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Diagnosis and Treatment

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Diagnosis: Acute osteomyelitis of the humerus mimicking malignancy

Diagnosing 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.
Blood culture: A blood culture is a test used to detect bacteria. A sample of blood is taken and
then placed into an environment that will support the growth of bacteria. By allowing the bacteria
to grow, the infectious agent can then be identified and tested against different antibiotics in
hopes of finding the most effective treatment.
Needle aspiration: During this test, a needle is used to remove a sample of fluid and cells from
the vertebral space, or bony area. It is then sent to the lab to be evaluated by allowing the
infectious agent to grow on media.
Biopsy: A biopsy (tissue sample) of the infected bone may be taken and tested for signs of an
invading organism.
Bone scan: During this test, a small amount of Technetium-99 pyrophosphate, a radioactive
material, is injected intravenously into the body. If the bone tissue is healthy, the material will
spread in a uniform fashion. However, a tumor or infection in the bone will absorb the material
and show an increased concentration of the radioactive material, which can be seen with a
special camera that produces the images on a computer screen. The scan can help your doctor
detect these abnormalities in their early stages, when X-ray findings may only show normal
findings.
Treatment for osteomyelitis
The objective of treating osteomyelitis is to eliminate the infection and prevent the development
of chronic infection. Chronic osteomyelitis can lead to permanent deformity, possible fracture,
and chronic problems, so it is important to treat the disease as soon as possible.
Drainage: If there is an open wound or abscess, it may be drained through a procedure called
needle aspiration. In this procedure, a needle is inserted into the infected area and the fluid is
withdrawn. For culturing to identify the bacteria, deep aspiration is preferred over oftenunreliable surface swabs. Most pockets of infected fluid collections (pus pocket or abscess) are
drained by open surgical procedures.
Medication: Prophylactic treatment with the bead pouch technique has been suggested in open
fractures to reduce the risk of infection, with systemic antibiotics supplemented with antibiotic
beads compared to using systemic antibiotics alone.
Treatment of osteomyelitis depends on appropriate antibiotic therapy and often requires surgical
removal of infected and necrotic tissue. Choice of antibiotic therapy should be determined by
culture and susceptibility.In the absence of such information, broad-spectrum, empiric antibiotics
should be administered. False-negative blood or biopsy cultures are common in patients who
have begun antibiotic therapy. If clinically possible, delaying antibiotics is recommended until
microbial culture and sensitivity results are available. Indications for surgery include antibiotic
failure, infected surgical hardware, and chronic osteomyelitis with necrotic bone and soft tissue.

Initial Antibiotic Therapy for Treatment of Osteomyelitis in Adults
ORGANISM

PREFERRED REGIMENS

ALTERNATIVE REGIMENS

Anaerobes

Clindamycin,
600
mg IV every 6 hours
Ticarcillin/clavulanat
e (Timentin), 3.1 g
IV every 4 hours

Cefotetan (Cefotan), 2 g IV
every 12 hours
Metronidazole, 500 mg IV
every 6 hours

Enterobacteriaceae
(e.g., Escherichia
coli),
quinoloneresistant

Ticarcillin/clavulanat
e, 3.1 g IV every 4
hours
Piperacillin/tazobact
am (Zosyn), 3.375 g
IV every 6 hours

Ceftriaxone, 2 g IV every
24 hours

Enterobacteriaceae
,
quinolonesensitive

Fluoroquinolone
(e.g., ciprofloxacin
[Cipro], 400 mg IV
every 8 to 12 hours)

Ceftriaxone, 2 g IV every
24 hours

Pseudomonas
aeruginosa

Cefepime, 2 g IV
every 8 to 12 hours,
plus
ciprofloxacin,
400 mg IV every 8 to
12 hours
Piperacillin/tazobact
am, 3.375 g IV every
6
hours,
plus
ciprofloxacin,
400
mg IV every 12
hours

Imipenem/cilastatin
(Primaxin), 1 g IV every 8
hours, plus aminoglycoside

Staphylococcus
aureus, methicillinresistant

Vancomycin, 1 g IV
every 12 hours
For patients allergic
to
vancomycin: Linezol
id (Zyvox), 600 mg
IV every 12 hours

Trimethoprim/sulfamethoxa
zole (Bactrim, Septra), 1
double-strength
tablet
every 12 hours
Minocycline (Minocin), 200
mg orally initially, then 100
mg daily
Fluoroquinolone
(e.g.,
levofloxacin[Levaquin], 750
mg) IV daily plus rifampin,
600 mg IV every 12 hours

ORGANISM

PREFERRED REGIMENS

ALTERNATIVE REGIMENS

S.
aureus,
methicillinsensitive

Nafcillin or oxacillin,
1 to 2 g IV every 4
hours
Cefazolin, 1 to 1.5 g
IV every 6 hours

Ceftriaxone, 2 g IV every
24 hours
Vancomycin, 1 g IV every
12 hours

Streptococcusspeci
es

Penicillin G, 2 to 4
million units IV every
4 hours

Ceftriaxone, 2 g IV every
24 hours
Clindamycin, 600 mg IV
every 6 hours

Splinting or cast immobilization: This may be necessary to immobilize the affected bone and
nearby joints in order to avoid further trauma and to help the area heal adequately and as
quickly as possible. Splinting and cast immobilization are frequently done in children, although
motion of joints after initial control is important to prevent stiffness and atrophy.
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.
The Cierny-Mader classification system plays an important role in guiding 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.
When a fracture and stable hardware are involved, surgery is used to treat a residual infection
after suppressing the infection until the fracture heals. Techniques involve second-stage
hardware removal followed by treatment of an infected nonunion, often with an external fixator.
Remission or cure is most likely with extensive debridement, obliteration of dead space, removal
of any hardware, and appropriate antibiotic therapy.
Ilizarov method
The Ilizarov method, developed by G. A. Ilizarov in 1951, promotes bone growth through
distraction osteogenesis using a specialized device and systematic approach. This technique
has facilitated limb lengthening, decreased the incidence of many complications, and decreased
the level of surgical intervention necessary.

The Ilizarov method involves the use of a tissue-sparing, cortical osteotomy-osteoclasis
technique that preserves the osteogenic elements in the limb. To create a preliminary callus that
can be lengthened, Ilizarov advocated a delay of several days before initiating distraction. A
high-frequency, small-step distraction rhythm permits regeneration of good-quality bone and
less soft-tissue complications such as nerve and vessel injury. An advantage of using this
procedure is that it minimizes the prevalence of nonunion and thus further bone grafting by
producing good-quality bone formation.
The risk of repeat osteotomy and osteoclasis is also decreased owing to less-premature
consolidation of the lengthened segment. However, Ilizarov techniques are often not tolerated
well by patients, and other options, including amputation, may be preferred.
Wound closure
To arrest infection, it is necessary to provide adequate soft-tissue coverage. Over small softtissue defects, a split-thickness skin graft may be placed, whereas large soft-tissue defects may
be covered with local muscle flaps and free vascularized muscle flaps. Rotation of a local
muscle with its neurovascular supply must be possible anatomically for that procedure to be
successful.
These flaps bring in a blood supply, which is important for host defense mechanisms, new bone
regeneration, delivery of antibiotics, and healing. They also may be used in combination with
antibiotics and surgical debridement of necrotic and infected tissues. The fibula and iliac crest
are common donor sites for free flaps.
Hyperbaric oxygen therapy
Adjunctive hyperbaric oxygen therapy can promote collagen production, angiogenesis, and
healing in an ischemic or infected wound.

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