I.

INTRODUCTION

Osteomyelitis is a local or generalized pyogenic disease of the bone, bone

marrow and surrounding tissue. In children, the disease usually results from untreated
acute hematogenous osteomyelitis. Chronic osteomyelitis may also be seen after
traumatic injuries, especially in times of civil unrest or war, or as a complication of
surgical procedures such as open reduction and internal fixation of fractures. The long
bones are affected most commonly, and the femur and tibia account for approximately
half of the cases. Predisposing factors include poor hygiene, anemia, malnutrition, and
a coexisting infectious disease burden (parasites, mycobacteria, acquired autoimmune
deficiency syndrome), or any other factors that decrease immune function. Chronic
osteomyelitis is defined by the presence of residual foci of infection (avascular bone and
soft tissue debris), which give rise to recurrent episodes of clinical infection.
Eradication of the infection is difficult, and complications associated with both
the infection and their treatments are frequent. Our goals are to review the
pathophysiology, natural history, and management for children with chronic
osteomyelitis within the context of a developing world setting.

II. ANATOMY AND PHYSIOLOGY

Human musculoskeletal system

A musculoskeletal system (also known as the locomotor system) is an organ

system that gives animals (including humans) the ability to move using
the muscular and skeletal systems. The musculoskeletal system provides form, support,
stability, and movement to the body.

It is made up of the body’s bone (the skeleton), muscles,

cartilage, tendons, ligaments, joints, and other connective tissue (the tissue that
supports and binds tissues and organs together). The musculoskeletal system's primary
functions include supporting the body, allowing motion, and protecting vital organs. The
skeletal portion of the system serves as the main storage system for calcium and
phosphorus and contains critical components of the hematopoietic system.

This system describes how bones are connected to other bones

and muscle fibers via connective tissue such as tendons and ligaments. The bones
provide the stability to a body in analogy to iron rods in concrete construction. Muscles
keep bones in place and also play a role in movement of the bones. To allow motion
different bones are connected by joints. Cartilage prevents the bone ends from rubbing
directly on to each other. Muscles contract (bunch up) to move the bone attached at the
joint.

There are, however, diseases and disorders that may adversely affect the
function and overall effectiveness of the system. These diseases can be difficult
to diagnose due to the close relation of the musculoskeletal system to other internal
systems. The musculoskeletal system refers to the system having its muscles attached
to an internal skeletal system and is necessary for humans to move to a more favorable
position.

Subsystems

Skeletal

The Skeletal System serves many important functions; it provides the shape
and form for our bodies in addition to supporting, protecting, allowing bodily movement,
producing blood for the body, and storing minerals. The number of bones in the human
skeletal system is a controversial topic. Humans are born with about 300 to 350 bones,
however, many bones fuse together between birth and maturity. As a result an average
adult skeleton consists of 206 bones. The number of bones varies according to the
method used to derive the count. While some consider certain structures to be a single
bone with multiple parts, others may see it as a single part with multiple bones. There are
five general classifications of bones. These are long bones, short bones, flat bones,
irregular bones, and sesamoid bones. The human skeleton is composed of both fused and
individual bones supported by ligaments, tendons, muscles and cartilage. It is a complex
structure with two distinct divisions. These are the axial skeleton and the appendicular
skeleton.

Function

The Skeletal System serves as a framework for tissues and organs to attach
themselves to. This system acts as a protective structure for vital organs. Major
examples of this are thebrain being protected by the skull and the lungs being protected
by the rib cage

Located in long bones are two distinctions of bone marrow (yellow and red). The
yellow marrow has fatty connective tissue and is found in the marrow cavity. During
starvation, the body uses the fat in yellow marrow for energy. The red marrow of some
bones is an important site for blood cell production, approximately 2.6 million red blood
cells per second in order to replace existing cells that have been destroyed by the liver.
Here all erythrocytes, platelets, and most leukocytes form in adults. From the red
marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their special
tasks.

Another function of bones is the storage of certain minerals. Calcium and

phosphorus are among the main minerals being stored. The importance of this storage
"device" helps to regulate mineral balance in the bloodstream. When the fluctuation
of minerals is high, these minerals are stored in bone; when it is low it will be withdrawn
from the bone.
 Muscular

There are three types of muscles cardiac, skeletal, and smooth. Smooth muscles
are used to control the flow of substances within the lumens of hollow organs, and are not
consciously controlled. Skeletal and cardiac muscles have striations that are visible
under a microscope due to the components within their cells. Only skeletal and smooth
muscles are part of the musculoskeletal system and only the skeletal muscles can move
the body. Cardiac muscles are found in the heart and are used only to circulate blood; like
the smooth muscles, these muscles are not under conscious control. Skeletal muscles are
attached to bones and arranged in opposing groups around joints. Muscles are innervated,
to communicate nervous energy to, by nerves, which conduct electrical currents from the
central nervous system and cause the muscles to contract.

