osteomyelitis

• Osteomyelitis

  Acute or chronic inflammatory process of bone and its structures that occurs secondary to infection
• Mortality from osteomyelitis has decreased from 50% to less than 1% due to antibiotic therapy
• Classification of osteomyelitis based on duration

  • Acute: < 2 weeks
  • Subacute: 2 weeks - 3 months
  • Chronic: > 3 months
• Chronic refractory osteomyelitis


  When unresponsive to antibiotics (6 weeks) or surgical treatment
• Pathophysiology of osteomyelitis


  1. Infection occurs via hematogenous route, contiguous spread, or direct inoculation

  2. Pus produced and pressure builds in medullary cavity

  3. Pus forces through haversian canals, subperiosteal abscess forms, bone deprived of blood supply

  4. Necrosis results, new bone formation stimulated, dead bone detaches and exits
• Causes of acute osteomyelitis


  • Hematogenous delivery
  • Fungi, bacteria, and viruses
  • Pseudomonas aeruginosa
  • Staphylococcus aureus (methicillin-resistant S. aureus, most common)
  • Streptococcus pyogenes
  • Kingella kingae
  • Salmonella
• Risk factors for osteomyelitis


  • Chronic kidney disease
  • Immunosuppression
  • Long-term corticosteroid therapy
  • Rheumatoid arthritis
  • Sickle cell disease
  • Vascular insufficiency
  • Diabetes mellitus
  • Chronic granulomatous disease
  • Recent injury
  • Minor traumatic injury
  • Compound factor
  • Ischemia
  • Presence of a foreign body
• Incidence of osteomyelitis in children


  • Increasing, 9.2 cases per 100,000 children
  • > 50% in kids younger than 5 yrs
  • Acute hematogenous more common due to rich vascular supply in growing bones
  • Males > females
  • Long bones
  • Multifocal incidence more common in neonates
  • Immunocompromised
• Acute osteomyelitis


  Affects rapidly growing children, especially boys, and primarily affects the long bones
• Complications of osteomyelitis


  • Bone growth disturbances
  • Limb-length discrepancies
  • Septic arthritis
  • Abnormal gait
  • Pathologic fractures
  • Bone necrosis and fibrosis
  • Chronic osteomyelitis
  • Deep vein thrombosis
  • Intraosseous and subperiosteal abscess
  • Sepsis
  • Multisystem organ failure (rare)
• History findings


  • Inability to support weight and asymmetrical movement of extremities (in neonates and young infants)
  • Fever, bone pain, swelling, redness, and guarding of affected body part
  • Previous injury, surgery, or primary infection
  • Dull pain at involved site or sudden severe pain in affected bone
  • Pain unrelieved by rest and worsens with motion
  • Fatigue
  • Irritability
  • Related chills, nausea, and malaise
• Physical findings


  • Tachycardia
  • Swelling and restricted movement over infection site
  • Tenderness and warmth over infection site
  • Persistent pus drainage from old pocket in sinus tract
  • Nonhealing ulcer
  • Pseudoparalysis (in infants)
• Determining the causative organism is essential for successful treatment
• Diagnostic tests


  • White blood cell count and differential (leukocytosis in acute)
  • Erythrocyte sedimentation rate and C-reactive protein (increased)
  • Blood culture to identify pathogen
  • Radiography (edema, bone involvement, periosteal changes)
  • Bone scan (early infection, localize pathology in infants/toddlers)
  • Ultrasonography (soft-tissue abscess or fluid collection)
  • CT and MRI (extent of infection, abscesses, early edema)
• Needle biopsy or open bone biopsy is the gold standard to identify the organism
• Treatment


  • Empirical antimicrobial therapy
  • Hyperbaric oxygen therapy (for chronic refractory osteomyelitis)
  • Usual diet as tolerated
  • Activity as tolerated, with immobilization and protected weight bearing
  • IV antibiotics initially, then oral antibiotics
  • Analgesics for fever and pain
  • IV fluids to maintain hydration
  • Surgical drainage and debridement
• Nursing interventions


