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Chronic Osteomyelitis of The Right Knee + UNION FRACTURE RIGHT DISTA FE!

UR AND DISTA TI"IA

By: Rismayanti. H (C 111 07 245) Advisor : dr. Rico dr. Luthfi SUPER !S"R: dr. #. S$%ryadi S%."&

'(%artm(nt o) "rt*o%a(di+ and &ra$mato,o-y .a+$,ty o) /(di+in( Hasan$ddin Univ(rsity

PA&!E0& !'E0&!&1

0am( A-( S(2

: /r. A : 71 y(ars o,d : /a,( : 0ov(m3(r : 517766

Admission 'at( 04t* 5 2016 R(-istration 0o.

History T#$ing
Chief complaint : Wound & discharge at the right knee Anamnesis : Suffered since 1 month ago before admitted to Wahidin hospital. Pain ( !" fe#er ($!" %istor& of fe#er ( ! since ' months ago" s(elling ( !. %istor& of operation (ith implantation on the right femur and right tibia on )o#ember *+11 at Wahidin hospital due to traffic accidents. %e (as ridding and got hit b& another motorc&cle from opposite direction.

%hysic#l E&#min#tion
7(n(ra, Stat$s : Composmentis,-ood nourished ita, Si-n
.P:

1*+,/+ %0 : /12,mnt 00 : *+2,mnt 3 : 4'"' 5C

oc#li'e( St#t)s
Ri-*t 8n(( r(-io

6nspection:

Wound on anterior aspect of right 7nee si8e of * 2 1 cm" serous discharge ( ! " reddish and blackish color around the (ound " deformit& ($!" hematoma ($!" edema ( !

Palpation :

3enderness ( !" (arm ( !

09::

Acti#e and passi#e motions of knee ;oint are limitted due to pain.

)<=:

-ood sensiti#it&" =orsalis pedis arter& palpable"

C03 > *?

C INICA I!AGING

R#(iologic E&#min#tion
Plate & screws are visualized at 1/3 distal of femur, callus forming on the fracture line (+), cortex irreguler and narrowing !itic lesion at right femur (the sign of acute osteom"elitis) #one mineralisation is decrease $oint s%ace and soft tissue still inta&

Plate & 'crews are visualized at 1/3 distal of ti(ia, callus forming on the fracture line (+) !itic lesion at os ti(ia and fi(ula ( the sigh of acute osteom"elitis) #one mineralisation is decrease (sign of osteo%orosis senilis) )arrowing of femoroti(ial *oint es%eciall" still inta& 'oft tissue still inta& at medial as%ect (osteoarthritis genu), an&le *oint

#*or#tory Fin(ing
Laboratory examination WBC RBC HGB HCT PLT GDS Ur/ Cr GOT /GPT CT /BT HBsAg L&D '"( ) '"( )) Results 7,3 x 103 3.92 x 106 10,4 32,5 465 x 103 153 25/0,9 20/12 800/300 !g"#$% 116 123

RESUME

+ male , ,1 "ears old with (ound and discharge at the right knee, since 1 months (efore admitted to wahidin hos%ital Pain (+), -istor" of fever (+) since . months ago, swelling (+) -istor" of o%eration with im%lantation on the right femur and right ti(ia on novem(er /011 at wahidin hos%ital due to traffic accidents %e (as ridding and got hit b& another motorc&cle from opposite direction 1n %h"sical examination of the right &nee 2 3ound on anterior as%ect of right &nee size of /x1 cm, serous discharge (+), reddish and (lac&ish color around the wound, deformit" (4), hematoma (4), edema (+)

Di#gnosis

Chronic

9steom&elitis of 3he 0ight 7nee

@nion right distal femur and distal tibia

!#n#gement
:edicamentosa:

Antibiotic
Surger&:

