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Non union fracture 1/3 distal left femur susp.chronic osteomyelitis

By Yanuar Aditya K 030. 08. 258

Preface
Osteomyelitis is an infection of the bone Osteomyelitis develops when staphylococcus bacteria enters the bone either through the blood stream or as a result of an injury. Although bone is normally resistant to bacterial colonization, events such as trauma, surgery, presence of foreign bodies, or prostheses may disrupt bony integrity and lead to the onset of bone infection. When prosthetic joints are associated with infection, microorganisms typically grow in biofilm, which protects bacteria from antimicrobial treatment and the host immune response. The major cause of bone infections is Staphylococcus aureus. When biofilm microorganisms are involved, as in joint prostheses, a combination of rifampicin with other antibiotics might be necessary for treatment.2

CASE REPORT

CASE
PATIENT IDENTITY Name Age Gender Status Religion Occupation Education Address Date of admission : : : : : : : : : Mr. A 35 yo Man Married Islam Senior High School 17 3 - 2013

Anamnese
History taken have been done from Autoanamnese on 28-032013, 10.30 am

Chief complaint :
Pain on the left thigh since 2 years ago

Additional complaint:
Fever with chill and malaise 3 days before admission

History of present illness:

The patient confessed that 2 years ago before admission, he get involved in accident on august 2011. The patient was riding a motorcyle when his bike got hit by a car from the right side and was dragged for approximately 2 meter with low velocity.He refuse loss of consciousness and no trauma in his head. Blood come out from wound on his leg. He was admitted to the orthopaedic unit at 1 month ago. He experienced that his left thight pain. At admission, he was afebrile but 3 days ago before admission the patient feels fever.

His left lower limb was shortened. He deny having the crepitation on his knee.

Anamnese
History of past illnes He never having problem like this before. He have a hypertension since 3 years ago and never control at the doctor. History of past medical story He never undergoes an operation and never consume the medicine for a long time. Family history Never have the same illnes in his famly. His mother suffered Hypertension. No diabetes mellitus, asthma and heart disease Habits of history Never consume alcohol and Smoking. Take the Balanced diet(3x/every day + meet + vegetable)

PHYSICAL EXAMINATION
Awareness General State Mobility (active / passive) Height Weight : : : : : Compos mentis Moderately sick Passive 168 cm 76 kg

Heart Rate : 96 times/minute

Blood pressure

160/90 mmHg

VITAL SIGN

Respiratory rate :

Temperature : 36,7 C

20 times/minute

PHYSICAL EXAMINATION
normalcephaly, black hair with normal distribution, difficult unpulg, no lesion and bump normal shape, symmetric , pupile isokor, conjunctiva anemis(-/-), sclera icterik(-/-) direct light reflex(+/+) undirectly light reflex(+/+) normotia, no hyperemis, no secret(-/-), serumen(+/+), membran tympani intact with light reflex at 5 oclock for right ear and 7 oclock for left ear, corpus alenium(/-)

Nose

normal in shape, no deformity, septum deviation(-), concha hyperthrophy(-/-). No hyperemi, secret(-/-)

Mouth

lips not dry trismus(-), tongue not dirty, teeth normal, good oral hygien, phrynx not anemia

Neck

normal in shape, no palpable the enlargement of lymph node

Thoraks

Thorax Examination
Cor S1-S2 normal reguler, murmur (-), gallop (-)

Pulmo sound of breathing right and left vesikuler, ronchi(-/-), wheezing(-/-)

ABDOMEN
Inspection: flat, smilling umbilicus(-), operation scar(-), veins dilatation(-), Kidney: ballotement(-/-), CVA(-/-) Abdomen
Palpation: supel, no compresive pain(-), defens muscular(-) Liver: no palpable Spleen: no palpable

Auscultation: sound of intestine (+) 4x/min Percusion: tympani, shiffting dullness(-)

