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OSTEOMYELITIS

Ronny S,dr,SpOT
General aspect of infection
Micro-organisms enter the bones
and joints :
directly : a break in the skin (a
pinprick, a stab wound, a laceration,
an open fracture or an operation)
indirectly via the blood stream from
a distant site:
the nose or mouth, the respiratory
tract, the bowel or the genito-urinary
tract.

Langsung : benturan pada kulit


(ketusuk peniti, luka sayatan, luka
gores, fraktur terbuka, atau operasi)
Tak langsung : lewat pemb darah
-hidung atau mulut, saluran respirasi,
sal. Pencernaan atau sal. perkemihan
GENERAL ASPECTS OF INFECTION

Acute pyogenic infections are characterized by:


The formation of pus or abscess (Local effect)
a concentrate of defunct leucocytes, dead and dying bacteria and tissue debris

Infeksi piogenik akut karakteristiknya adalah sbb:


Bentuk pus atau abses
Cairan dari leukosit yang sudah mati, bakteri yang sudah mati, dan debris (kulit2) dari
jaringan yang telah mati

Spread further a field via lymphatics or via the bloodstream (systemic effect)
causing lymphangitis and lymphadenopathy, bacteraemia and septicaemia, with systemic
reaction : fatigue, mild pyrexia, severe illness, fever, toxaemia and shock.

Penyebaran lanjut pada bidang lewat sis limfatik atau lewat sal pemb darah (efek sistemik)
Menyebabkan limfangitis dan limfadenopati, bakteremia dan septicaemia, dengan reaksi
sistemik : kelelahan, pirexia, nyeri hebat, demam, toxaema, dan syok.
GENERAL ASPECT OF INFECTION
Chronic infection
follow on acute infection or start from beginning
The formation of granulation tissue (a combination of fibroblastic and vascular proliferation) fibrosis.
Infeksi kronis
Lanjutan dari infeksi akut atau permulaan dari infeksi
Susunan dari jaringan yang bergranulasi ( kombinasi dari fibroblastik dan proliferasi dari vaskular) -> fibrosis
Host Response:
Age of patient (very young or too old is more resistance),
state of malnutrition,
immunosuppressant
other disease like diabetes
Respon host :
Umur pasien
Bag dr malnutrisi
Imunosupresan
Penyakit lain spt diabetes

Local Factors :
damaged muscle and foreign bodies
bone structure itself consist of collection of rigid compartment make it more susceptible for vascular damage and cell death..
Faktor lokal
Kerusakan otot dan bag tubuh asing
Struktur tulang yang terdiri dr kumpulan dr kompartemen yang kaku yang menyebabkan mudah rentan untuk kerusakan
vaskuler dan kematian sel
GENERAL ASPECT OF INFECTION
The principles of treatment are:
(1) to provide analgesia and general supportive measures;
(2) to rest the affected part;
(3) effective antibiotic or chemotherapy; and
(4) surgical eradication of infected and necrotic tissue
Prinsip2 dari penatalaksanaan
1. Memberikan analgesik dan pengobatan suportif yang umum yang terukur
2. Mengistirahatkan bagian yang terkena
3. Memberi antibiotik atau kemo yang efektif
4. Operasi pengambiilan bagian yang infeksi dan jaringan nekrotik

For acute infections, the timing of surgery is all-important: in the early stages, antibiotics should be given a
chance and the clinical condition carefully monitored to detect signs of improvement or deterioration; if there
is pus, it must be let out and the sooner the better.
Untuk infeksi akut, pemilihan waktu untuk operasi sangat penting, dalam taraf awal, antibiotik seharusnya
diberikan dan scr kondisi klinis harus benar-benar dimonitor untuk mendeteksi perkembangan atau
memburuknya, jika adanya pus, maka itu harus dikeluarkan, dan lebih cepat lebih baik.
ACUTE HAEMATOGENOUS
OSTEOMYELITIS
Acute osteomyelitis is almost invariably a disease of children

