IDENTITY

Name
: Mr S
Age
: 24 years old
Sex
: Female
Date of Admission : February 2
2016

th

HISTORY TAKING

Chief Complain : Wound at left thigh

History of Illness :
Suffered since 10 years ago and the wound did
healed completely. The wound secrete pus dan
are smelly
Patient has history of ups and down fever and
pain at the wound region for the past 10 years
and only took paracetamol for reliever. History of
tenderness (+). History of warmness at the site
of wound (+)
Patient has history of undergoing treatment at
Palewali Hospital but the wound did not healed.
Then the patient is referred toUniversitas
Hasanuddin Hospital
No history of of DM , hypertension and

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

LOCAL STATUS
Look

Left Leg Region

Wound on the medial aspect with sixe
2x2cm. Wound on the lateral aspect with
size 1x1cm, Discharge (+) deformity (-),
scar (+), swelling (-), hematoma (-) The
area around the wound is more darker
then the other area.

Feel
Move

Tenderness (+)
Active and pasive movement of hip joint
within normal limit
Active and passive movement left knee
joint , flexion and extension 0- 90

NVD

Sensibility is good
Pulsation of the dorsalis pedis and tibialis
posterior are palpable.

CLINICAL
FINDING

RADIOLOGIC FINDING

Tibia Sinistra AP/Lateral

LABORATORY
FINDINGS
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 6 months ago and worsen this past 2 months. Patient has
history of trauma and undergo surgery for external fixation on
September 2015. After discharge, patient never came back for
medical check up and wound care. 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. Exposed tibial bone (+), discharge (+),
and movement of flexion extension of knee is 0- 90
From radiologic finding there is external fixation attached, signs of
osteomilitis at left tibial bone.

DIAGNOSIS
Chronic osteomyelitis left tibia

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
6months
History of trauma
(+)
History of fever
(+) HISTORY

TAKING

PHYSICAL
EXAMINATI
ON
Open wound (+)
Tenderness (+)
Expose tibia
bone (+)

Elevated ESR

LABORATOR
Y

RADIOLOGY FINDING

PHYSICAL
EXAMINATI
ON

HISTORY
TAKING

RADIOLOGY
FINDING +
LABORATOR
Y FINDINGS

CHRONIC
OSTEOMYELITIS

PATHOPHYSIOLOGY

CLINICAL MANIFESTATION

RADIOLOGY

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
Osteonecrosis
Arthritis septic
Skin cancer (squamous carcinoma )

PROGNOSIS

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).

THANK YOU