Contraction initiation

In mammals, when a muscle contracts, a series of reactions occur. Muscle

contraction is stimulated by the motor neuron sending a message to the muscles from the
somatic nervous system. Depolarization of the motor neuron results in neurotransmitters
being released from the nerve terminal. The space between the nerve terminal and the
muscle cell is called the neuromuscular junction. These neurotransmitters diffuse across
the synapse and bind to specific receptor sites on the cell membrane of the muscle fiber.
When enough receptors are stimulated, an action potential is generated and the
permeability of the sarcolemma is altered. This process is known as initiation.

Tendons

A tendon is a tough, flexible band of fibrous connective tissue that connects

muscles to bones. Muscles gradually become tendon as the cells become closer to the
origins and insertions on bones, eventually becoming solid bands of tendon that merge
into theperiosteum of individual bones. As muscles contract, tendons transmit the forces
to the rigid bones, pulling on them and causing movement.

Joints, ligaments, and bursae

Joints

Joints are structures that connect individual bones and may allow bones to move
against each other to cause movement. There are two divisions of joints, diarthroses
which allow extensive mobility between two or more articular heads, and false joints or
synarthroses, joints that are immovable, that allow little or no movement and are
predominantly fibrous. Synovial joints, joints that are not directly joined, are lubricated
by a solution called synovial that is produced by the synovial membranes. This fluid
lowers the friction between the articular surfaces and is kept within an articular capsule,
binding the joint with its taut tissue.

Ligaments

A ligament is a small band of dense, white, fibrous elastic tissue. Ligaments connect the
ends of bones together in order to form a joint. Most ligaments limit dislocation, or
prevent certain movements that may cause breaks. Since they are only elastic they
increasingly lengthen when under pressure. When this occurs the ligament may be
susceptible to break resulting in an unstable joint.

Ligaments may also restrict some actions: movements such

as hyperextension and hyperflexion are restricted by ligaments to an extent. Also
ligaments prevent certain directional movement.

Bursa

A bursa is a small fluid-filled sac made of white fibrous tissue and lined with synovial
membrane. Bursa may also be formed by a synovial membrane that extends outside of
the join capsule. It provides a cushion between bones and tendons and/or muscles around
a joint; bursa are filled with synovial fluid and are found around almost every major joint
of the body.

III. REVIEW OF RELATED LITERATURE

DEFINITION

Osteomyelitis (osteo- derived from the Greek word osteon, meaning bone, myelo-
meaning marrow, and -itis meaning inflammation) simply means an infection of the
bone or bone marrow. It can be usefully subclassified on (pyogenic bacteria or
mycobacteria), the route, duration and anatomic location of the infection.

Causes
It can be caused by a variety of microbial agents (most common in staphylococcus
aureus) and situations, including:

•An open injury to the bone, such as an open fracture with the bone ends
piercing the skin.

•An infection from elsewhere in the body, such as pneumonia or a urinary tract
infection that has spread to the bone through the blood (bacteremia, sepsis).

•A minor trauma, which can lead to a blood clot around the bone and then a
secondary infection from seeding of bacteria.
 •Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a
focal (localized) area of the bone. This bacterial site in the bone then grows, resulting in
destruction of the bone. However, new bone often forms around the site.

•A chronic open wound or soft tissue infection can eventually extend down to the
bone surface, leading to a secondary bone infection. (Black and Hawks, 2005)

Risk Factors

Males are affected more often than females, often as a result of trauma.
Susceptibility to infection increases with IV drug use, diabetes, immunocompromising
diseases or a history of blood- stream infections. (Black and Hawks, 2005).

Prognosis
Prognosis varies depending on how quickly an infection is identified, and what
other underlying conditions exist to complicate the infection. With quick, appropriate
treatment, only about 5% of all cases of acute osteomyelitis will eventually become
chronic osteomyelitis. Patients with chronic osteomyelitis may require antibiotics
periodically for the rest of their lives,

Mortality/Morbidity

•Mortality from osteomyelitis was 5-25% in the preantibiotic era. Currently, the mortality
rate approaches 0%.

