Transcript
Page 1: Osteomyelitis Case Report Session

Case Report SessionOsteomyelitis

Pembimbing:Dr. Yoyos Dias Ismiranto, dr. SpOT., M.Kes FICS

Penyusun: Devyashini Prabhakaran

Bagian Orthopedi dan TraumatologiFakultas Kedokteran

Universitas PadjadjaranBandung

2014

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1. Identitas Pasien• Nama :Tn. DA

• Umur :30 thn

• Jenis kelamin : Laki-laki

• Agama : Islam

• Alamat : Kg. Babakan,RT 01, RW 06,Citapen, Cihampelas, Bandung

• Status Pernikahan : Bernikah

• Pekerjaan : Buruh

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• Anamnesa

KU: Keluar nanah dari lengan atas kanan

• Anamnesa khusus:

– 2 tahun SMRS, os mengeluh timbul bisul dilengan atas kanan. Bisul pecah denganmengeluarkan nanah. 1 bulan yang lalu, osdilakukan operasi pembersihan tulang danpemasangan selang antibiotik. Sekarang nanahberkurang dan selang antibiotik nyeridilepaskan.

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• Riwayat penyakit dahulu: Post op debridement + sequestrectomy + AB beads

• Riwayat penyakit pada keluarga: tidak ada.

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Pemeriksaan Fisik

Keadaan umum : Compos MentisTanda vital Tensi : 100/70 mmHg Nadi : 80 x/menit Respirasi : 20 x/menit Suhu : 36,6 oCStatus GeneralisKepala : Konjungtiva tidak anemis, Sklera tidak ikterikLeher : KGB tidak teraba membesarDada : Bentuk dan gerak simetris, VBS ki=ka, rhonki (-/-)

wheezing (-/-),Bunyi jantung murni regulerAbdomen : Datar dan lembut, Bising usus (+) normal, Hepar dan

lien tidak teraba, Ruang traube kosongEkstremitas : Lihat status lokalis

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Status Lokalis:

a/r humerus

L : Scar (+),Swelling (+), pus (+), fistel (+)

F : NT (+), sensitibilitas dalam batas normal, kapiler refil (+ <2 detik)

M : elbow stiffness 90°

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Pemeriksaan Penunjang

• Lab Darah

• X-ray

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• Tampak lesi litik dansklerotik pada 1/3 distal oshumerus dan 1/3 proximal os radius.

• Tampak lesi periosteal pada1/3 distal os humeruskanan dan 1/3 proksimal osradius kanan

• Kesan: menyokong suatuosteomielitis kronis

Foto elbow

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Foto Thorax

•Kesan: Cor dan pulmo tidaktampak kelainan

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Diagnosis kerja

• Post debridement + sequestrectomy + AB beads due to chronis ostemomyelitis a/rHumerus

Treatment• Removal of AB beads and debridement

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Prognosis

• Ad vitam : Bonam

• Ad fungtionam : Dubia ad bonam

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Pembahasan Osteomyelitis

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Definisi

• Suatu proses inflamasi akut ataupun kronis daritulang dan struktur-struktur disekitarnya akibatinfeksi dari kuman-kuman piogenik

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Patogenesis

• Infeksi dapat berkembang melaluibeberapacara, yaitu :

– Penyebaran hematogen dari infeksi di bagiantubuh lain (osteomielitis hematogen)

– Pembedahan jaringan tubuh terpapardenganlingkungan sekitarnya (osteomielitisesogenik)

– Luka penetrasi langsung (osteomielitis esogenik)

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Insiden

• Osteomielitis akut hematogen : anak-anak

• Osteomielitis dari trauma direk /contiguous: usiaremaja dan dewasa muda

• Spinal osteomielitis : usia > 45 tahun

• dapat pula ditemukan pada bayi dan ‘infant’

• Anak laki-laki > anak perempuan (4:1)

• Lokasi yang tersering : tulang-tulang panjang

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Klasifikasi

• Menurut durasi (tradisional)– Akut (7-14 hari)– Subakut (14 hari -3 bulan)– Kronik (> 3 bulan)

