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The Orthotech rarely sees the patient when everything’s fine. Usually, there has been trauma and/or surgery to address it. Especially in the cast room, where there is opportunity to treat open wounds through which bone has recently protruded or which will allow access to bone, careful attention to prevention of infection can help save a person’s limb.

Osteomyelitis is a bone infection that is progressive and results in inflammatory destruction of the bone, and new bone formation. Acute osteo sets in gradually over several days to a week. Patients present with bone pain, tenderness, warmth and swelling; pain occurs with and without movement. Most people have fever and sometimes shaking chills. Chronic osteo takes weeks or months to develop. It is easily recognized in patients with a history of acute osteo who experience a recurrence of pain, redness, swelling, and a draining sinus. One must be suspicious of osteomyelitis where the patient has a painful orthopedic prosthesis, a pressure ulcer, or a foot ulcer associated with peripheral vascular disease or diabetes. In the adult with post-traumatic osteomyelitis, the tibia is the most frequent site for this infection (Figure 2).

Focusing on the treatment of traumatic wounds that probe to bone or expose bone, aggressive attempts to minimize infection are crucial to prevention of
osteo.

The Four Ps of excellent wound care should always be practiced, with attention paid to the future. Nowhere is this more important than where the wound probes to bone. If you can see it, if you can feel it, the bone is at risk for osteomyelitis.

Pain: Make sure the patient is as comfortable as possible. Pre-medicate, anticipate the discomfort that dressing change, cast or splint application, and wound manipulation will create. Explain all procedures to minimize anxiety and fear, which escalates pain perception.

Purge the wound: Cleanse, irrigate, debride the wound. No matter how aggressive the antibiotic use, if the wound is not thoroughly debrided of dead tissue, including dead bone, the wound will not heal (Figure 3).

Pack: Fill dead space or expect an abscess. This is especially important in wounds that expose bone. Use packing material that is hostile to bacteria, such as silver-permeated ribbon like Silverlon or Select Silver, and think about the use of silver VAC sponge if negative pressure wound therapy will be used. There are multiple silver calcium alginate products on the market for soft tissue injuries vulnerable to infection. Mesalt is a packing material useful in wet, draining wound management that will osmotically pull purulence from a wound tract, and kill bacteria effectively.

Protect: Again, think ahead. Will the wound be under a cast or splint? Anticipate the effect of too much moisture: tissue maceration and yeast rash. Will there be pressure over the wound or joint? There may be a pressure ulcer on the horizon. Use a very absorbent foam over a wet wound, and find one with silver. Apply silver calcium alginate under the foam as an alternative, to supply antibacterial effect, and ramp up absorption. If it will be days or a week before the next cast change, those super absorbent materials will be real friends to the wound.

Carefully address pressure: Pad the tibia and distal femur to protect the knee under a splint. Pressure ulcers are difficult to heal once established. Be especially vigilant about the heel, which has little subcutaneous tissue, and only the heel pad to protect the calcaneus.

These basics do not comprise a wound-care formulary, just the beginning of a good approach to the wound. Critically important to wound management are antibiotic therapy, oxygenation, and nutrition (Figure 4).

References:
1. Calhoun, J; Bal, B. S; Yin, L. Pathogenisis of osteomyelitis. www.UpToDate.com, 2007.

2. Calhoun, J.; Sexton, D; Bal, B. S; Yin, L. Adult posttraumatic osteomyelitis. www.UpToDate.com, 2007.

3. Bryant, R. and D. Nix. Acute and chronic wounds: current management concepts. Philadelphia: Mosby Elsevier, 2007. Pg. 161.

4. Baranoski, S. and E. A. Ayello. Wound care essentials: practice principles, 2nd edition. Philadelphia: Lippincott Williams and Wilkins, 2007. Pgs: 93-118.

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