•Complications of osteomyelitis include (1) septic arthritis, (2) destruction of the adjacent
soft tissues, (3) malignant transformation (eg, Marjolin ulcer [squamous cell carcinoma],
epidermoid carcinoma of the sinus tract), (4) secondary amyloidoses, and (5) pathologic
fractures.

Signs and Symptoms

Clinical manifestations may slightly vary according to the site of

involvement. Infection in the long bones is accompanied by acute localized pain and
redness or drainage often with a history of recent trauma or newly acquired prostheses.
Fever and malaise may be present. Infection in the vertebrae usually brings pain and
mobility difficulties. The client with vertebral osteomyelitis often reports a history of
genitourinary infection or drug abuse. Osteomyelitis in the foot is most commonly
associated with vascular insufficiency. (Black and Hawks, 2005)

Acute osteomyelitis refers to the initial infection or an infection of less than 1

month duration. The clinical manifestations of acute myelitis are both systemic and local.
Systemic manifestations include fever, night sweat, chills restlessness, nausea and
malaise. Local manifestations include constant bone pain that is unrelieved by rest and
worsens with activity; swelling, tenderness and warmth at the infection site; and
restricted movement of the affected part. Later signs include drainage from sinus tracts to
the skin and/or the fracture site. (Lewis, 2004)

Chronic myelitis refers to a bone infection that persists for longer than 1 month or
an infection that has failed to respond to the initial course of antibiotic therapy. Systemic
signs may be diminished, with local signs of infection more common, including constant
bone pain and swelling, tenderness and warmth at the infection site. (Lewis, 2004).

Laboratory Studies

Laboratory studies and X-rays or bone scans are important in the definitive
diagnosis of osteomyelitis. Elevated WBC and ESR, an elevated level of C-reactive
protein (a protein that circulates in the blood and dramatically increases in level when
there is inflammation) usually occur. Along with clinical manifestations, usually allow
initial diagnosis and early treatment while the physician waits for further evidence from
blood cultures or needle aspirate analysis. To diagnose a bone infection and identify the
organisms causing it, doctors may take samples of blood, pus, joint fluid, or the bone
itself to test. Usually, for vertebral osteomyelitis, samples of bone tissue are removed
with a needle or during surgery.
Radiographic changes related to osteomyelitis are generally evident within 7 to 10
days, but in some cases the diagnosis is not confirmed on X-rays until 3 to 4 weeks after
infection develops. Early acute osteomyelitis is more efficiently identified by
radionuclide bone scans, which can detect lesions within 24 to 72 hours after the onset of
infection. Because of its ability to distinguish between soft tissue and bone marrow,
magnetic resonance imaging It is also being used increasingly for definitive diagnosis of
osteomyelitis.
To diagnose osteomyelitis, the doctor will first perform a history, review of
systems, and a complete physical examination. In doing so, the physician will look for
signs or symptoms of soft tissue and bone tenderness and possibly swelling and redness.
The doctor will also ask you to describe your symptoms and will evaluate your personal
and family medical history. The doctor can then order any of the following tests to assist
in confirming the diagnosis:

•Blood tests: When testing the blood, measurements are taken to confirm an
infection: a CBC (complete blood count), which will show if there is an increased white
blood cell count; an ESR (erythrocyte sedimentation rate); and/or CRP (C-reactive
protein) in the bloodstream, which detects and measures inflammation in the body.

•Blood culture: A blood culture is a test used to detect bacteria. A sample of

blood is taken and then placed into an environment that will support the growth of
bacteria. By allowing the bacteria to grow, the infectious agent can then be identified and
tested against different antibiotics in hopes of finding the most effective treatment.
 •Needle aspiration: During this test, a needle is used to remove a sample of fluid
and cells from the vertebral space, or bony area. It is then sent to the lab to be evaluated
by allowing the infectious agent to grow on media.

•Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested
for signs of an invading organism.

•Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a

radioactive material, is injected intravenously into the body. If the bone tissue is healthy,
the material will spread in a uniform fashion. However, a tumor or infection in the bone
will absorb the material and show an increased concentration of the radioactive material,
which can be seen with a special camera that produces the images on a computer screen.
The scan can help your doctor detect these abnormalities in their early stages, when
X-ray findings may only show normal findings.