=ebridement 0emo#e

of implant

DISCUSSION
Osteomyelitis

ANATOMI OF THE THIGH

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ANTERIOR COMPARTMENT
MUSCLE Sartorius Re!tus "emoralis astus lateralis astus interme#ius astus me#ialis ORIGIN AS)S 1.A))S 2.S/.. "3!#",. r$( G#r. #r*34" #!r, 2"#. 2$ !" "s.!r" Pr*x$("2 %!(*r"2 s4"%# ) #!r#r*34" #. 2$ !, (!+. 2$ !" "s.!r" INSERTION Pr*x. (!+. #$,$" -.!s " s!r$/s0 P"#!22"/#$,$" #/,!r32! L"#. ."#!22"/#$,$" #/,!r32! P"#!22"/#$,$" #/,!r32! 5!+$"2 ."#!22"/#$,$" #/,!r32! NER E 1!(*r"2 1!(*r"2

1!(*r"2 1!(*r"2

1!(*r"2

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MEDIAL COMPARTMENT
MUSCLE Obturator externus ORIGIN )s34$*./,$3 r"($, *,#/r"#*r (!(, INSERTION P$r$%*r($s %*ss" NER E O,#/r"#*r

$##u!tor lon%us $##u!tor bre&is $##u!tor ma%nus

B*+6 *% ./,$s -$ %!r$*r0 B*+6 " + $ %!r$*r ./,$3 r"(/s 1.P/,$3 r"(/s 2. )sx4$"2 #/,.

L$ !" "s.!r" -($+ 1/30 P!3#$ !"2 2$ !, 2$ !" "s.!r" L$ !" "s.!r", "++. #/,!r32!

O,#/r"#*r O,#/r"#*r

1.O,#/r"#*r 2.S3$"s#$3

Gra!ilis

B*+6 " + $ %!r$*r ./,$3 r"(/s P!3#$ !"2 2$ ! *% ./,$s

Pr*x. (!+. #$,$" -.!s " s!r$/s0 P!3#$ !"2 2$ ! *% %!(/r

O,#/r"#*r

'e!tineus

1!(*r"2

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POSTERIOR COMPARTMENT
MUSCLE Semiten#inosus ORIGIN )s34$"2 #/,!rs$#6 )s34$"2 #/,!rs$#6 )s34$"2 #/,!rs$#6 L$ !" "s.!r", s/.r"3* +62"r 2$ ! INSERTION Pr*x$("2 (!+$"2 #$,$" -.!s " s!r$/s0 P*s#!r$*r (!+$"2 #$,$"2 3* +62! H!"+ *% %$,/2" 1$,/2", 2"#!r"2 #$,$" NER E S3$"s#$3 -#$,$"20 S3$"s#$3 -#$,$"20 S3$"s#$3 -#$,$"20 S3$"s#$3 -.!r* !"20

Semimembrano sus (i!e)s "emoris * Lon% +ea# (i!e)s "emoris *S+ort +ea#

7!##!rs C* 3$s! Or#4*.!+$3 A "#*(6 2 + !+$#$*

An#tomy of the leg

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'()inition o) "st(omy(,itis
3he

root (ords osteon (bone! and m&elo (marro(! are combined (ith itis (inflammation! 9steom&elitis is an infectious process that in#ol#es bone and its medullar& ca#it& (hich leads to a subseAuent 6nflammator& process.

Gr!! !,8. 7!##!rs Or#4*."!+$3 1s# !+

C,assi)i+ation
Bas(d

on ons(t
Hem#togeno)s

Acute Chronic

So$r+( o) in)(+tion
%ematogenous Contagenous =irect

Cont#geno)s

Direct infection

Port D entry

6nfection

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A+$t( "st(omy(,itis
9 9
Acute haematogenous osteom&elitis is mainl& a disease of children Btiolog&: Staph. aureus" gram$negati#e bacili" group . streptococcus

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Infection in the met#+hysis may spread towards the surface, to form a subperiosteal abscess Some of the *one m#y (ie, #n( is enc#se( in periosteal new bone as a sequestrum The enc#sing involucrum is sometimes perforated by sinuses

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%#thology
$nflammation (uppuration Bone &ecrosis
ascular con!estion "#udation of the fluid $nfiltratin! by P%&

Pus form within the bone and forces it way alon! the ol'man canal to the surface where it produce subperiosteal abcess

Bone death sequstra

Reactive new bone formation Resolution or chronic

&ew bone forms from the deep layers of the periosteum involucrum

$n some cases, remodellin! may restore the normal contour) $n others, the bone is left permanently deformed

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Si-n 9 Sym%toms
Signs

and s&mptoms can #ar& significantl&.

