Refleksi Kasus

Visa
14/381551/KU/18018
Kel 15108

Kasus
Osteomielitis

Identitas
Nama : An. R
Tanggal lahir/Usia

: 24/2/2011

Dokter Pengirim : Bagian Bedah anak

Alamat
No. RM

: Wanujoyo Lor Rt 3, srimartani

: 01.77.43.xx

Tanggal Pemeriksaan

: 16/7/2016

Keterangan Klinis
Susp. Fraktur humerus

Anamnesis
Keluhan Utama : Benjolan diketiak kiri
RPS

1BSMRS : Muncul benjolan kecil sebesar biji jeruk dibagian belakang

ketiak, benjolan dirasakan semakin membesar dan warna kulit agak
kemerahan, tidak nyeri. Os berobat ke RSUD Panembahan senopati
diberi obat antibiotik, keluhan tidak membaik.
10HSMRS: Berobat kembali Ke RSUD Panembahan Senopati karena
benjolan dirasakan tidak mengecil, lalu dirujuk ke RSS.
RPD

: Riw. kel serupa (-)

Riw. Trauma (+) -> luka (-), fraktur(-), infeksi lokal (-)

RPK

: Riw. Serupa (-)

Riw. Keganasan (-)

Foto Radiologi (29/2/2016)

Hasil : Tampak
periosteal reaction,
penebalan cortex
dan lesi lytik serta
sklerotik dihumerus
sinistra
Kesan : Mengarah
gambaran
osteomyelitis
humerus sinistra

Foto Radiologi ( 16/07/2016)

Uraian Hasil Pemeriksaan

Foto Humerus sinistra proyeksi AP dan Lateral, kondisi
cukup. Hasil:
Tak tampak soft tissue swelling
Tampak lesi titik sklerotik dimetafise dan diafise os
humerus sinistra, batas tak tegas, tampak penebalan
cortex, involucrus (+) dan cloaca (+) di
superiorolecranon os humerus sinitra
Facies articularis licin
Caput humeri di fossa glenoidea
Joints space tak melebar maupun menyempit

Kesan
Osteomielitis kronis humerus sinistra
Tak tampak tanda- tanda fraktur os humerus sinistra

Pemeriksaan Sebelumnya

Keterangan Klinis

Foto Radiologi

Kesan

Teori
Osteomielitis

Definisi
Inflamasi pada tulang dan sumsum tulang karena
infeksi bakteri
Terbagi :
1. akut ( sering pada anak- anak)
2. Kronis : karena pengobatan infeksi terlambat atau
tidak adekuat

Epidemiologi
Dapat dialami semua usia ( paling sering usia 2-12 th)
M:F 3:1
In the U.S., 0.11.8% of otherwise healthy adults are
affected by acute osteomyelitis; 3040% of adults with
diabetes develop osteomyelitis after a foot puncture.
Orthopedic surgery (particularly with implantation of
hardware), obesity, diabetes, trauma, bacteremia, poor
circulation, and older age are risk factors for
osteomyelitis.
Osteomyelitis can occur at any age. In those without
specific risk factors, it is particularly common between
the ages of 2-12 years of age and is more common in
males (M:F of 3:1).

Types of Osteomyelitis
Pyogenic Osteomyelitis
Tuberculous Osteomyelitis
Vertebral Osteomyelitis

Etiologi

Etiologi

Route of Infection
Hematogenous dissemination (most common)
Extension from an infection in adjacent joint or soft
tissue
Traumatic implantation after compound
fractures/Orthopedic procedures

Location
Frequency in descending order by location
lower limb(most common)
vertebrae: lumbar > thoracic > cervical
radial styloid
sacroiliac joint
The location of osteomyelitis within a bone varies with
age, on account of changing blood supply
neonates:metaphysis and/or epiphysis
children:metaphysis
adults:epiphyses and subchondral regions

Patofisiologi

Macroscopic

Macroscopic
Necrosis area, abscess, subperiosteal abscess, sinus
drainage (akut)
Cloaca -> hole formed in the bone during the formation
of a draining sinus.
Sequestrum -> fragment of necrotic bone embedded in
pus.
Brodie abscess -> reactive bone from the periosteum
and endosteum, which surrounds and contains the
infection.
Involucrum -> a lesion in which periosteal new bone
formation forms a sheath around the necrotic
sequestrum.
Sometimes accompanied by pathological fractures

Manifestasi Klinis
Pts generally have a febrile illness, with localized pain
and tenderness. A history of surgery or trauma in the
affected regioneven in the remote pastshould raise
suspicion.

Diagnosis
Diagnosis requires 2 of the 4 following criteria:
Purulent material on aspiration of affected bone
Positive findings of bone tissue or blood culture
Localized classic physical findings of bony tenderness,
with overlying soft-tissue erythema or edema
Positive radiological imaging study

Imaging for Osteomyelitis

Plain Radiography
Plain radiography is a useful first step that may reveal
other diagnoses, such as metastases or osteoporotic
fractures. It generally complements information provided
by other modalities and should not be omitted, even if
more advanced imaging is planned.

