Osteomyelitis

Osteomyelitis – Acute Marrow

DEFINE

It is an acute infection of bone and bone marrow secondary to non-traumatic, from a primary extra-bone infection, hematogenous to bone fixation, caused by common bacteria.

This is an absolute first aid, must be handled quickly by:

• “The right antibiotic should be given within hour”
• Powder bandages motionless must be completed within the first two hours” (Musset, 1989).

CHARACTERISTIC

In terms of infection

Common bacteria

• Most are Staphylococcus aureus
• The coccidiosis, pneumococci, Haemophilus, cocci, etc.

The primary source of infection is in the patient's body

• Ear, nose and throat
• Tooth
• Lung
• Urology
• Digest
• Out skin

Blood-borne infections 

Produces an early severe sepsis

To the bone - marrow

• Bacteria immobilized in the medullary venous sinuses cause acute osteomyelitis, which obstructs blood flow from the periosteum and increases intramedullary pressure. Normal pressure in children is < 60 mm of water. The pressure in the osteomyelitis can increase from 300 to 500 mm of water (YF Ysakov) causing severe pain, such as stabbing thigh, side-to-side awl, which also prevents antibiotics from being administered or Oral instillation into the osteomyelitis area at very low doses, is less effective.
• Subperiosteal abscess formation
• Congested blood vessels also facilitate osteomyelitis for dead, dead bones.

In terms of blood vessels in the medulla oblongata:

• In the nursing infant (infant) there are many lateral vessels that connect the vessels at the tip of the bone to the metaphysis. Therefore, osteomyelitis - myelitis in nursing infants, in addition to general characteristics, spreads to the bone body, the infection is also easy to spread into the joint causing joint infection.
• In older children, synaptic cartilage is clearly formed, preventing the communication between blood vessels in the medulla oblongata. At this age, acute osteomyelitis does not spread into the joint.
• In adults, without the synovial cartilage, acute osteomyelitis can also spread to the joint.
• Particularly for all ages, the metaphysis of the lateral femoral head is within the scope of hip joint. So osteomyelitis - the bulbar fascia on the femur is more likely to develop into hip arthritis.

CLASSIFICATION OF Osteoarthritis – Marrow

Weiland (1989), divided osteomyelitis according to the degree of osteomyelitis as follows:

• Grade I: only causes soft tissue lesions
• Độ II: các tổn thương bao gồm các tổn thương mô mềm, xương và tủy xương
• Grade III: like grade II osteomyelitis, with additional bone loss. Regarding the nature of osteomyelitis - the above author prescribes:
• Acute: if bone fistula, appears short-term, less than 6 months
• Chronic: if the fistula persists for more than 6 months. Chronic osteomyelitis can last for years or even decades.

If traumatic osteomyelitis is a purely surgical infection, then hematogenous osteomyelitis is a medical-surgical infection:

If osteomyelitis-myelitis is detected early, has not caused any damage or only caused mild soft tissue damage, it is completely possible to use antibiotics and other conservative treatment means (casting, ...) to cure. not completely

Once the bone and marrow lesions have formed, only surgery combined with antibiotics can be expected to cure.

SUCCESSFUL Acute Osteomyelitis

Take the case of a perfectly healthy suckling baby, suddenly the following factors appear:

Severe infection syndrome

High fever 40^oC, whole body shivering, sweating and rapid pulse.

Severe acute bulbar pain syndrome

Pain like a burn person, like "being stabbed through the thigh from side to side, pain like an awl" into the flesh.

Pain is like being fracture (which actually has no fractures); was hungry, but the mother took the baby's breast and brushed it away.

The baby keeps the thighs lying very still, does not dare to move, does not let them touch the thighs.

Initially diffuse pain due to pus stasis, later high intramedullary pressure causes typical severe pain.

Based on only two conditions: severe pain syndrome, accompanied by high fever, an acute case of osteomyelitis can already be thought of.