This predilection for the metaphysis has been attributed to the peculiar
arrangement of the blood vessels in that area: the non-anastomosing
terminal branches of the nutrient artery twist back in hairpin loops
before entering the large network of sinusoidal veins; the relative
vascular stasis favors bacterial colonization.
Lebih sering ditemukan pada metafisis yang telah menghubungkan pada
susunan peculiar dari pemb darah pd area tsb:non-anastomosing (hub
antara sesama pemb darah yg letaknya berdekatan)yang cabangnya
bersambungan pada arteri nutrien yang membelit pada jalur seperti
tusuk konde sebelum masuk pada jaringan yang lebih besar pada vena
sinusoid, yang berhubungan dengan statis vaskular menyokong bakteri
berkoloni.
In young infants, in whom there is still a
free anastomosis between metaphyseal
and epiphyseal blood vessels, infection
can just as easily lodge in the epiphysis
Pada anak2, dimana masih ada raung
anastomosis antara pemb darah
metafiseal dan epifiseal, infeksi dengan
mudahnya numpang pada epifisis

In adults, haematogenous infection is


more common in the vertebrae than in
the long bones.
Pada dewasa, infeksi hematogenus lebih
sering di vertebrae daripada di tulang
panjang
Pathology of
acute ostemyelitis
Inflammation
acute inflammatory reaction, vascular congestion, exudation of fluid, infiltration of
PMN, increase of intraosseus pressure
Peradangan
Reaksi Inflamasi akut, tersumbatnya pemb darah, eksudat cairan, infiltrasi dari PMN,
penambahan tekanan intraoseus
Suppuration
Subperiosteal abscess, end plate and intervertebral disc infection
Supurasi
Abses subperiosteal dll
Necrosis
avascular necrosis of growth plate in infant. Bacterial toxins and leucocytic
enzymes also may play their part in the advancing tissue destruction.
Nekrosis
Nekrosis avaskular dari pertumbuhan lapisan pada anak2. toksin bakteri dan
enzim leukositik biasanya memainkan perannya dalam destruksi jaringan
yang terkena
reactive new bone formation
Susunan reaktif dari tulang baru
resolution and healing.
Resolusi dan penyembuhan
NEW BONE FORMATION
New bone forms from the deep layers of the stripped
periosteum.
This is typical of pyogenic infection and is usually obvious by
the end of the second week. With rime the new bone thickens
to form an involucrum enclosing the infected tissue and
sequester.
If the infection persists, pus and tiny sequestrated splcules of
bone may continue to discharge through perforations
(cloacae) in the involucrum and track by sinuses to the skin
surfaces; the condition is now established as a chronic
osteomyelitis.
PATOGENESIS
(A) INFECTION IN THE METAPHYSIS MAY SPREAD COWARDS THE
SURFACE, TO FORM A SUBPERIOSTEAL ABSCESS (B). SOME OF THE
BONE MAY DIE, AND IS ENCASED IN PERIO STEAL NEW BONE AS A
SEQUESTRUM (C).THE ENCASING INVOLUCRUM IS SOMETIMES
PERFORATED BY SINUSES.
RESOLUTION
Once common, chronic osteomyelitis following on
acute is nowadays seldom seen. If infection is
controlled and intraosseous pressure released at an
early stage, this dire progress can be aborted. The
bone around the zone of infection is at first
osteoporotic.
CLINICAL FEATURES
The patient, usually a child, presents with
severe pain, malaise and a fever; in
neglected cases, toxaemia may be
marked.
Nyeri hebat, malaise, dan demam. Dalam
segelintir kasus, toxaemia mungkin dapat
ditandai
X-RAYS NORMAL DURING FIRST 10 DAYS
X RAY NORMAL PADA 10 HARI PERTAMA
Ultrasound may detect a subperiosteal
collection of fluid in the early stages of
osteomyelitis, but it cannot distinguish
between a haematoma and pus.
Ultrasound mungkin dapat mendeteksi
kumpulan cairan di subperiosteal pada
Radioscintigrapby with 99mTc-HDP reveals increased activity in both the perfusion
phase and the bone phase.. It has relatively low specificity and other
inflammatory lesions can show similar changes.
Radioscintigrafi dengan 99mTc-HDP membuktikan peningkatan aktivitas dalam
fase perfusi dan fase tulang. Keduanya mempunyai hubungan rendahnya
spesifitas dan peradangan lesi lain yang menunjukkan kesamaan perubahan
In doubtful cases, scanning with Ga-citrate or In labelled leucocytes may be
more revealing.
Pada kasus yang meragukan, scanning dengan ga-citrate atau In labelled
leucocyte dapat mebuktikan secara lebih baik
MRI is extremely sensitive, even in the early phase of bone infection, and can
help to differentiate between soft-tissue infection and osteomyelitis.
MRI sangat sensitif, walaupun dalam fase awal dari infeksi tulang dan dapat
membantu untuk membedakan jaringan lunak dan OM
The most typical feature is a reduced intensity signal in T1-weighted images.
Yang paling khas dari gejala adalah berkurangnya intensitas sinyal T1wi
MRI
Acute:
marrow fat
granulation tissue H2O
Chronic: thickened cortex
Kronik : Korteks tebal
Low signal on all scans
Cellulitis: no marrow changes
INVESTIGATIONS
The most certain way to confirm the clinical diagnosis is to aspirate pus
from the metaphyseal subperiosteal abscess or the adjacent joint.
The white cell count and C-reactive protein values are usually high and
the haemoglobin concentration diminished; the ESR also rises but it may
take several days to do so and it often remains elevated even after the
infection subsides.
Blood culture
Cara yang paling pasti untuk menegakkan diagnosis klinis adalah
mengaspirasi pus dari abses subperiosteal pada metafiseal atau pada
sendi yang berdekatan
Penghitungan sel putih dan nilai c- protein reaktif (CRP) yang biasanya
tinggi dan konsentrasi dari hemoglobin berkurang; ESR LED biasanya
naik tapi membutuhkan beberapa hari dan biasanya bekasnya tinggi
walaupun infeksi mereda
DIFFERENTIAL DIAGNOSIS

