4. Hematogenous Osteomyelitis
Hematogenous osteomyelitis is typically seen in children
in the metaphyseal ends of long bones in the lower extremities.
The proximal end of the tibia is the most common site. Staph
aures bacteria arising from a peripheral site such as the skin or
nose and throat gain access to the peripheral circulation where
they travel to the terminal end-arterial circulation just beneath
the growth plate where a primary focal abscess will arise. The
abscess will then increase in size resulting in local thrombosis
followed by bone necrosis as the purulent mass works its way
thru the adjacent cortex gaining access to the subperiosteal
space thus lifting the periosteum which then goes on to form
a healing involucrum. In the early days prior to antibiotics,
osteomyelitis was a very aggressive disease process associated
with severe local pain, high fevers and septacemia resulting
in high white counts and sed rates. The disease was frequently
5. multi focal in bones as well as in various organs such as the
lung, liver and brain resulting in death in a high number of
cases. However, since the advent of antibiotics the modern
form of osteomyelitis is far less aggressive and may present
with minimal symptoms of pain with a minimal elevation of
the white count or sed rate and for this reason my go on
without diagnosis or treatment.
6. 8/17/39 8/26/39
10 yr male with acute onset of pain in tibia 4 days before the
1st x-ray with high fever of 104 degrees and a 20,000 WBC
74. Squamous cell CA arising from chronic osteomyelitis
Macro section and microscopic of amputated leg of an older
patient with a long history of chronic osteo of the tibia
78. Salmonella Dactylitis hands and feet
Infant black male with 3mo
history of SS disease and
painful swelling of hands
and feet along with diarrhea
and fever
89. Staph pyarthosis
1.5 yr female with fever and
extremely irritable left
hip held in flexion and
external rotation
2 mos following posterior
surgical drainage and
antibiotic therapy
91. Septic necrosis of femoral head
Initial 2 mos 6 mos
X-ray PO PO
10 yr male with initial diagnosis of rheumatic fever of hip
treated with steroids, ASA and antibiotics without success
93. Musculoskeletal Tubrculous Infections
Tuberculous infection of the musculoskeletal system is seen in
about 5% of patients with pulmonary TBc. The problem is more
common in Asian and Mexican populations of the world. In the
USA musculoskeletal TBc is rare in children but is more common
in adults with immunodeficiency conditions related to IV drug
abuse, alcoholism, HIV disorders and patients on corticosteroid
medication. The most common skeletal site for TBc infection is
the spine followed next by the hip and knee. The TB mico-
bacterial organism enters the blood stream in the lung and travels
to a metaphyseal bone site in the spine, hip or knee area which
then results in discitis or psoas abscess of the spine or tuberculous
arthritis of the hip or knee. The tuberculous micobacterium
stimulates the formation of a caseating granulomatous lesion
made up of epithelioid cells, Langhans giant cells and lymphs.
A similar granuloma is seen in sarcoidosis which is none infectious
and none caseating. Antituberculous drugs include streptomycin,
PAS, INAH, myambutol, and rifampin.
109. Tuberculous Tenosynovoitis
Epithelioid granuloma
27 yr male with 1 yr history
of carpal tunnel syndrome
2nd to TBc tenosynovitis
110. Sarcoidosis
Sarcoidosis is a nonspecific noncaseating epithelioid granuloma-
tous process that affects the reticuloendothelial system of young
adults that pathologically resembles the histology of TBc, fungus
infections, viruses and even low grade lymphomas such as
Hodgkin’s disease. In the US it is seen more commonly in the
southeastern states and is ten times more common in blacks then
whites. 90% will have pulmonary infiltrates or hialar adenopathy
along with systemic symptoms of fever, coughing, inflammatory
arthropathy and iritis. Other systemic symptoms include weight
loss, lymphadenopathy and hepatosplenomegaly as seen in
lymphomas. Granulomatous skin lesion similar to erythema
nodosum can be seen. Hypercalcemia can be seen in 25% of case
second to an increase of calcium absorption at the gut level. 70%
of cases will have a positive Kveim skin test to help separate out
other granulomatous disorders such as TBc. 5% of cases involve
the middle and distal phalanges of the hand (most common) and
111. feet associated with overlying subcutaneous nodularities that
might suggest the diagnosis of TBc, gout, Ollier’s disease or
tuberous sclerosis. The homeycomb or latticework lytic pattern
of sarcoidosis will help differentiate from these other diagnostic
considerations. The bony lesions are asymptomatic unless
associated with a pathologic fracture. Bony changes in large bones
are very rare and can present with a sclerotic pattern seen in low
grade lymphomas such as Hodgkin’s disease. The prognosis
for minor lesions of the hands and feet is excellent but with
greater reticuloendothelial involvement of multi organ systems
the prognosis is more guarded like that of a low grade
lymphoma.
