2. OSTEOMYELITIS
Nelaton coined
osteomyelitis in 1834
It includes three root words
osteon (bone)
myelo (marrow)
Combination: itis
(inflammation)
to define the clinical state in
hich bone is infected with
microorganisms.
3. Infection of bone and marrow is known as osteomyelitis.
It may remain localized, or it may spread through the
bone to involve the marrow, cortex, periosteum, and soft
tissue surrounding the bone.
5. Osteomyelitis is divided into 3 forms as per duration:
1. Acute osteomyelitis
2. Subacute osteomyelitis
3. Chronic osteomyelitis
6. OSTEOMYELITIS
BASED ON THE DURATION AND TYPE OF SYMPTOMS
Acute: <2weeks Early acute
Late acute( -
5days)
Subacute 2weeks Less virulent –
: — more immune
3months
Chronic: >3month
s
7. Three basic mechanisms allow an infection to reach the
bone;
1. Haematogenous spread
2. Contagious source
of infection
3. Direct implantation
8. HAEMATOGENOUS OSTEOMYELITIS
- Primary haematogenous osteomyelitis is characterized by an
acute infection of bone caused by seeding of bacteria within
the bone from a remote source
- Haematogenous osteomyelitis usually occurs during period of
growth and thus occur primarily in children. However, all ages
may be affected and cases are even found in old age.
9. CAUSES: OSTEOMYELITIS
General factors
Anaemia
Local factors
Hair pin bend vessels
Metaphyseal haemorrhage
Defective Phagocytosis
Rapid growth at metaphysis
Vasospasm
Debility
Infection
Poor nutrition
Poor immune status
10. TYPE OF ORGANISMS
Bacteria, viruses and fungi can all infect bone, soft
tissues and joints. Generally, bacterial infections
are more destructive and move rapidly.
Fungi tend to produce slow and chronic infections.
Tuberculosis and brucellosis range from aggressive
to reparative
11. PATHOPHYSIOLOGY:
Metaphysis of the long bones are
highly vascularized zones.
From the diaphysis the medullary
arteries reach upto the growth
plate—the area of greatest activity
and branch into capillaries. The
venous systems in this area
drains towards diaphysis
Thus, the vessel in this zone are
arranged in the form of loop (hair
pin arrangement) resulting in
“sluggish flow” of blood, leading to
bacterial enlodgement and thus
haematogenous osteomyelitis.
12. CLINICAL FEATURES
Early Acute Febrile illness
Limping to walk
Avoidance of using the extremity
Late Acute
•
•
Swelling
pain
Sub acute
Chronic
Cannot pinpoint onset
Fever/swellin mild
purulent drainage
13. GENERAL SYMPTOMS OF OSTEOMYELITIS ARE :-
Fever
Fatigue
Irritability
Malaise
Restriction of movement of limb
Local edema, erythema and tenderness
15. RISK FACTORS
Trauma (orthopaedic surgery or open fracture)
Prosthetic orthopaedic device
Diabetes
Peripheral vascular disease
Intravenous drug abuse
Chronic steroid use
Immunosuppression
Tuberculosis
HIV and AIDS
Sickle cell disease
16. DIAGNOSIS
Early diagnosis of acute osteomyelitis is critical
because prompt antibiotic therapy may prevent
necrosis of bone.
Osteomyelitis is primarily a clinical diagnosis,
although the clinical picture may be confusing.
An inadequate or late diagnosis significantly
diminishes the cure rate and increases the degree
of complications and morbidity.
17. LAB FINDINGS:
Aspirate pus or fluid, a smear is examined for cells
and organisms(to identify a type of infection)
WBC counts are elevated with increased
polymorphoneuclear leukocyte count.
C-reactive proteins – level is elevated
ESR usually elevate up to 90%.
Blood culture results are positive in patients with
haematogenous osteomyelitis.
18. RADIOLOGICAL FINDINGS
Plain X-ray
The earliest radiographic signs of bone infection are soft
tissue swelling and loss of fascial planes.
These are usually encountered with in 24 to 48 hours of
infection.
Plain radiographs shows:
Ist week: No abnormality of bone
2
nd
week : Faint extra cortical outline due to periosteal new
bone formation ( a classic x-ray sign of early pyogenic
osteomyelitis.)
7 to 10 days : destructive lytic lesion, usually occurs.
3 to 6 weeks : elevation of periosteum and layered new bone
formation .
3-8 weeks :The dead bone (i.e. sequestrum formation) occurs.
19.
20.
21.