• Menurut etiologi dan kronisitas (Waldvogel)– Hematogen– Contiguous– Kronik

• Menurut penyebaran anatomis (Cierny-Mader )– Stadium I -Medular– Stadium II -Cortex superfisial– Stadium III- medular dan korteks terlokalisasi– Stadium IV- Medular dan korteks difus

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Presentasi klinis

• Osteomielitis hematogen

• Sesuai gejala dan tanda inflamasi akut

• Nyeri terlokalisasi

• Penderita menghindari menggunakan bagiantubuhyang sakit

• PF : nyeri tekan lokal, pergerakan sendi terbatas,oedemdan kemerahan jarang ditemukan

• Gejala sistemik : demam, malaise, menggigil, nafsumakan menurun

• Lab : peningkatan CRP ,LED, dan leukosit

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Presentasi klinis

• Osteomyelitis subakut

• Sering pada anak-anak

• Akibat kuman bervirulensi rendah tanpa gejala

• Gambaran radiologis :– Seperti osteomielitis akut osteolisis dan elevasi

periosteal

– Seperti osteomielitis kronik zona sirkumferensialtulangyang sklerotik

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Presentasi klinis

• Osteomielitis kronik

• Akibat infeksi akut atau subakut yang tidakdiobati

• Ulkus persisten

• Fistel atau drainase pus

• Fatigue

• Malaise

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Pemeriksaan Penunjang

• Pemeriksaan darah lengkap

• Kultur

• Fotopolos

• Ultrasound

• Radionuklir

• CT Scan

• MRI

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Pemeriksaan radiologis• Foto polos

– Osteomielitis awal : tidak ada kelainan radiologis– 7-10 hari: area osteopeni yang mengarah ke destruksi tulang, tampak

reaksi periosteal

• Osteomielitis kronik– Destruksi tulang yang masif– Involukrum (new bone formation)– Sequestrum (dead bone)

• Gas gangrene radiolusen• USG

– Berguna untuk mengidentifikasi efusi sendi– Baik digunakan utk osteomielitis akut pada pediatrik dapat

mendeteksi dalam 1-2 hari awal penyakit– Soft tissue abses dan reaksi periosteal– Tidak dapat mendeteksi infeksi korteks

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Pemeriksaan radiologis

• CT Scan

– Digunakan pada tulang-tulang dengan anatomikompleks pelvis, calcaneum, sternum, vertebra

– Dapat mendeteksi kalsifikasi, osifikasi, danabnormalitas intrakortikal

• Radionuklir

– Menggunakan technetium 99m

– Sangat sensitif namun tidak spesifik untuk infeksItulang

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Diagnosis Banding

• Osteomielitis: – Jaringan lunak terjadi pembengkakan yang difus

– 4-6 mingguuntukmenghancurkantulang

• Histiocytosis sel Langerhans:– Tidak terlihatsecara signifikan

pembengkakan jaringan lunak atau massa

– 7-10 hari untukmenghancurkantulang

• Ewing Sarkoma– Jaringan lunaknya terlihat sebuah massa

– 4-6 bulan untuk menghancurkan tulang

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Penatalaksanaan

• Tirah baring

• Pertahankan keseimbangan cairan, elektrolit danstatus gizi

• Antipiretik bila demam, analgesik bila nyeri

• Antibiotika diteruskan hingga 6 minggu– Ciprofloksasin, Ceftriaxone

– Ceftazidime, Ceftazolin, Nafcillin

• Evaluasi hasil terapi dengan pemeriksaan CRP danLED setiap minggu

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Penatalaksanaan

• Intervensi bedah

– Menghilangkan semua jaringan mati dan bendaasing

– Sequestrum dibuang dengan meninggalkaninvolukrum

– Debridemen kulit, subkutan, dan otot

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Komplikasi

• Abses tulang

• Bakteremia

• Fraktur

• Selulitis

• Fistel

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Surgical treatment

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Bone Debridement:

• The goal of debridement is to leave healthy, viable tissue.

• Débridement of bone is done until punctate bleeding is noted, giving rise to the term the paprika sign.