  • Administer medications and monitor effects
  • Administer IV fluids, maintain access, monitor for infiltration
  • Anticipate need for PICC line
  • Obtain specimens for testing, monitor results
  • Provide meticulous skin care
  • Assess fall risk, implement precautions
  • Assess and manage pain
  • Perform wound care using aseptic technique
  • Protect bone from injury, assist with immobilization
  • Encourage verbalization of questions/concerns, provide support
  • Consult nutritionist, monitor intake/output
  • Encourage participation in care, self-care, rest/relaxation
  • Collaborate with OT and PT
  • Assess cardiovascular status, monitor for changes
  • Prepare for surgery, involve child life specialist
  • Collaborate with social services and care management
• Nursing procedures


  • Intake and output measurement
  • IV bag preparation
  • IV bolus injection
  • IV catheter insertion
  • IV pump use
  • Oral temperature measurement
  • Pain assessment
  • Pain management
  • Patient teaching
  • PICC line insertion
• Prepare the child and the family for surgery


  If appropriate
• Consult with a child life specialist


  Provide age-appropriate distractions and support
• Collaborate with social services

  Provide counseling, community resources, and support
• Collaborate with care management


  Ensure that all home-going needs are met prior to discharge
• Monitoring


  • Vital signs
  • Wound status
  • Culture results
  • Pain level and relief
  • IV site
  • Intake and output
  • Skin and tissue integrity
  • Anxiety level
  • Joint mobility and muscle strength
  • Fluid balance
  • Signs and symptoms of complications
• Associated Nursing Procedures


  • Intake and output measurement, pediatric
  • IV bag preparation
  • IV bolus injection
  • IV catheter insertion, pediatric
  • IV pump use
  • Oral temperature measurement, pediatric
  • Pain assessment, pediatric
  • Pain management
  • Patient teaching
  • Peripherally inserted central catheter (PICC) insertion, pediatric
  • Postoperative care
  • Preoperative care, pediatric
  • Pulse assessment, pediatric
  • Temperature measurement
  • Temporal artery temperature measurement, pediatric
  • Venipuncture, pediatric
  • Wound care, pediatric
• Patient and Family Teaching

  • Include the child's family or caregiver in your teaching, when appropriate
  • Provide information according to their individual communication and learning needs
  • Disease; diagnosis; underlying cause; treatment, including the need for antibiotic therapy and possible wound care; and prognosis
  • Prescribed medications, including drug names; dosages; indications for use; frequency, route, and duration of administration; expected results; potential adverse effects; and signs and symptoms of toxicity
  • Possible adverse effects of antibiotic therapy, such as GI upset, hypersensitivity, and superinfection
  • Signs and symptoms of hypersensitivity and superinfection, including the need to notify the practitioner if any occur
  • Central venous access device care
  • Wound care measures and signs and symptoms of wound healing and infection
  • Techniques for promoting rest and relaxation
  • Need to adhere to the medication regimen, even if the child is feeling better, to ensure complete recovery from the infection
  • Importance of immobilizing the affected area, including the proper method
  • Need for ongoing follow-up examinations, including laboratory and diagnostic testing, to evaluate healing
• Discharge Planning


  1. Participate in discharge planning with other members of the multidisciplinary team

  2. Assess the child's (if appropriate) and the parents' or caregiver's understanding of the diagnosis, treatment regimen, need for follow-up care, and warning signs or potential problems that require medical attention

  3. Use the teach-back method, when possible

  4. Explain the importance of scheduling and attending all follow-up appointments

  5. Confirm transportation arrangements for initial follow-up appointments

  6. Ensure that the parents or caregivers understand the treatment regimen, including the purpose and desired effect of each medication, the dosage and how to administer it, and potential adverse effects

  7. Ensure that the parents or caregivers are able to obtain the prescribed medications

  8. Ensure that the child (if appropriate) and the parents or caregivers have the name and contact information of someone to call if they encounter a problem

  9. Document the discharge planning evaluation in the child's medical record