Treatment and Management

Elimination of the infecting organisms, both locally from the bone and
systemically from the body, is the major treatment goal for osteomyelitis. Prompt
treatment also prevents further bone deformity and injury, increases client comfort, and
avoids complications of impaired mobility. Surgery is initially performed on the adult
client with osteomyelitis to ensure effective debridement and drainage, elimination if
dead space, and adequate soft tissue coverage. Antibiotics alone rarely resolve infection
in adults, but they do work more efficiently after surgical preparation of the treatment
area. High doses of parenteral antibiotics are frequently administered for 4 to 8 weeks to
achieve a bactericidal level in the bone tissue. Oral antibiotics are continued for another 4
to 8 weeks, with serial bone scans and ESR measurements performed to evaluate the
effectiveness of drug therapy. Open drainage wounds are packed with gauze to promote
drainage. If initial treatment is delayed or inadequate, the necrotic bone separates from
the living bone to form sequestra, which serves as a medium for additional
microorganism growth. Chronic osteomyelitis can result.(Black and Hawks, 2005)
The objective of treating osteomyelitis is to eliminate the infection and prevent
the development of chronic infection. Chronic osteomyelitis can lead to permanent
deformity, possible fracture, and chronic problems, so it is important to treat the disease
as soon as possible.

Drainage: If there is an open wound or abscess, it may be drained through a procedure

called needle aspiration. In this procedure, a needle is inserted into the infected area and
the fluid is withdrawn. For culturing to identify the bacteria, deep aspiration is preferred
over often- unreliable surface swabs. Most pockets of infected fluid collections (pus
pocket or abscess) are drained by open surgical procedures.

Medications: Prescribing antibiotics is the first step in treating osteomyelitis. Antibiotics

help the body get rid of bacteria in the bloodstream that may otherwise re-infect the bone.
The dosage and type of antibiotic prescribed depends on the type of bacteria present and
the extent of infection. While antibiotics are often given intravenously, some are also
very effective when given in an oral dosage. It is important to first identify the
offending organism through blood cultures, aspiration, and biopsy so that the organism is
not masked by an initial inappropriate dose of antibiotics. The preference is to first make
attempts to do procedures (aspiration or bone biopsy) to identify the organisms prior to
starting antibiotics.

Splinting or cast immobilization: This may be necessary to immobilize the affected

bone and nearby joints in order to avoid further trauma and to help the area heal
adequately and as quickly as possible. Splinting and cast immobilization are
frequently done in children, although motion of joints after initial control is important to
prevent stiffness and atrophy.

Surgery: Most well-established bone infections are managed through open surgical
procedures during which the destroyed bone is scraped out. In the case of spinal
abscesses, surgery is not performed unless there is compression of the spinal cord or
nerve roots. Instead, patients with spinal osteomyelitis are given intravenous antibiotics.
After surgery, antibiotics against the specific bacteria involved in the infection are then
intensively administered during the hospital stay and for many weeks afterward.
With proper treatment, the outcome is usually good for osteomyelitis, although
results tend to be worse for chronic osteomyelitis, even with surgery. Some cases of
chronic osteomyelitis can be so resistant to treatment that amputation may be required;
however, this is rare. Also, over many years, chronic infectious draining sites can evolve
into a squamous-cell type of skin cancer; this, too, is rare. Any change in the nature of the
chronic drainage, or change of the nature of the chronic drainage site, should be evaluated
by a physician experienced in treating chronic bone infections. Because it is important
that osteomyelitis receives prompt medical attention, people who are at a higher risk of
developing osteomyelitis should call their doctors as soon as possible if any symptoms
arise.
 IV. VITAL INFORMATION
NAME: K.C.
ADDRESS: Caloocan City
AGE: 7 years old
SEX: Female
WEIGHT: 15.9 kg
NATIONALITY: Filipino
RELIGION: Roman Catholic
BIRTHDAY: April 03, 2002
STATUS: Child
ADMISSION DATE: March 22, 2010; 4:30 pm
WARD: Children’s ward
ATTENDING PHYSICIAN: Dr. Caltila
DIAGNOSIS: Chronic osteomyelitis: 3rd digit, right foot

A. GENERAL STUDY

General Appearance

Patient appears her stated age. She is awake sitting on bed with
ongoing IVF of D5 0.3NaCl 500cc to run for KVO @ 100cc level,
inserted @ right basilic vein. Patient is active and playful. Her right foot is
slightly bigger than her left due to inflammation process secondary to
chronic osteomyelitis.

Body Structure
Other body parts look equal bilaterally and are in relative
proportion to each other.