• Copious irrigation with 10 to 14 L of normal saline.• Pulsatile lavage using fluid pressures 50-70 pounds

per square inch and 800 pulses per min.• The extent of resection is important in B hosts as B

hosts treated with marginal resection (i.e., with a clearance margin of <5 mm) found to have a higher rate of recurrence than normal hosts.

• Repeated debridements may be required.

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Sequestrectomy and curettage. A, Affected bone is exposed, and sequestrum is removed. B, All infected matter is removed. C, Wound is either packed open or closed loosely over drains.

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Early sequestrectomy

- Eradicate infection

-Better environment for periosteum to respond

Delayed sequestrectomy

-Wait till sufficient involucrum has formed beforedoing a sequestrectomy to mimimize the risk offracture, deformity & segmental loss

When to do sequestrectomy?

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Prerequisites for Sequestrectomy

Radiological

• Well formed involucrumsurrounding the discretely visible sequestrumadequately at least 2/3rd diameter of bone (3 intact walls on two views ensure 3/4th intact walls)

Clinical

• Symptomatic patient with pus discharge or chronic unreleaveddisabling pain due to osteomyelitis per se and type A/B host.

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Management of Dead Space:Antibiotic Beads

May be used to sterilize and temporarily maintain adead space.

Beads are made with PMMA+ab

Cement -40 gm.

Genta- 1-2 gm. or vanco 1-2 gm.

Other antibiotics that can be used are Tobramycin,Penicillin, cephalosporins, amikacin, vancomycin.

The gentamycin concentration remain for 30 daysafter implantation.

The shape and type of methylmethacrylate has asignificant effect on the amount of antibioticdelivery, as well as duration.

The best delivery profile was with PMMA beadsimpregnated with gentamicin.

Usually removed within two to four weeks and arereplaced with a cancellous bone graft.

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Antibiotic beads:

• Can act as a biomaterial surface to which bacteriapreferentially adhere.

• To avoid such a problem, biodegradable antibiotic-impregnated (calcium sulfate) beads have beenemployed recently and have shown favorable antibioticrelease kinetics

– Elution testing of 4% by weight loaded calciumsulfate pellets revealed a maximum concentrationof 828 µg/ml and undetectable levels by day 15.

• Antibiotic-impregnated cancellous bone grafts wererecently used in a clinical trial of forty-six patients, andthe osteomyelitis was arrested in 95% of them

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Management of Dead Space:

• Antibiotics (clindamycin and amikacin) havealso been delivered directly into dead spaceswith an implantable pump.

• Very high local and low systemic levels ofantibiotics have been achieved.

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Soft-Tissue Coverage:

• Three methods commonly used:– Primary closure- if no infection– Let tissue heal by secondary intention– Small soft-tissue defects may be covered with a split-

thickness skin graft.– Local muscle flaps and free vascularized muscle flaps in

the presence of a large soft-tissue defect or aninadequate soft-tissue envelope.

• Healing by so-called secondary intention should bediscouraged, since the scar tissue that fills the defect maylater become avascular.

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Bone Stabilization:

• If skeletal instability is present at the site of an infection, measures must be taken to achieve stability with

– Plates

– Screws

– Rods

– An external fixator

• External fixation is preferred over internal fixation because

– of the tendency of the sites of medullary rods to become secondarily infected and to spread the extent of the infection.

• Rigid fixation helpful in union of fracture sites.

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Limb reconstruction:• Ilizarov external fixation

– Is used for reconstruction of segmental defects and difficult infectednonunions.

– Based on the technique of distraction osteogenesis whereby anosteotomy created in the metaphyseal region of the bone is graduallydistracted to fill in the defect.

– Used for difficult cases of osteomyelitis when stabilization and bone-lengthening are necessary.

– May also be used to compress nonunions and to correct malunions.

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AMPUTATION:

• Infrequently performed

• INDICATIONS

1. Malignancy

2. Arterial insufficiency

3. Nerve paralysis

4. Jt. Contracture & stiffness making limbnonfunctional

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