112. Case #1 Sarcoidosis of Hand
46 yr male with recent path fracture ring finger
117. Tuberculous Spondylitis
About 60% of all TBc involves the spine and is frequently
seen in Asian or Mexican patients. In Hong Kong where this
disease is common they see over 100 cases per year, 70% of
which are seen in children. L-1 is the most common vertabra
involved and from there it can spread up and down the spine
under the anterior longitudinal ligament or thru the Batson’s
para vertebral plexes. In China multiple vertabrae are involved
compared to only one or two vertabrae in mid aged adults in
the USA. As with pyogenic spondylitis it is felt that the
tuberculous organism gains access to the vertebral body thru
the blood supply to the spine. Even though there is no primary
infection of the avascular disc space, extensive destruction of
the vertebral body with collapse of the disc into the body
results in significant gibbus deformity not common in pyo-
genic spondylitis.
133. Leprosy
Leprosy is not very common in the USA but is seen in other
countries such as South America, Africa, southern Europe
India and China. There are two clinical types of leprosy. The
more common and non infectious form is the neural or
tuberculoid form that is of interest to orthopedic surgeons
because of the peripheral neuropathies and neuropathic joints
that are seen in this form. The lepromatous form which is
infectious because of the draining skin ulcerations has a poor
chance for survival.
In the neural form of leprosy the micobacterium lepri organ-
ism finds its way into periperal nerves causing them to enlarge
resulting in a loss of both motor and sensory components. The
loss of sensation results in trophic skin changes including loss
of pigmentation, hair and ulcerations. Neuropathic joints are
seen in 27% of cases.
134. Neural or tuberculoid form of leprosy
Short finger
Neurotrophic foot ulcers and Gynecomastia 2nd to
claw hand deformities testicular leprosy
135. Neural leprosy
Combined median & ulnar N
involvement with trophic skin
changes, clawing, lack of
sweating, and short finger tips
from terminal phylangeal
osteolysis
Loss of skin pigmentation
in areas of anesthesia
136. Neural leprosy
Social stigma of
eyebrow alopecia
Neuropathic feet with deformity
and shortening due to osteolysis
and neuropathic joints
140. Leutic Infections
Syphilis is a disease caused by the treponema pallidum
organism which was first introduced to America by Christopher
Columbus. 50% of cases will involve bone. The two major clinical
types include the adult and congenital forms. The acute form of
the disease is a soft tissue problem and the late or tarda form
of the disease is the type that involves bone and joints that
would be of interest to an orthopedic surgeon . The two most
common bones affected with syphilis include the cranium and
the tibia.
143. Luetic periostitis
2.5 yr female with saber shin lesion
from congenital lues looking like
hypervitaminosis A, juvenile Paget’s
disease, Englemann’s disease and
Caffey’s disease
148. Rubella metaphysitis
Infant born with dwarfism,
thrombocytopenia, congenital
heart defects, cataracts, enlarged
liver & spleen, chorioretinitis
and deafness to a mother who
had measles in 1st trimester
149. Caffey’s disease (viral osteomyelitis ?)
8 mo, old infant with 6 weeks of painful swollen forearm
156. Coccidiomycosis
The two most common fungus infections seen by orthopedic
surgeons are coccidiomycosis and blastomycosis. Coccidio-
mycosis is most common and seen in the south western part of
the USA whereas, blastomycosis has no special location.
coccidiomycosis is usually seen in the San Joaquin Valley area
where it starts with an upper respiratory infection and a
fever known as valley fever followed in a few weeks by an
acute pneumonitis which usually heals without recurrence.
In a very small percent of cases a granulomatous response is
seen in joints, bone, muscle and skin that can lead to the death
of the patient. The granulation tissue is similar to that seen in
TBc except for the presence of endospores seen in the cytoplasm
of the Langhans type giant cells. Coccidiomycosis replicates
thru a process of endosporulation within the mother cell where-
as in blastomycosis the reproduction takes place thru a process
of external budding from the mother spore.
157. Coccidiomycosis of knee
82 yr old farmer from Fresno with mild painful swelling of knee
with lytic epiphyseal lesion like GCT except for anterior breakout
158. Surgical clean out
Yellow arrow sinus track lead to
necrotising cavitary abscess space
with granulomatous granulation
tissue revealing Langhans type
giant cells with blue arrow
endospore of coccidiomycosis
159. Coccidiomycosis of Knee
Bone scan
40 yr old farmer from Stockton with pain and swelling of knee 3 mos
160. Coccidiomycosis
arthritis
23 year Asian male with painful swollen knee 2 years
164. Coccidiomycotic synovial cyst
79 yr male with MRI evidence
of a large popliteal cyst arising
from the knee joint similar to
the appearance of a rheumatoid
synovitis
165. Coccidiomycosis of knee
Sag T-2
23 yr male with mixed synovial
and bony involvement for 1 yr
172. Sagittal T-2 MRI shows the
high signal cocci inflammatory
tissue extruding anteriorly
beneath the anterior longitudinal
ligament in order to spread to
adjacent vertabrae as we see
in TBc spondylitis
177. Echinococcal osteomyelitis (hydatid disease)
35 yr male from Southern Italy
with hip pain for 2 yrs with chronic
deformation suggestive of Large calcific
fibrous dysplasia cyst in liver