EXTREMITY

Warm + + + +

Oedema

EXTREMITY
Right Left

Muscle
Tonnus Mass Joints

Atrophy
Normotony No abnormality No abnormality

Eutrophy
Hypothony No abnormality No abnormality

Movement
Strenght Edem

Active
Normal No Edema

Not Active
Weak Edema

LOCAL STATUS (LEFT DISTAL FEMUR)

Right Look Scar (-) Scar (+)

Left

Edema and redness in right

distal femur (-) No laceration No ecchymosis Deformity: No Rotation No angulation Warm (-) Tenderness (-) Circumference 32 cm No fluctuation No crepitation Pulse (+)

Edema (+)
Redness in right distal femur (-) No laceration No ecchymosis Deformity: No Rotation No angulation Warm (-) Tenderness (+) Circumference 34 cm DEFORMITY(discrepancy/sho rtening) True length: 67 cm Apparents length:57cm Anatomical length:10cm

Feel

No fluctuation
No crepitation Pulse (+)

Right Move Active( knee joint) Flextion : 150o ( normal range 0-150o) Extention: 0o(normal 150-00) Normal Passive(knee joint) -

Left Active( knee joint) Flextion : 40o ( normal range 0-150o) Extention: 100 (normal 15000) Passive(knee joint) Flextion :50o Extention: -10o

Neurological status
Sensory
Pain upper part of the upper leg (L2) Feel the sensation symmetrical left and right lower-medial part of the upper leg (L3) Feel the sensation symmetrical left and right medial lower leg (L4) Feel the sensation symmetrical left and right lateral lower leg (L5) Feel the sensation symmetrical left and right sole of foot (S1) Feel the sensation symmetrical left and right Light touch Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right Feel the sensation symmetrical left and right

Neurological status
Motoric
Right Hip joint Normal power(5) left Normal power(5)

Reflex
Physiology reflex Knee reflex Right Positive normal Left Not examined because pain

Achiles reflex
Pathological reflex Kerniq & laseq Barbinsky

Positive normal

Positive normal

Negative Negative

Negative Negative

y
Result Haemathology Hb Ht Leukocyte Thrombocyte ESR APTT PT 12,7 39 10.400 333.000 47 32,9 14,4 13,5 17,5 g/dl 41 53 % 4.100 10.900 /ul 140.000 440.000 /ul < 10 mm / hour 27 42 second 12 19 second Normal

Liver function

Albumin
Globulin Total protein AST ALT

4,69
4,05 8,74 17 25

4,0 5,2 g/dl

1,3 2,7 g/dl 6 8 g/dl 10 35 u/l 9 43 u/l

ry
Result Normal 20 40 mg/dl 0,7 1,5 mg/dl

Renal function
Ureum Creatinin Electrolite Na K 146 4,2 135 147 mmol/l 3,5 5,0 mmol/l 29 2,1

Cl

103

96 108 mmol/l

Radiology Examination
1st x ray Identity : Mr. Andiyas Age : 35 yo Date : 19/02/2013 Type : Os Femur sinistra (AP Lateral) Description :
There is old fracture at left femur distal section and the fracture fragments are not straight at distal section, part of the bone is not intact. looks osteolytic and sclerotic at the distal femur

Summary : Susp. Osteomyelitis chronic

Radiology Examination
2nd X RAY Identity : Age : Date : Type : posterior) Description : normally

Mr. Andiyas 35 yo 19/02/2013 Chest x ray (anterior

Cor and pulmo are

RESUME
Men, 35 years old came to RSUD Kojas with complain pain in left tight . The patient confessed that 2 years ago he get involved in accident on august 2011. He went to bonesetter, and was treating with some kind of herbal ointment and also apply the maneuver of traction. In 3 days prior admission patient complaint of the episodic febrile fever with chill and also malaise. From physical examination, the tempreture is afebrile 36,7oC and from local status in left femur , look some scar on knee. From feel, found out, warm , compresive pain(+), no active movement, range of scope limited, pain on movement from passive movement positive but still imited From laboratry finding, increasing of eritrosit sedimention rate(47 mm/hour). From thoraxs x ray photo didnt find any problem, no active or passive process of tuberculosis and CTR<50%. For left femur x ray, found the non union fracture at 1/3 femur and susp. osteomyelitis chronic.