Cellulitis
Streptococcal necrotizing myositis
Acute suppurative arthritis
Acute rheumatism
Sickle-cell crisis
Gaucher's disease
TREATMENT

Supportive treatment for pain and dehydration;


Terapi suportif utk nyeri dan dehidrasi
Splintage of the affected part;
Balut pada bagian yg terkena
Antibiotic therapy 3 6 weeks; and
Surgical drainage operasi pengeringan

Jika osteomyelitis diduga pada manifestasi linis,


darah dan cairan sampel harus diambil dan lalu
penatalaksaan dimulai secepatnya tanpa
menunggu dari penegakkan diagnosis yang
terakhir
ANTIBIOTIK TREATMENT
Older children and fit adult : Staphylococcus group
Flucloxacillin and fusidic acid i.v 1 2 weeks
Orally antibiotics 3 6 weeks
Children < 4 years ; Haemophilus group and gram
negatife organisms
Cephalosporins (cefuroxime or cefotaxime) i.v or orally
Amoxicillin-clavulanic acid combination (co-amoxiclav, a -
lactamase inhibitor)
Acute/Hematogenous
SUBACUTE OSTEOMYELITIS osteomielitis
subakut
Relative mildness
Relatif ringan
The organism being less virulent
(Staphylococcus aureusor ) and the
patient more resistance (or both);
Organisme lebih jarang menjadi virulen
(s.aureus) dan pasien lebih resisten
(atau keduanya)
More variable in skeletal distribution
than acute osteomyelitis
Lebih banyak pada distribusi pada
kerangka daripada om akut
The Distal femur and the proximal and
distal tibia are favorite sites.
Femur distal dan prox dan tibia distal
adalah bag tersering
PATHOLOGY
Well defined cavity in cancellous bone glairy
seropurulent fluid (rare pus)
Cavity is lined by granulation tissue of mixture of
acute and chronic inflammatory cells.
The surrounding bone trabeculae are often thickened
ditemukan dengan baik pada tulang cancellous
cairan glairy seropurulent (pus langka)
Cavitas ditandai oleh jaringan yang bergranulasi oleh
campuran sel peradangan akut dan kronik
Tulang sekitar trabekula biasanya tebal
Clinical features
The patient : child or adolescent
Pain near one of the larger joints for several weeks or
even months
A limp or slight swelling, muscle wasting and local
tenderness
Bengkak kecil, pelebaran otot, dan nyeri tekan
Normal temperature to slight higher (+/- sama atau lbh
tinggi)
White cell count may be normal but ESR is raised
IMAGING
Plain X-Ray
A circumscribed, oval or round cavity 1 2 cm in diameter
on tibia or femoral metaphysis or in epiphysis or in
cuboidal bone (calcaneus)
Cavity surrounded by halo of sclerosis (the classic
Brodies abscess)
Metaphysis lesion little or no periosteal reaction
Diaphysial lesion periosteal new bone formation and
cortical thickening
Foto polos
Batas tegas, cavitas lonjong atau bulat 1-2 cm diameternya
pada metafisis atau epifisis tibia atau femoral atau pada
tulang kuboid (calcaneus)
DIAGNOSIS
Differential diagnosis : Osteoid
osteoma with appearance as malignant
bone tumour
Certain examination by Biopsy for
bacteriological culture.
TREATMENT
Conservative
Immobilization and antibiotics
(flucloxacillin and fusidic acid) for 6
weeks than thereafter for 6 12
months
Curretage; indicate for lesion after
biopsy and also for the case with no
healing with conservative treatment.
Antibiotics
CHRONIC OSTEOMYELITIS