3he patient" usuall& a child" presents (ith se#ere pain" malaise and a fe#er 6n infants" elderl& patients" or immunocompromised patients" clinical findings ma& be minimal. Pain and local tenderness are common findings.

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:a3oratory
3he

most certain (a& to confirm the clinical diagnosis is to aspirate pus from the metaph&seal subperiosteal abscess or the ad;acent ;oint. 3he W.C and C0P #alues are usuall& high. .lood culture is positi#e in onl& about half the cases of pro#en infection.

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PCA6)

D$0AE

!ma-in-

Standard radiographs generall& are negati#e" but ma& sho( soft$ tissue s(elling. Skeletal changes" such as periosteal reaction or bone destruction" generall& are not seen on plain films until 1+ to 1* da&s into the infection

The first x-ray, 2 days after symptoms began, is normal it always is; metaphyseal mottling and periosteal changes were not obvious until the second film, taken 1 days later; eventually much of the shaft was involved!

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Soft

tissue s(elling (earl&!" bone deminerali8ation (1+$11 da&s!" seAuestra (dead bone (ith surrounding granulation tissue!" and in#olucrum (periosteal ne( bone! later. :06 : e2tremel& sensiti#e" e#en in the earl& phase of bone infection" and can help to differentiate bet(een soft$tissue infection and osteom&elitis. 0adioscintigraph& Sensiti#e but not specific.
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!#n#gement

Supporti#e treatment for pain and deh&dration Splintage of the affected part Antibiotic therap& Surgical drainage

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Com%,i+ation

Suppurati#e arthritis Pathological fracture Chronic osteom&elitis

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Chronic Osteomyelitis
Chronic

osteom&elitis represents unresol#ed acute infection

continuation

of

)o( da&s" it more freAuentl& follo(s an open fracture or operation. @sual organisms are staph&lococcus aureus" Bscherichia coli" Streptococcus p&ogens" Proteus and Pseudomonas.

APLEYS SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

St#ging For A()lt Chronic Osteomyelitis *y Cierny et #l. /01123

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Pat*o,o-y
.one

is destro&ed or de#itali8ed in a discrete area at the focus of infection. Ca#ities containing pus and pieces of dead bone (seAuestra! are surrounded b& #ascular tissue" and be&ond that b& areas of sclerosis the result of chronic reacti#e ne( bone formation. 3he histological picture is one of chronic inflammator& cell infiltration around areas of acellular bone or microscopic seAuestra.

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B$OP(*
+,old (tandard-

C/$&$C./

DIAGNOSIS

$%.,$&,

/.BOR.0OR*

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C,ini+a, )(at$r(s
Pain"

p&re2ia" redness and tenderness ha#e recurred" or (ith a discharging sinus. 3here ma& be a sero$purulent discharge and e2coriation of the surrounding skin.

APLEYS SYSTEM OF ORTHOPAEDICS AND FRACTURES 9TH EDITION

:a3oratory

BS0 and (hite blood cell count ma& be in+r(as(d 9rganisms cultured from discharging sinuses should be tested repeatedl& for antibiotic sensiti#it&.

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!ma-in D$ra&

e2amination
resorption (ith thickening there are marked #ariation:

.one

and sclerosis of surrounding bone


%o(e#er"

there ma& be no more than locali8ed loss of trabecculation" or a area osteoporosis" periosteal thickening" seAuestra sho( up as unnaturall& dense fragments.
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0adioscintigraph& Sensiti#e but not specific.

C3 and :06

Sho( the e2tent of bone destruction and reacti#e edema" hidden abscess and seAuestra

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/ana-(m(nt

Antibiotics 9peration :
=ebridement =ealing Soft

(ith the dead space

tissue co#er

APLEYS SYSTEM OF ORTHOPAEDICS AND FRACTURES 8TH EDITION

Com%,i+ation

A pathologic fracture )on union or segmental bone loss

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Th#n$ 4o)

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