Working diagnosis
Non-union fracture at 1/3 left distal femur Susspected osteomyelitis chronic

Base of diagnosis
From anamnese History of accident 2 years ago at left femur History of alternative treatment which is increasing the factor of infection Febrile and malaise 3 days before admission Felt Sharp pain on his knee which is spread to his hip , but day by day the intensity of pain became less From local status Physical examination
Look Scar (+) at left knee Edema (+) Feel Warm Tenderness Circumferences 34 cm and the difference height of right foot and left foot about 10 cm

Base of diagnosis
From laboratory finding
ESR rate 47 mm/hour

From radiology finding

There is old fracture at left femur distal section and the fracture fragments are not straight at distal section, part of the bone is not intact. looks osteolytic and sclerotic at the distal femur

Management
Operable Debridement Use external fixation

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Management
Non operable Skin traction 5 kg Bedrest IVFD RL Fosmycin 2 x 2gr iv Hypobhac 2 x 200 mg iv Ranitidin 2 x 1 iv Ketopain 3 x 1 iv

PROGNOSIS
Ad vitam : dubia ad bonam Ad functionam : dubia ad malam Ad sanationam : dubia ad malam

CASE REVIEW

OSTEOMYELITIS

BONE
The adult human skeleton has a total of 213 bones, excluding the sesamoid bones. The appendicular skeleton has 126 bones, axial skeleton 74 bones, and auditory ossicles six bones.

The four general categories of bones

Long bones the clavicles, humeri, radii, ulnae, metacarpals, femurs, tibiae, fibulae, metatarsals, and phalanges Short bones the carpal and tarsal bones, patellae, and sesamoid bones Flat bones the skull, mandible, scapulae, sternum, and ribs Irregular bones the vertebrae, sacrum, coccyx, and hyoid bone

The skeleton serves a variety of functions

Structural support for the rest of the body, Permit movement and locomotion by providing levers for the muscles, Protect vital internal organs and structures, Provide the environment for hematopoiesis within the marrow spaces

Definition
Osteomyelitis is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Osteomyelitis can also begin in the bone itself if an injury exposes the bone to germs.

Epidemiology
Approximately 20% of adult cases of osteomyelitis are hematogenous, which is more common in males for unknown reasons. Acute hematogenous osteomyelitis is decreasing in incidence, whereas the incidence of osteomyelitis due to direct inoculation or contiguous focus of infection is increasing. This is attributed to the increase in both trauma (due to motor vehicle accidents) and orthopedic surgical procedures. Osteomyelitis secondary to open fractures occurs in 3% to 25% of cases, usually in young men in their twenties and thirties. Vertebral osteomyelitis is responsible for 2% to 4% of all cases of osteomyelitis, with an annual incidence of 5.3 cases per million persons. Men are more commonly affected than women, with a mean age at presentation of 61 years Foot ulcers occur in 2% of patients with diabetes every year, 15% of whom will develop osteomyelitis. Recurrent infection occurs in up to 36% of patients with diabetes.

Etiology
In most cases, the body's immune system is capable of preventing the colonization of pathogens. The micro-environment determines whether infection occurs. The timing and extent of treatment are critical in determining whether infection develops. The likelihood of developing ostemyelitis increases with impaired immune function, extensive tissue damage, or reduced blood supply to the affected area. Patients with diabetes, poor circulation or low white blood cell count are at greater risk. Bacterial or fungal infection cause most osteomyelitis. Infection induces a large polymorphonuclear response from bone marrow, particularly staphylococcus aureus, streptococcus and haemophilus influenza.

