OSTEOMYELITIS

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 Definition
O Osteomyelitis is an infection of the bone
that results in inflammation, necrosis, and
formation of new bone

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 Classification
O Hematogenous osteomyelitis - due to
bloodborne spread of infection

O Contiguous-focus osteomyelitis - from

contamination from bone surgery, open
fracture, or traumatic injury

O Osteomyelitis with vascular insufficiency-

diabetes and peripheral vascular disease, most
commonly affecting the feet

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 Risk factors
O Poorly nourished

O Old age

O Obesity

O Impaired immune systems

O Chronic illnesses

O Use of long-term corticosteroid therapy or other

immunosuppressive agents. 4
 Osteomyelitis
O Bone infections are more difficult to
eradicate because the infected bone is
mostly avascular and not accessible to the
body’s natural immune response

O There is decreased penetration by

antibiotics

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 Pathophysiology
O The initial response to infection is inflammation,
increased vascularity, and edema

O After 2 or 3 days, thrombosis of the local blood

vessels occurs, resulting in ischemia with bone
necrosis.

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 Pathophysiology…..
O The infection extends into the medullary cavity and
under the periosteum and may spread into adjacent soft
tissues and joints

O A bone abscess forms

O The resulting abscess cavity contains dead bone tissue

(the sequestrum), which does not easily liquefy and
drain
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 Pathophysiology…..
O New bone growth (the involucrum) forms and
surrounds the sequestrum

O Although healing appears to take place, a

chronically infected sequestrum remains and
produces recurring abscesses throughout the
patient’s life.

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 Clinical Manifestations
O When the infection is bloodborne, the onset is
usually sudden, occurring often with the clinical
and laboratory manifestations of sepsis (eg,
chills, high fever, rapid pulse, general malaise).

O As the infection extends through the cortex of the

bone, it involves the periosteum and the soft
tissues.

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 Clinical Manifestations….
O The infected area becomes painful, swollen, and
extremely tender

O Patient may describe a constant, pulsating pain

that intensifies with movement as a result of the
pressure of the collecting purulent material

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 Clinical Manifestations….
O When osteomyelitis occurs from spread of
adjacent infection or from direct
contamination, there are no symptoms of
sepsis

O The area is swollen, warm, painful, and tender

to touch

O The patient presents with a nonhealing ulcer

that overlies the infected bone with a
connecting sinus that will intermittently and
spontaneously drain pus
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Assessment & Diagnostic Findings
O In acute osteomyelitis, early x-ray findings
demonstrate soft tissue edema

O In about 2 to 3 weeks, areas of periosteal

elevation and bone necrosis are evident

O Radioisotope bone scans & MRI help with early

definitive diagnosis

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Assessment & Diagnostic Findings

O Blood studies reveal leukocytosis and an

elevated ESR

O Wound and blood culture studies are

performed

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 Assessment & Diagnostic Findings

O With chronic osteomyelitis, large, irregular

cavities; raised periosteum; sequestra; or
dense bone formations are seen on x-ray

O Bone scans may be performed to identify

areas of infection

O Anemia, associated with chronic infection,

may be evident

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 Prevention
O Elective orthopedic surgery should be
postponed if the patient has a current infection

O During orthopedic surgery - attention is paid to

the surgical environment & to techniques to
decrease direct bone contamination.

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 Prevention….
O Prophylactic antibiotics can be administered

O Urinary catheters and drains are removed as soon as

possible to decrease the incidence of hematogenous
spread of infection

O Prompt management of soft tissue infections reduces

extension of infection to the bone

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 Medical Management
Pharmacologic Therapy
O IV antibiotic therapy - as soon as the culture specimens are
obtained

O Aim is to control the infection before the blood supply to the

area diminishes as a result of thrombosis

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 Medical Management
O Around-the-clock dosing is necessary to maintain a
high therapeutic blood level of the antibiotic

O IV antibiotic therapy continues for 3 to 6 weeks

O After the infection appears to be controlled, the

antibiotic may be administered orally for up to 3
months

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 Surgical Management
O If the infection is chronic and does not respond
to antibiotic therapy, surgical débridement is
indicated

O The infected bone is surgically exposed

O the purulent and necrotic material is removed

O The area is irrigated with sterile saline solution

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 Surgical Management
O Antibiotic-impregnated beads may be placed in
the wound for direct application of antibiotics for
2 to 4 weeks

O IV antibiotic therapy is continued.

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 Surgical Management…
O In chronic osteomyelitis, sequestrectomy (removal of
enough involucrum to enable the surgeon to remove
the sequestrum) is performed

O All dead, infected bone and cartilage must be

removed before permanent healing can occur

O A closed suction irrigation system may be used to

remove debris

O Wound irrigation using sterile saline solution may be

performed for 7 to 8 days. 23
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Surgical Management…
O The wound is either closed tightly to

obliterate the dead space or packed and

closed later by granulation or by grafting.

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 Nursing Interventions – pain
O Immobilize the affected part – to relieve pain and
muscle spasm

O Monitor the neurovascular status of the affected

extremity

O Elevation reduces swelling and associated discomfort

O Pain is controlled with prescribed analgesic agents and

other pain-reducing techniques.
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 Improving physical mobility
O Restrict activity

O The bone is weakened by the infective process -

must be protected by immobilization devices/
avoidance of stress on the bone

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 Controlling the Infectious Process
O Monitor the patient’s response to antibiotic
therapy

O Observe the IV access site for evidence of

phlebitis, infection, or infiltration

O Monitor the patient for signs of

superinfection (eg, oral or vaginal
candidiasis, loose or foul-smelling stools)

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 Nutrition
O Monitor the general health and nutrition of the
patient

O A diet high in protein promotes a positive

nitrogen balance and healing

O Encourage adequate hydration

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