1. Clinical examination

- Ask the patient:

+ Age of the pediatric patient: this case is the baby at nursing age (most other cases are in childhood, sometimes the disease begins in adults, but very rarely)

+ Old acquired diseases

+ Have you recently had an injury?

- On-site examination:

The affected area is in near the knee joint, trong khi đó: khớp gối ở tư thế gấp nhẹ, song khớp gối vẫn có thể gấp từ tốn nhẹ nhàng được. Khớp gối màu sắc da bình thường. Không có dấu hiệu chạm xương bánh chè.

Pathological pain center is metatarsal region, above the knee joint. As for the knee joint, although in a slightly flexed position, when examined skillfully and gently, there are absolutely no symptoms.

No skin infection, no swollen lymph nodes, no pain.

- Full body examination:

The typical case of sepsis is described above.

+ Check for splenomegaly

+ Try to find the primary source of infection: in the ears, nose, throat, skin, lungs.

2. Differential diagnosis

- Tuberculosis of bone:

+ Chronic disease

+ Only causes bone destruction (the process of creating new bone is very poor)

Infectious arthritis:

+ Location of disease: in joints

– Bone tumor:

+ Non-infectious disease: completely different disease (no history of infection).

3. Immediate treatment

Sufficient severe pain in the metaphysis and severe sepsis are sufficient to warrant immediate treatment, even though no musculoskeletal lesions have been observed. X-ray, no need to wait for subclinical results. With early treatment, it is hoped that medical treatment can control acute hematogenous osteomyelitis.

Children must be admitted to the hospital:

• Prompt and appropriate antibiotic treatment
• The immobilizer band is long enough to immobilize both joints (hip and knee joints).

4. Additional tests

Immediately in the emergency room:

X-ray: compare both knee joints (full two aspects), guaranteed film quality.

Usually when the early X-ray films do not give any clear pictures, it is necessary to do to:

• Eliminate other injuries or illnesses
• Using the initial film as a standard to compare images with later radiographs is very useful for monitoring the progression of inflammation.

Tests:

• Blood cultures: at least 3 times before antibiotic treatment
• Culture of fluids taken from foci of skin infection (ear, nose, throat)
• Antibiotic chart
• Complete blood count (white blood cell count, erythrocyte sedimentation rate).

5. how to perform antibiotic treatment quickly

As mentioned in the infection section, antibiotics given orally and intravenously (muscular and intravenous) are difficult to cross the periosteal thrombophlebitis barrier; Large doses of antibiotics for inflammation have a low rate and have little therapeutic effect.

Using a trocar, penetrate the hard wall of the inflamed metatarsal region (the patient is anesthetized) into the canal. This move serves three purposes:

• Lowers the pressure in the inflamed canal. After the root canal, the patient stopped crying, ate and slept well
• Take bone marrow fluid for bacteriological and antibiotic testing. Timely identification of disease bacteria
• Trocar (with barrel) fixed to the cast is an antibiotic infusion directly into the fovea of osteomyelitis according to the required dose per day. Store the trocar for the duration of antibiotic use.

Monitor the effectiveness of treatment

Regular mass inspection every 10 days.

• Clinically:

+ Osteitis area: open the powder window: examine for pain, heat, other signs of inflammation.

+ Whole body: daily temperature evolution line

+ Weight

• Eat and sleep
• General condition

• Regarding biochemistry:

+ Polymorphonuclear leukocytes, VS

Continuous blood culture at each fever peak

+ Antibiogram.

• X-ray of the area of osteomyelitis: when removing the powder, take both sides, the quality is guaranteed.

Instant developments

After 10 days of treatment, one of the following three conditions may be encountered:

• Complete remission of the disease:

Is prescribed a total return to normal after 10 days of emergency treatment, with the following controls:

Clinical control:

• No signs of pain and inflammation
• Temperature back to normal
• Better overall condition.

Biochemical control:

• Blood count, VS back to normal
• Blood culture: bacteria do not grow.

However, cure was only determined based on strict criteria of prolongation of normal values, according to regular statistical tables every 10 days.