Risk factors
Diabetes mellitus Immunocompromise Neuropathy Vascular insufficiency Intravenous drug use Open fractures Local trauma Orthopedic hardware (including prosthetic joints) Hemodialysis Sickle cell disease Dental infections Urinary tract infections Catheter-related bloodstream infection

PATHOPHYSIOLOGY
Bone is normally resistant to infection. However, when microorganisms are introduced into bone hematogenously from surrounding structures or from direct inoculation related to surgery or trauma, osteomyelitis can occur. Bone infection may result from the treatment of trauma, which allows pathogens to enter bone and proliferate in the traumatized tissue. When bone infection persists for months, the resulting infection is referred to as chronic osteomyelitis (depicted in the image below) and may be polymicrobial. Although all bones are subject to infection, the lower extremity is most commonly involved. Some important factors in the pathogenesis of osteomyelitis include the virulence of the infecting organism, underlying disease, immune status of the host, and the type, location, and vascularity of the bone. Bacteria may possess various factors that may contribute to the development of osteomyelitis. For example, factors promoted by S aureus may promote bacterial adherence, resistance to host defense mechanism, and proteolytic activity.

Staging (Cierny-Mader)
Stage 1 Disease involves medullary bone and is usually caused by a single organism. Stage 2 Disease involves the surfaces of bones and may occur with deep softtissue wounds or ulcers. Stage 3 Disease is an advanced local infection of bone and soft tissue that often results from a polymicrobially infected intramedullary rod or open fracture. Stage 3 osteomyelitis often responds well to limited surgical intervention that preserves bony stability. Stage 4 Osteomyelitis represents extensive disease involving multiple bony and soft tissue layers. This stage is complex and requires a combination of medical and surgical therapies, with postsurgical stabilization as an essential part of therapy.

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Cierny-Mader classification system describes the physiologic status of the host

Class A hosts
normal physiologic, metabolic, and immune functions.

Class B hosts
Systemically (Bs) or locally (Bl) immunocompromised.

Class C hosts
Treatment poses a greater risk of harm than osteomyelitis itself.

Clinical Manifestation
The classic signs of inflammation, including local pain, swelling, or redness, may also occur and normally disappear within 5-7 days. Fever, chills, fatigue, lethargy, or irritability On physical examination, scars or local disturbance of wound healing may be noted along with the cardinal signs of inflammation. Range of motion, deformity, and local signs of impaired vascularity are also sought in the involved extremity. If periosteal tissues are involved, point tenderness may be present.

Laboratory Studies
Complete blood cell count A complete blood cell (CBC) count is useful for evaluating leukocytosis and anemia. Leukocytosis is common in acute osteomyelitis before therapy. The leukocyte count rarely exceeds 15,000/L acutely and is usually normal in chronic osteomyelitis. Erythrocyte sedimentation rate and C-reactive protein levels are usually increased. Culture Blood cultures are positive in only 50% of cases of osteomyelitis. They should be obtained before or at least 48 hours after antibiotic treatment. Although sinus tract cultures do not predict the presence of gram-negative organisms, they are helpful for confirming S aureus. Bone biopsy leads to a definitive diagnosis by isolation of pathogens directly from the bone lesion.

Imaging Studies
Radiography
Conventional radiography is the initial imaging study at presentation of acute osteomyelitis. It is helpful to interpret current and old radiographs together. Radiographic findings include periosteal thickening or elevation, as well as cortical thickening, sclerosis, and irregularity.

Ultrasonography
The presence of fluid collection adjacent to the bone without intervening soft tissue usually suggests osteomyelitis. Other findings on ultrasonography include elevation and thickening of the periosteum

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Imaging Studies
CT scanning CT is useful for guiding needle biopsies in closed infections and for preoperative planning to detect osseous abnormalities, foreign bodies, or necrotic bone and soft tissue. MRI MRI is a very useful modality in detecting osteomyelitis and gauging the success of therapy because of high sensitivity and excellent spatial resolution. The extent and location of osteomyelitis is demonstrated along with pathologic changes of bone marrow and soft tissue. MRI shows a localized marrow abnormality in osteomyelitis.