Behavior

She has good eye to eye contact. She does attend and responds to
questions appropriately.

Initial V/S
Temperature: 36.3C
Cardiac Rate: 79bpm
Respiratory Rate: 35bpm
 B. PHYSICAL ASSESSMENT

Area Assessed Method Normal Findings Actual Remarks

Used Findings
Skin

•Color Inspection >Varies from light >Brownish > normal

to
deep brown, from
ruddy pink to light
pink, from yellow
overtones to olive

•Uniformity of Inspection >Generally >Normal

skin color >Generally uniform except
uniform in areas with
except in areas swelling tissues
exposed to the sun,
areas of lighter
pigmentations
•Temperature Palpation (palms, lips and >Uniform within >Normal
nail beds). normal
>Uniform within range(36.3)
normal range(36.5- >Moisture in the
•Moisture Inspection; 37.5) skin >Normal
Palpation folds and the
>Moisture in the axilla
skin
folds and the axilla
(varies with
nvironmental
temperature and >Springs back
•Turgor Inspection; humidity, body to normal when >Normal
temperature and pinched
activity)
>Springs back to >Epidermis is
•Thickness Palpation normal when uniformly thin >Normal
Inspection pinched over most of the
body
>Skin surfaces
•Tenderness Palpation >Epidermis is are non-tender >Normal
uniformly thin >With lesions
 •Lesions Inspection over >Onset of
most of the body >With swelling infection
•Edema Inspection of the right foot >Due to
>Skin surfaces are inflammation
non-tender
>Absence of
lesions

Hair >Absence of
•Distribution Inspection edema >Evenlydistributed >Normal
over the scalp
• Texture Palpation >With straight, >Normal
thick hair
>Evenly
distributed
•Color Inspection over the scalp >Black color >Normal
>Fine or thick hair;
straight, curly or
•Seborrhea Inspection kinky; silky, >Absence of >Normal
resilient hair seborrhea
>Black color or
gray
Nails color, considering
•Appearance Inspection the age >Clean nails >Normal
>Absence of
•Color of nailbed Inspection seborrhea >Pink >Normal

•Shape
Inspection >Convex to >Normal
•Texture >Clean nails curvature
Inspection >Smooth >Normal
•Capllary refill >Pink
time Palpation >Return within 2 >Normal
seconds
>Convex to
Head curvature
•Shape and size >Smooth
Inspection >Rounded, >Normal
>Return within 2-3 smooth skull
seconds contour
•Facial features
Inspection >Symmetric >Normal
Inspection
>Rounded, smooth
•Symmetry of skull contour
facial features >Symmetric >Normal
 facial
>Symmetric or movements
Ears slightly
Auricle asymmetric facial
•Position features
Inspection >Symmetric facial >At the level of >Normal
movements the external cantus
•Texture of the eyes
External Auditory Inspection >Smooth without >Normal
canal lesion
•Discharges
•Color of canal >At the level of the
walls Inspection external cantus of >None >Normal
Inspection the eyes >Normal
>Smooth without >Pink
lesion

Nose
•Color Inspection >Same color with >Same color with >Normal
the face the face
•Sinuses Inspection >Not inflamed >Not inflamed >Normal

•Nares Inspection >No obstruction; >No obstruction; >Normal

oval oval and
and symmetric symmetric
•Lesion/Tenderness Palpation >Not tender, >Not tender, >Normal
absence absence
of lesion of lesion

Lips
•Symmetry Inspection >Symmetrical >Symmetrical >Normal
•Color Inspection >Pinkish >Pinkish >Normal
•Texture Palpation >Smooth >Smooth >Normal

Teeth Inspection >Free from decays, >Free from >Normal

white, smooth and decays
shin

Tongue
•Position Inspection >Center >Center >Normal
•Color Inspection >Pink >Pink >Normal
Neck
•Position Inspection >Centrally located >Centrally located >Centrally
on the shoulder on the shoulder located on
the shoulder
•Movement Inspection >Able to flex and >Able to flex and >Able to flex and
extend head extend head extend head
without pain and without pain and without pain and
resistance resistance resistance
•Lymph nodes Palpation >Not palpable >Not palpable >Not palpable
Thyroid glands
•Consistency Inspection >Not visible when >Not visible when >Not visible
swallowing swallowing when swallowing
• Size Palpation >Small >Small >Small

•Texture Palpation >Smooth and free >Smooth and free >Smooth and free
from nodules from nodules from nodules

Musculoskeletal
•Joints Inspection >No swelling on >With swelling >Due to
the on the skin and inflammation
skin and tissues tissues over the process
over joints of the right
the joints foot
•ROM Inspection >Full ROM against >Active motion >Normal
gravity, full against gravity,
resistance, average
5/5 weakness, 5/5

C. HISTORY OF PRESENT ILLNESS

Two years PTA, patient had a small blister on the sole of the right foot.
Patient’s mother ignored the lesion for she perceived it as a minor cut only.
No treatment or consultation was done.