The cast should be removed only after clinical, biochemical, and radiological values have returned to normal for at least one month.

• Incomplete remission:

If after 10 days of treatment there are still minor symptoms of infection or inflammation:

Clinically:

• Mild pain, mild edema, heat in the inflamed area, soft tissue feeling a little cake (empâtement) in the inflamed area.
• Slight fever.

+ Biochemistry

• Slight increase in polymorphonuclear leukocytes
• VS ramps up a bit fast.

+ Must be extended:

• Antibiotic
• Immobilized cast iron.

Usually the osteomyelitis goes away eventually.

Sometimes, late purulent or chronic osteomyelitis occurs.

• Purulent development:

Purulent appearance from 10 days followed by another 10 days, subperiosteal pus, accompanied by:

+ Persistent pain when bending

+ Touching the inflamed extremities feels "cold" or clumsy

+ Signs of inflammation are back (swelling, heat, redness, pain)

+ Body as a whole: fluctuating fever (sometimes not high), polymorphonuclear leukocyte elevation, VS speed up

+ X-ray (casting removed): two typical images

• If the contrast is poor (osteoporosis)
• The solid periosteal border (periosteal reaction, dead bone) creates an image of hard, double-walled bones.

With the above purulent developments, the lesions have formed clearly:

+ The period of only conservative treatment with antibiotics is over, if it continues, it will fail

+ Must be resolved from this stage with surgery accompanied by appropriate antibiotics.

Late developments

Immediate progression to complete remission of osteomyelitis can occur, but is rare. The majority of cases of osteomyelitis - hematopoietic osteomyelitis develop later in life.

• Favorable developments:

+ Osteomyelitis - blood sugar is completely cured, must be based on strict criteria to determine for sure:

• The patient's fever is gone, fluctuating for a long time, local signs are completely gone
• WBC count and erythrocyte sedimentation rate normalized stable for at least 1 month
• The X-ray images are normal, stable for at least 1 month.

If all of the above symptoms are met, the immobilizer can be removed and the antibiotic should be discontinued 3 months later.

• Chronic osteomyelitis:

It is the common condition of most cases of hematopoietic osteomyelitis. A big risk today is because bacteria are resistant to antibiotics, giving antibiotics not enough and not matching the type, because a doctor suddenly used corticosteroids in the treatment of osteomyelitis - myelitis.

All clinical signs, biochemical tests, and radiographs do not completely eliminate pathological signs.

Prolonged antibiotic use appears to improve, but disease criteria persist.

This is the stage to prepare for chronic osteomyelitis.

ABSTRACT

Acute hematogenous osteomyelitis is an absolute emergency:

• Need to be diagnosed very early, to
• Timely emergency treatment. Early diagnosis is based on two conditions:
• A severe sepsis syndrome
• Acute severe pain in the metatarsal region in an otherwise healthy child.

Physicians can quickly identify the disease by lumbar puncture (and long-term trocar storage):

• Take specimens for microbiological testing: fresh scan, culture
• The patient's pain is gone immediately after the puncture

Emergency treatment must be done quickly (do not wait for test results, from fresh scan results).

Hospitalize:

• Give antibiotics (intravenous drip and injection into the inflammatory site through the probing trocar)
• The cast immobilizes both joints at both ends of the inflamed bone.

Only with urgent early treatment as above can we hope to cure acute osteomyelitis by medical alone (antibiotics + immobilization). When bone-marrow lesions have formed, it is necessary to have surgery + appropriate antibiotics to hope to cure the disease.

osteitis and osteitis – MEDAL MEDICINE

PREAMBLE

Relatively less acute osteomyelitis and osteomyelitis in adults is very different from osteomyelitis in children:

In adults with acute osteomyelitis, blood glucose is rare

The disease here is mainly post-traumatic osteomyelitis and chronic osteomyelitis.

Define

• Infected bone from the outside into the bone directly, the causative factor of trauma (open fracture) or due to surgery (combination of a fracture or osteotomy, etc.). Traumatic osteomyelitis is a primary surgical infection. Only surgical removal can cure the disease.

