CASE REPORT

OSTEOMYELITIS OF LEFT TIBIA

BY:
Nurul Nadiah binti Nor Sukor
ADVISOR:
dr. Shandy L. Putra
dr. Anak. A.G. Putra
SUPERVISOR:
dr. M. Sakti , Sp.OT(K)
Orthopaedic and Traumatology Department
Medical Faculty of Hasanuddin University
Makassar

PATIENTS IDENTITY

Name
: Mr. S
Number Register : 747167
Sex
: Male
Age
: 39 years old
Date of Admission : February 29th ,
2016

HISTORY TAKING

Chief Complain : Wound on the

Suffered
leftsince
leg 7 months before admitted to Wahidin

Sudirohusodo hospital and worsen for the last 2 months. Patient

had a complained of wound.
The patient had a history of traffic accident and undergo for
internal fixation due to fracture on his left leg. However, one
month after that, the wound did not healed, he then undergo
external fixation on his left leg.
This patient has a history of relapsing fever and pain at the
wound region for the last two months and only took paracetamol
as a reliever and history of tenderness (+)
No history of diabetes mellitus, hypertension and cardiovascular
disease.

GENERAL STATUS
BP : 110/80 mmHg
HR : 84X/min
RR : 20X/min
Temp : 36,8oC

LOCAL STATUS
Left Leg Region
Look

Feel
Move

NVD

: External fixation is attached, open wound size

1 cm x 3 cm x 1 cm at 1/3 middle tibia
anterior aspect, tibial bone exposed(+)
yellow in colour, deformity(-), scar (+),
shortening (-), swelling (-), hematoma (-), pus
(+)
: Tenderness (-)
: Active and pasive motion of left knee
extension 0o-10o flexion 120o
Active and passive movement of ankle
plantar fleksi 45o, dorso fleksi 20o
: Sensibility is good, dorsalis pedis artery and

CLINICAL FINDINGS

Anterior view

CLINICAL FINDINGS

Lateral
view

CLINICAL FINDINGS

RADIOLOGICAL FINDINGS

Sequestru
m

Tibia Sinistra AP/Lateral

LABORATORY
EXAMINATION
WBC

5,35

4,00-10,0

RBC

4,59

4,00-5,50

HGB

12,5

12,0-16,0

LED

13/34

<10

PLT

349

150-400

CT

4-10

BT

1-7

HBsAg

Non

Non

Reactive

Reactive

RESUME
A 39 years old man admitted to the Wahidin Sudirohusodo
Hospital with chief complain of open wound at left leg, suffered
since 7 months ago and worsen this past 2 months. The patient
had a history of traffic accident and undergo for internal fixation due to
fracture on his left leg. However, one month after that, the wound did not
healed, he then undergo external fixation on his left leg.
Patient has a history of ups and down fever and pain at the
wound region for pass 2 month but only took paracetamol for
reliever. History of tenderness (+)
On physical examination findings there is external fixation
attached and from anterior aspect there is open wound size
1cm x 3cm x1cm at 1/3 middle tibia, area around the wound is
darker than surrounding area. Tibial bone exposed (+), pus (+),
scar (+).
From radiologic finding there is external fixation attached, there
is sequestrum on the left tibial bone.

DIAGNOSIS
Post Traumatic Chronic
osteomyelitis left tibia with
external fixation

TREATMENT
IVFD RL 20TPM
Cefazoline 1gram/12jam/intravenous
Planning for debridement,
sequestrectomy and drainage
Bacteriology culture and sensitivity
test

DISCUSSION

INTRODUCTION
Osteomyelitis is an acute or
chronic inflammatory process of
the bone and its structures
secondary to infection.
When bone infection persists for
months, the resulting infection is
referred to as chronic osteomyelitis

Appleys system of orthopaedics and fractures, 9th ED.

ETIOLOGY
Posttraumatic osteomyelitis accounts
for as many as 47% of cases of
osteomyelitis.
Other major causes of osteomyelitis
include vascular insufficiency (mostly
occurring in persons with diabetes;
34%)
hematogenous seeding (19%).

STUCTURE OF BONE

EVIDANCE LEADING TO
DIAGNOSIS
Open wound with
pus since 7
months
History of trauma
(+)
History of
relapsing
fever
HISTORY
(+)

TAKING

PHYSICAL
EXAMINATION

Elevated ESR

Open wound (+)

Expose tibia
bone (+)

RADIOLOGICAL
FINDINGS
Sequestrum

LABORATORY

RADIOLOGY FINDING

HISTORY
TAKING
PHYSICAL
EXAMINATION

RADIOLOGY
FINDING +
LABORATORY
FINDINGS

CHRONIC OSTEOMYELITIS

PATHOPHYSIOLOGY
Direct
inoculation of
bacteria via
trauma, surgical
reduction and
internal fixation
of fractures,
prosthetic
devices, spread
from soft-tissue
infection

infection begins
outside the
bony cortex and
works its way in
toward the
medullary
canal.

A progression
through
inflammation >
suppuration >
necrosis > new
bone formation
> to resolution
or intractable
chronicity.

CLINICAL MANIFESTATION
ACUTE

CHRONIC

Pain
Fever
Refusal to bear weight
Elevated white cell count
Elevated ESR
Elevated CRP

decreased sensation
poor capillary refill
decreased dorsalis pedis and posterior tibial
pulses.
Classic signs are healed and discharging
sinuses and x-ray features of bone
rarefaction surrounded by dense sclerosis
and cortical thickening; within that area
there may be an obvious sequestrum.

RADIOLOGY

STAGING

Staging the condition helps in riskbenefit assessment and has some predictive
value concerning the outcome of treatment. The system popularized by Cierny et
al. (2003) is based on both the local pathological anatomy and the host
background (Table 2.2).

TREATMENT
The principles of treatment are:
to provide analgesia and general supportive
measures
to rest the affected part
to identify the infecting organism and administer
effective antibiotic treatment or chemotherapy
to release pus as soon as it is detected
to stabilize the bone if it has fractured
to eradicate avascular and necrotic tissue
to restore continuity if there is a gap in the bone
to maintain soft-tissue and skin cover.

ANTIBIOTICS :
to suppress the infection and prevent its spread
to healthy bone and to control acute flares.
The choice of antibiotic depends on
microbiological studies, but the drug must be
capable of penetrating sclerotic bone and
should be non-toxic with long-term use.
administered for 46 weeks (starting from the
beginning of treatment or the last debridement)
before considering operative treatment.

OPERATIVE
1. DEBRIDEMENT :
. At operation all infected soft tissue and
dead or devitalized bone, as well as
any infected implant, must be excised.
. After three or four days the wound is
inspected and if there are renewed
signs of tissue death the debridement
may have to be repeated several
times if necessary.

2. DRAINAGE :
If pus is found and released there is little to
be gained by drilling into the medullary cavity.
If there is no obvious abscess, it is reasonable
to drill a few holes into the bone in various
directions.
If there is an extensive intramedullary abscess,
drainage can be better achieved by cutting a
small window in the cortex. The wound is
closed without a drain and the splint (or
traction) is reapplied

3. SOFT TISSUE COVER

The bone must be adequately
covered with skin. For small defects
splitthickness skin grafts may suffice
for larger wounds local
musculocutaneous flaps, or free
vascularized flaps, are needed.

AFTER CARE
Once the signs of infection subside,
movements are allowed - walk with
the aid of crutches. Full
weightbearing is usually possible
after 34 weeks.
Local trauma must be avoided and
any recurrence of symptoms,
however slight, should be taken
seriously and investigated.

COMPLICATION
Pathological fracture
Growth disturbance

THANK YOU