W. Netters Orthopaedic 1st ed

EPIDEMIOLOGY
Incidence : The incidence is higher in children than in
adults, with a peak occurring in the later years of the
1st decade.
Prevalence : A male predilection appears, which is not
clearly understood, It affects <1% of children.

Apleys System of Orthopaedics and fracture, Chapter 2: Infection

ETIOLOGY
INFANT

CHILDREN

ADULT

Staphylococ
cus aureus
Streptococc
us B
Gramnegative
bacilli

Staphylococ
cus aureus
Hemophilus
influenzae

Staphylococ
cus aureus
Staphylococ
cus
epidermidis
Pseudomona
s aeruginosa

PATHOGENESIS

Hematogenous spread usually

involves the metaphysis of long
bone in children or vertebrae
bodies in adult

Direct inoculation of
microorganism into bone
penetrating injuries and
surgical contamination is
the most common causes

Microorganis
m in bone

OSTEOMYELITIS

Contiguous focus of infection

Apleys System Of Orthopaedics And Fractures
seen in patients with severe
vascular disease

8th Edition

Pathophysiology There are end artery

branches of the nutrient
artery
Acute inflammatory
respose due to infection
Tissues necrosis,
Breakdown of
bone
Obstruction
Avascular necrosis
of the bone
Squetra
formation
Chronic
osteomyelitis

Apleys System Of Orthopaedics And Fractures 8th Edition

Pathology

Infection in the metaphysis may spread towards the surface,

to form a subperiosteal abscess
Some of the bone may die, and is encased in periosteal
new bone as a sequestrum
The encasing involucrum is sometimes perforated by sinuses
Apleys System Of Orthopaedics And Fractures 9th Edition

Classification
Based on the duration and type of symptoms:

Type

Duration

Acute

<2 weeks

Subacute

2-6 weeks

Chronic

>6weeks

Apleys System Of Orthopaedics And Fractures 8 th Edition

DIAGNOSIS

CLINICA
L

BIOPSY
Gold
Standard

DIAGNO
SIS

LABORATO
RY

IMAGING

CLINICAL FEATURES
In a study of eighty six children, 50% of them presented
with vague symptoms (nonspecific pain and low-grade
fever of one to three months duration) including pain in
the involved limb of one to three months duration and
minimal, if any, temperature elevation.
The joint is usually spared from infection unless the
metaphysis is intracapsular, as is found in the proximal
part of the radius, humerus, or femur.
Luca Lazzarini, Jon T. Mader and Jason H. Calhoun. The Journal of bone& Joint Surgery

LABORATORY
The leukocyte count may be elevated in cases of acute
osteomyelitis, but it is often normal in chronic cases.
The erythrocyte sedimentation rate is usually elevated
in both acute and chronic osteomyelitis.

Luca Lazzarini, Jon T. Mader and Jason H. Calhoun. The Journal of bone& Joint Surgery

IMAGING
X-ray examination
Often show lytic region surrounded by an
area of sclerotic
Bone lose must be 30-40% before evident on
plain films
Sequestrum:devitalized bone that serves as
a
nidus for infection
involucrum: formation of new bone around
an area of bony necrosis

 CT : Useful for surgical planning and determining

extent of bony destruction
MRI : Useful for soft tissue evaluation

IMAGING
In this case:
XRAY FEMUR AP+LATERAL D/S: Normal.
MRI THIGH with contrast: Chronic Osteomyelitis regio
proximal femur dextra with soft tissue abscess

MANAGEMENT
1. Antibiotics
2. Operation :
Debridement
Dealing with the dead space
Soft tissue cover

COMPLICATIONS
Pathologic Fracture
Non-union or segmental bone loss
Sepsis

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