Common bacteria may be encountered.

• The severity of this type of osteomyelitis is in the following factors:

+ Can't get rid of osteoarthritis naturally

+ Difficult treatment, often ineffective

+ Tendency of osteomyelitis to chronic disease.

It is the most common form of bone infection in adults.

Note: Children can also develop these forms if they are caused by an open fracture or by an infected bone surgery.

Early stage of infection

This is mainly the new infection stage (before the third week), before the bone inflammation has already formed. Days following initial surgery, the following symptoms (sometimes acute) appear:

• High fever
• Chills
• Inflammation of the incision site, with pus at the site
• Hurt.

Often when symptoms are very insidious:

• Temperature ranges from 37.5 to 38^o, sometimes with a higher fever peak
• Examination reveals normal wound, sometimes it is necessary to poke to see pus in the incision.

Osteoarthritis stage

The term imperative refers to an untreated or poorly treated post-traumatic infection.

• Need to see:

+ Has the bone healed yet?

+ Are there still bone fusion devices in place?

• Diagnosis is not difficult:

History of trauma or surgery. Infection after surgery

+ Fistula distal to surgical scar or oozing of surgical scar tip or chronic ulceration of skin directly above or soft tissue abscess

+ Inflammation of the surgically operated limb

The term imperative refers to an untreated or poorly treated post-traumatic infection.

• Need to see:

+ Has the bone healed yet?

+ Are there still bone fusion devices in place?

• Diagnosis is not difficult:

History of trauma or surgery. Infection after surgery

+ Fistula distal to surgical scar or oozing of surgical scar tip or chronic ulceration of skin directly above or soft tissue abscess

+ Inflammation of the surgically operated limb

Examination with pictures

• Standard X-ray:

+ The two planes of the face and the side can see the whole inflamed bone and the two joints at both ends

+ Focused film

+ Film taken in ¾ position.

• CT scan
• Soft-ray film.

• Visible symptoms of infection:

+ Bone loss: images of obtuse bone, bone loss cavity

+ Blur image around the inflammatory area

Reaction of the periosteum.

• Hard-to-identify images:

+ Fistula capture (minimum two basic planes)

+ Computed tomography (only taken when there is no bone fusion material inside).

THE PRINCIPLES OF TREATMENT

Antibiotic treatment:

Alone, even based on antibiogram, it does not cure traumatic osteomyelitis.

It is necessary to use surgical treatment to be effective

1. Clean the infection drive

Remove the prison bone, remove the infected tissue and caseation, remove foreign bodies, especially remove bone-combining materials that are no longer effective in stabilizing (if the device is necessary to fix broken bones, it can be kept, waiting until bone healing steady; when the ostomy device is allowed to be removed, the pus will clear).

2. If the area of bone loss may threaten to break must make a cast or better use an external fixed frame for immobilization protection.

3. Inflammatory drainage is mandatory

4. Filling the cavity of bone loss due to excision with

Wick gauze impregnated with tamanu oil, change the dressing continuously to stimulate granulation tissue to fill up (Nguyen Quang Long) or pull soft tissue to cover if the cavity is shallow bone loss.

Use flaps with feeders or use bone grafts (Papineau style) to fill in deep bone loss cavities.

5. Cover the skin with

• Closed first period with continuous suction drainage
• Ghép da nông hoặc skin flap cơ
• Or make natural skin healing with Beck drill and tau tau (NQ Long) oil impregnated tape.

Healing from osteomyelitis

It is difficult to confirm, requiring a long clinical and radiological follow-up for many years.

ABSTRACT

• As a primary osteomyelitis, pathogenic bacteria from the external environment enter the bone through a wound (or incision).
• This is a completely surgical bone and marrow infection: only proper early wound debridement (surgical management) + appropriate short-term antibiotics can cure osteomyelitis.

All attempts to treat with antibiotics alone have failed.