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INTRODUCTION
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.
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
Tendons
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.
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.
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.
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.
•Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested
for signs of an invading organism.
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
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
Lips
•Symmetry Inspection >Symmetrical >Symmetrical >Normal
•Color Inspection >Pinkish >Pinkish >Normal
•Texture Palpation >Smooth >Smooth >Normal
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
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
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.
F. LABORATORY ANALYSIS
Composition Result Normal Values Interpretation Nursing
Responsibility
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)