The usual organisms (and with time there is always a


mixed infection) are Staph. aureus, E. coti, S. pyogenes,
Proteus and Pseudomonas;
In the presence of foreign implants Staph. cpidermidis,
which is normally non-pathogenic, is the commonest of
all.
PATHOLOGY
Bone is destroyed or devitalized in a discrete area at the focus of infection
or more diffusely along the surface of a foreign implant.
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. The sequestra act as substrates
The histological picture is one of chronic inflammatory cell infiltration around
areas of acellular bone or microscopic sequestra.
Tulang dihancurkan pada area yang berlainan pada fokus infeksi atau lebih
berdifusi sepanjang permukaan implan luar
Cavitas2 yang berisi pus atau serpihan tulang yang mati (sequester)
mengelilingi sekitar jaringan vascular, dan melampaui area dari sklerosis
-Hasil dari pembentukan reaktif tulang baru kronik. Sequester sebagai
substrat -
Gambaran histologi adalah salah satu sel infiltrasi dari inflamasi kronik yang
berada sekitar area aselular tulang atau sequester mikroskopik
Example
Sinus tracts
Chronic skin
changes
CHRONIC OSTEOMYELITIS CHRONIC BONE INFECTION, WITH A
PERSISTENT SEQUESTRUM, MAY BE A SEQUEL TO ACUTE
OSTEOMYELITIS (A). MORE OFTEN IT FOLLOWS AN OPEN
FRACTURE OR OPERATION (B). OCCASIONALLY IT PRESENTS AS
A BRODIE'S ABSCESS (C).
CLINICAL FEATURES
The patient presents because pain, pyrexia, redness and tenderness have
recurred (a 'flare'), or with a discharging sinus.
Pasien datang dengan keluhan nyeri, pireksia, kemerahan dan nyeri tekan dan
merasakan rasa terbakar atau dengan sinus yang membengkak
In long-standing cases the tissues are thickened and often puckered or folded in
where a scar or sinus is attached to the underlying bone.
Pada kasus dalam waktu yang lama, jaringan menebal dan sering mengerut
atau terlipat dimana adanya bekas luka atau sinus yang terletak pada tulang
yang bawah (underlying bone)
There may be a sero-purulent discharge and excoriation of the surrounding skin.
Mungkin adanya pergantian sero-purulent dan eksoriasi dari jaringan sekitar
In post-traumatic osteomyelitis the bone may be deformed or non-united.
Pada post trauma OM, tulang mungkin mengalami deformitas atau non-union
Post Osteomyelitis Deformity of the Forearm
IMAGING
X-ray examination
Bone resorption with thickening and sclerosis of surrounding bone, loss
of trabeculation, area osteoporosis, periosteal thickening, sequestra, or
the bone crudely thickened and misshapen

Radioisotope scintigraphy
Sensitive but not specific. Using 99m Tc-HDP for showing increased
activity of perfusion and bone phase and 67 Ga-Citrate or In-labelled
leucocytes for showing hidden foci of infection

CT and MRI
Show the extent of bone destruction and reactive edema, hidden
abscess and sequestra
INVESTIGATIONS
ESR and blood white cell count may be
increased; are helpful in assessing the
progress of bone infection but they are not for
diagnostic.
LED dan penghitungan SDP mungkin meningkat
membantu dalam memperkirakan perkembangan
dari infeksi tulang tetapi bkn u/ diagnosis
Organisms cultured from discharging sinuses
should be tested repeatedly for antibiotic
sensitivity; with time, they often change their
characteristics and become resistant to treatment.
Kultur jaringan dari sinus yang rusak harus dites
sering untuk sensivitas antibiotik, dengan waktu,
mungkin dapat merubah karakteristik bakteri tsb
dan lebih resisten thd pengobatan
Treatment
Antibiotics ; Fucidic acid,
clindamycin and
cephalosporins
Local treatment : incision and
drainage
Operation
THANK
YOU