Two weeks PTA, patient’s mother noted swelling on the 3rddigit of the
right foot; this was associated with on and off fever.

On March 21, 2010, patient had high grade fever. They consult at a local
Hospital and urinalysis was done. The patient was diagnosed of UTI, and was
given antibiotics and pain medications. They were referred to the Philippine
Orthopedic Center (POC) for chronic osteomyelitis.
D. PAST MEDICAL HISTORY

The patient had a congenital heart defect—patent ductus arteriosus

(PDA) and an inborn soft palpable mass on the upper right buttocks.

On August 16, 2002, the patient was admitted to the Philippine Heart
Center after experiencing cyanosis and loss of breath PTA. On admission,
she was given oxygen and other unrecalled management according to her
mother. She was operated on October of the same year regarding her
PDA condition.

Patient also had urinary tract infection (UTI) a year ago. She
consulted to a local doctor and was given antibiotics.

E. FAMILY HEALTH HISTORY

There is a history of high blood pressure on her father’s side but no

account for any congenital defects of both sides.

F. LABORATORY ANALYSIS
Composition Result Normal Values Interpretation Nursing
Responsibility

March 23, 2010 •Assess for presence

Urinalysis: of, existence of, &
Color Light yellow Amber to history of risk
yellowish factors for infection.
Transparency Hazy Clear •Monitor laboratory
RBC 18-20 0-4 hpf studies.
Pus cells 20-22 0-5 hpf Actual infection •Monitor the ff. for
March 23, 2010 signs of infection.
Blood • Elevated
Chemistry: temp.
leukocyte 22.2 4.5-10 x 10^ g/L • Color of
respiratory
secretions
• Appearance
of urine
•Administer or teach
use of
antimicrobial drugs.
•Teach patient or
caregiver to
wash hands often,
especially
after toileting,
before meals
and after
administering self-
care.
•Teach patient or
caregiver the
signs & symptoms
of infection
and when to report
these to
the physician.
•Encourage to eat
foods high
in Vitamin C like
citrus fruits.

G. PATHOPHYSIOLOGY
 Direct entry osteomyelitis can occur at any age when there is an
open wound (e.g. penetrating wounds, fractures) and microorganisms gain
entry to the body. Osteomyelitis may also occur in the presence of a
foreign body such as an implant or an orthopedic prosthetic device (e.g.
plate, total joint prosthesis ). After gaining entrance to the bone by way of
the blood, the microorganisms then lodge in an area of the bone in which
circulation slows, usually the metaphysis. The microorganisms grow,
resulting in an increase in pressure because of the nonexpanding nature of
most bones. This increasing pressure eventually leads to ischemia and
vascular compromise of the periosteum. Eventually the infection passes
through the bone cortex and marrow cavity, ultimately resulting in cortical
devascularization and necrosis. Once ischemia occurs, the bone dies. The
area of devitalized bone eventually separates from the surrounding living
bone forming sequestra. The part of the periosteum that continues to have
blood supply forms new bone called involucrum. (Lewis, 2004)

Once formed, a sequestrum continues to be a infected island of

bone surrounded by pus and difficult to reach by blood-borne antibiotics
or white blood cells (WBCs). Sequestrum may enlarge and serve as a site
for microorganisms that spread to other sites, including the lungs and the
brain. The sequestrum can move out of the bone and into the soft tissue.
Once outside the bone, the sequestrum may revascularize and then
undergo removal by normal immune system process. Another possibility
is that the sequestrum can be surgically removed through debridement of
the necrotic bone. If the necrotic sequestrum is not resolved naturally or
surgically, it may develop a sinus tract, resulting n a chronic purulent
cutaneous drainage.(Lewis, 2004)

Chronic osteomyelitis is either a continuous persistent problem (a

result of inadequate acute treatment) or process of exacerbations and
remission. Over time, granulation tissue turns to scar tissue. This vascular
scar tissue provides an ideal site for continued microorganism growth in
impenetrable to antibiotics. (Lewis, 2004)