Diagnostic Procedure
Open bone biopsy with histopathologic examination and culture is the criterion standard for the microbiologic diagnosis of osteomyelitis. This procedure may not be necessary if blood cultures are positive with consistent radiologic findings. Needle biopsy may also be used to obtain bone for analysis. When clinical suspicion is high with negative blood cultures and needle biopsy, a repeat needle biopsy or open biopsy should be performed. A bone sample can be collected at the time of debridement for histopathologic diagnosis in patients with compromised vasculature.

Therapy
Medical Clindamycin, rifampin, trimethoprim-sulfamethoxazole, and fluoroquinolones. Surgery Surgery is indicated when the patient has not responded to specific antimicrobial treatment. The Cierny-Mader classification system plays an important role in guiding treatment. As described above, stage 1 and 2 disease usually do not require surgical treatment, whereas stage 3 and 4 respond well to surgical treatment. Operative treatment consists of adequate drainage, extensive debridement of necrotic tissue, management of dead space, adequate soft-tissue coverage, and restoration of blood supply.

Complication
Pin-tract infections and cellulitis, Flexion contractures above and below the frame, Limb edema, and Bone fragment rotation with malunion. The most common complication in children with osteomyelitis is recurrence of bone infection.

Prognosis
Inadequate therapy may lead to relapsing infection and progression to chronic infection. Because of the avascularity of bone, chronic osteomyelitis is curable only with radical resection or amputation. These chronic infections may recur as acute exacerbations, which can be suppressed by debridement followed by parenteral and oral antimicrobial therapy. Rare complications of bone infection include pathologic fractures, secondary amyloidosis, and squamous cell carcinoma at the sinus tract cutaneous orifice.

FEMUR FRACTURE

Definition
A femoral fracture is a break in the thigh bone, which is called the femur. The femur bone is also known as the thigh bone. It runs from the hip to the knee and is the longest and strongest bone in the body. It usually requires a great deal of force to break the femur.

 Fractures of the femur are common and may affect the femoral neck, the femoral shaft or distal (supracondylar) femur, which often also involve the knee joint. Fractures of the femoral neck are far more common in the elderly but fractures of the femoral shaft and supracondylar fractures are usually caused by violent trauma and most often occur in adolescents and young adults.

Causes
High energy trauma Motor vehicle trauma (eg, motorcycle accidents, motor vehicle accidents, plane crashes, pedestrian car accidents) Falls (eg, from height: mountain climbing, abseiling, workplace accidents) Sports (eg, high-speed and contact sports with direct trauma, skiing, downhill mountain bike riding) Gunshot wounds Low energy trauma People who have decreased bone density due to osteoporosis. Elderly women are at greatest risk of this. People who have had cancer that has spread to the bones People who have been on long term corticosteroids. This has the effect of decreasing bone density leading to weaker bones.

Causes
Stress fractures The third way to fracture the femur is through repetitive trauma. This occurs most commonly in athletes undergoing heavy training or military recruits. It is more common in women, particularly in women who are not menstruating. It is rare to have a stress fracture affecting the lower part of the femur. Most stress fractures of the femur affect the mid shaft area.

Types of Femoral Shaft Fractures

Transverse fracture In this type of fracture, the break is a straight horizontal line going across the femoral shaft. Oblique fracture This type of fracture has an angled line across the shaft. Spiral fracture The fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the thigh causes this type of fracture. Comminuted fracture In this type of fracture, the bone has broken into three or more pieces.

Symptom
Pain and swelling This will always be present in the instance of a femoral fracture. Deformity Numbness or weakness Bruising or bleeding In the case of a stress fracture, there will still be pain and swelling but not deformity, bruising or nerve damage. The pain and swelling will often come on gradually rather than immediately in the case of a fracture due to an accident.

Clinical assessment
The first step in diagnosing any problem is to obtain a thorough history of the problem. An examination of the the whole lower leg (ankle, knee, hip and pelvis) will be carried out. As femoral fractures are often caused by accidents involving a large amount of force, other areas may be damaged as well as the thigh bone. The doctor will also assess whether the nerves and blood vessels of the lower limb are working properly or whether they have been affected by the broken bone.