Plain Radiography
In general, osteomyelitis must extend at least 1 cm and
compromise 30 to 50% of bone mineral content to produce
noticeable changes in plain radiographs. Early findings may be
subtle, and changes may not be obvious until 5 to 7 days in
children and 10 to 14 days in adults. After this time a number of
changes may be noted:
regional osteopaenia
periosteal reaction/thickening (periostitis):variable, and may
appear aggressive including formation of aCodman's triangle
focal bony lysis or cortical loss
endosteal scalloping
loss of bony trabecular architecture
new bone apposition
eventual peripheral sclerosis

Regional Osteopenia

Describes a localised
or regional decrease
in
bone
mineral
density.

Contoh pada Disuse

Osteopenia

Periosteal Reaction
Also known as aperiostitis/periosteitis, is a non specific
radiographic finding that occurs with periosteal irritation. Periosteal
reactions may be broadly characterized as benign or aggressive, or
more specifically broken down by pattern.
Benign periosteal reaction
Low-grade chronic irritation allows time for the formation of normal
or near-normal cortex. The cortex will be thick and dense and have
a wavy or uniform appearance.
Aggressive periosteal reaction
Rapid irritative processes do not allow the periosteum time to lay
down and consolidate new bone to form normal cortex. The cortex
may appear lamellated, amorphous, or sunburst-like.

Periosteal Reaction

Periosteal Reaction Osteomyelitis

Focal bony lysis or cortical loss

Plain radiograph showing osteomyelitis

of the distal fourth metatarsal and
distal third and fourth
phalanges(arrows). Cortical disruption
and osteolysis are present.

Endosteal scalloping
Endosteal scallopingrefersto the focal resorption of
the inner margin of cortical bones, typically seen in long
bones, due to slow growing medullary lesions.

Endosteal
scalloping pada
multiple myeloma

Radiographic features are specific to a

region or a particular type of infection: 1)
Brodie's abscess

2) Subperiosteal abscess

3) Sclerosing osteomyelitis
Sclerosing osteomyelitis of Garris a specific type
ofchronic osteomyelitis.It mainly affects children and
young adults.It typically affectes the mandible and is
commonly associated with an odontogenic infection
resulting from dental caries.

CT Scan
The role of computed tomography in the diagnosis of
osteomyelitis is limited. Although computed tomography
is superior to MRI in detecting necrotic fragments of
bone, its overall value is generally less than that of other
imaging modalities. Computed tomography should be
used only to determine the extent of bony destruction
(especially in the spine), to guide biopsies, or in patients
with contraindications to MRI.

MRI
MRI provides better information for early detection of
osteomyelitis than do other imaging modalities.MRI
can detect osteomyelitis within three to five days of
disease onset.
Most studies of the diagnostic accuracy of MRI in
detecting osteomyelitis included patients with diabetic
foot ulcers.The sensitivity and specificity of MRI in the
diagnosis of osteomyelitis may be as high as 90
percent. Because MRI can also detect necrotic bone,
sinus tracts, or abscesses, it is superior to bone
scintigraphy
in
diagnosing
and
characterizing
osteomyelitis.Its use can be limited, however, if
surgical hardware is present.

Magnetic resonance image demonstrating abnormal T1-weighted

signal within the calcaneus(long arrow), consistent with
osteomyelitis. Inferior cortical disruption and contiguous soft
tissue fluid and edema are also present(short arrow)

Nuclear imaging
Nuclear imaging can be helpful in diagnosing
osteomyelitis. Three-phase technetium-99 bone
scintigraphy and leukocyte scintigraphy are usually
positive within a few days of the onset of
symptoms.The sensitivity of bone scintigraphy is
comparable to MRI, but the specificity is poor.
Leukocyte scintigraphy also has poor specificity, but
when combined with three-phase bone scintigraphy,
sensitivity and specificity are improved. Bone and
leukocyte scintigraphy can provide valuable information
if MRI is contraindicated or unavailable.

Bone scintigraphy

Bone scintigraphy images demonstrating localized increased radioactive tracer

uptake within the left calcaneus, consistent with osteomyelitis

Kompetensi
Kompetensi Dokter Umum : 3B
Mendiagnosis
Terapi awal (emergency)
Rujuk

Treatment
Osteomyelitis rarely requires emergent stabilization or
resuscitation.
Treatment for osteomyelitis involves the following:
Initiation of intravenous antibiotics that penetrate bone
and joint cavities
Referral of the patient to an orthopedist or general
surgeon
Possible medical infectious disease consultation

Terima Kasih

Aetiology Regional Osteopenia

Aetiology
disuse osteopaenia(usually an aggressive osteoporosis withpseudo-permeative pattern)
immobilization of fractures
paralysed segments
bone and joint infections

complex regional pain syndrome(a.k.a. Sudeck atrophy / reflex sympathetic dystrophy

syndrome)

post-traumatic
post-infective states
myocardial infarction
calcific tendinitis
cervical spondylosis

infection
early infectious invasion of the synovium 2
earlyosteomyelitis
tuberculosis

transient osteoporosis of the hip

regional migratory osteoporosis
erosive arthritis, e.g.rheumatoid arthritis
lytic phase ofPaget disease
earlybone infarct