IMAGING
X-rays This is an important first step in confirming that a fracture is present, but also the exact location and extent of the damage.

IMAGING
CT scans CT scan may be necessary to give the doctors a clearer picture of the fracture. This is particularly important if surgery is required to fix the broken bone. The advantage of CT over Xray is that it provides a 3D image of the leg and a more accurate picture of how far the fracture has spread, particularly if it affects the joint surfaces of the knee

IMAGING
Bone scan This test may be required if a stress fracture is suspected. Bone scan is a more accurate tool to diagnose a stress fracture.

TREATMENT
Non-surgical treatment Traction:
This involves pulling on the part of the bone below the break to ensure that the two ends of the bone line up and will heal without deformity.

Casting and bracing:

If the two ends of the broken bones are lined up well, it may be possible to simply apply a cast or a brace and wait for the bones to mend of their own accord. This approach can only be taken if there is good alignment of the bones following the break and there is not multiple pieces of broken bones.

TREATMENT
Non-surgical treatment Traction:
This involves pulling on the part of the bone below the break to ensure that the two ends of the bone line up and will heal without deformity.

Casting and bracing:

If the two ends of the broken bones are lined up well, it may be possible to simply apply a cast or a brace and wait for the bones to mend of their own accord. This approach can only be taken if there is good alignment of the bones following the break and there is not multiple pieces of broken bones.

TREATMENT
Surgical Treatment External fixation This means that the bones are held in place using a metal frame that is outside the body with pins that then penetrate the bones. This approach is favoured where the fracture has lead to damage of the surrounding muscles and skin. External fixation is often used to hold the bones together temporarily when the skin and muscles have been injured.

TREATMENT
Internal fixation This approach means that the surgeon places supports around the bone on the inside of the leg. There are two main approaches used that come under the category of internal fixation:
Intramedullary nailing
This involves a specifically designed rod to be placed through the centre of the bone shaft. The rod will cross the line of the fracture and keep the two ends of the bone together.

Plates and screws

This involves the use of metal plates and screws to hold together the fragments of bone created by the fracture.

Infection

Bone healing Problems Complications Compartment syndrome Nerve damage

Complications specific to the type of femoral fracture

Distal femoral fracture Stiffness of the knee which may resolve very slowly and may not fully resolve. Another way this type of fracture can affect the knee is by predisposing to osteoarthritis. This is most likely if the fracture line passes into the joint, disrupting the smooth layer of cartilage that lines the joint. Mid shaft fracture ligament damage to the knee which may require an operation in order to repair the damage Mid shaft fractures in teenagers and children may suffer leg length discrepancy where one leg is longer than the other.

REFERENCES
Reksoprodjo S, kumpulan ilmu bedah bahagian kedokteraan FKUI 1st edition Jakarta;binarupa aksara Pub sept 2002 Apley, A. Graham et al. Buku Ajar Ortopedi dan Fraktur Sistem Apley edisi ke-7. Widya Medika. Jakarta : 1995 Advanced Trauma Life Support 6th ed. American College of Surgeons Committee on Trauma. USA: 1997. Medscape, osteomyelitis(online). Available from URL: http://emedicine.medscape.com/article/1348767-overview#a0112, accessed on 6 April 2013 NHS.UK: different between acute and chronic osteomyelitis, 2012 july 30 available from URL: http:// www.nhs.uk/conditions/osteomyelitis/pages/prevention.aspx Mayoclinic, Osteomyelitis, 2012 Agust 1 available from URL: http://www.mayoclinic.com/health/osteomyelitis/DS00759/ Orthopedic examination 2012 Agust 1 available from URL: http://www.netterimages.com/image/8246.htm Cluett, J. Fracture femur. Available at http://orthopedics.about.com/od/brokenbones/a/femur.htm, accessed on 6 April 2013

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