22. INFECTION AT THE FRACTURE SITE HAS
DELAYED UNION IN THE HUMERUS. NOTE
THE EXTENSIVE PERIOSTEAL REACTION.
24. ULTRASOUND
Ultrasound may detect a sub periosteal collection
of fluid in the early stage of osteomyelitis but it
cannot distinguish between hematoma and pus.
25. CT SCANNING
CT is useful method to detect early osseous erosion and
to document the presence of sequestrum, foreign body, or
gas formation
Though of less value in diagnosis, CT demonstrates
changes in subacute or chronic osteomyelitis well.
Sequestra, as on conventional films is shown as area of
dense or high attenuation spicules of bone lying in areas
of osteolysis.
26. M.R.I. FINDINGS
MRI can be helpful in case of doubtful diagnosis
It is highly sensitive for detecting osteomyelitis as early
as 3 to 5 days after the onset of infection
It is best method of demonstrating bone marrow
inflammation.
It helps to differentiate between soft tissue infection and
osteomyelitis.
28. TREATMENT
1. General treatment: nutritional therapy or
general supportive treatment by intaking
enough caloric, protein, vitamin etc.
2. Antibiotic therapy
3. Surgical treatment
I&D
4. Immobilization
Splintage of affected part
31. SUB ACUTE OM TREATMENT
Conservative :
a) Immobilization
b) Antibiotics (flucloxacillin + fusidic acid) for 6weeks
Surgical (if the diagnosis is in doubt / failed conservative
treatment) :
a) Open biopsy
b) Perform curettage on the lesion
28
37. CHRONIC OSTEOMYELITIS
STAGING OF OSTEOMYELITIS:
The Cierny-Mader staging system.
It is determined by the status of the disease
process.
It takes into account the state of the bone, the
patient's overall condition and factors affecting the
development of osteomyelitis.
34
39. CHRONIC OSTEOMYELITIS
THE CIERNY-MADER CLASSIFICATION
Stage 1: Medullary Osteomyelitis -
Infection confined to medullary
cavity.
Stage 2: Superficial Osteomyelitis
Contiguous type of infection. Confined
to surface of bone.
Stage 3: Localized Osteomyelitis -
Full-thickness cortical sequestration
which can easily be removed
surgically.
Stage 4: Diffuse Osteomyelitis -Loss
of bone stability, even after surgical
debridement.
41. CHRONIC OSTEOMYELITIS
TREATMENT - ANTIBIOTICS
- Chronic infection is seldom eradicated by
antibiotics alone.
- Bactericidal drugs are important to:
a) Stop the spread of infection to healthy bone
b) Control acute flares
- Antibiotics used in treating chronic osteomyelitis
(Fusidic acid, Clindamycin, Vancomycin,
Cefazolin)
42. CHRONIC OSTEOMYELITIS
ANTIBIOTIC CHOICE
Guided by microbiology department
Clindamycin and vancomycin have good bone
penetration
Minimum length 6 weeks with 3 months being the
standard treatment course
May need to treat for 6-12 months
Antibiotic (IV route) is given for 10 days prior to
surgery.
After the major debridement surgery, antibiotic is
continued for another 6 weeks (min) but usually
>3months.
[treat until inflammatory parameters (ESR) are
normal]
39
43. CHRONIC OSTEOMYELITIS
SURGICAL TREATMENT
- After 10 days of
antibiotic
administration,
debridement is
done to remove:
a) All the infected
tissue
b) Dead /
devitalised bone Sequestrectomy and curettage. A, Affected
bone is exposed, and sequestrum is
removed. B, All infected matter is
removed. C, Wound is either packed open
or closed loosely over drains.
(Sequestrectomy
)
c) Sinus tract
44. CHRONIC OSTEOMYELITIS
Closure of dead space
-
-
After debridement is done, a large dead
space is left in the bone
Among the methods of managing dead
space:
Open cancellous grafting –Papineau
technique
Useful for bone deficiencies of less than
4cm
(preferably autogenous) mixed with an
antibiotic and fibrin sealant
Vascularised bone graft
Heals as a segmental fracture
Indicated when defect is > 6cm
Iliac crest for defects > 8cm
Fibula 6-35cm can be bridged
Bypass graft
Involves the establishment of a cross union
between the fibula and tibia proximally and
distally to the defect which has been
debrided and bone grafted
48. M.C.Q:-
1) involucrum is found
A. underneath the sequestrum B.metaphysis
C. around the sequestrum D.beneath the
periostium
2) acute haematogenous osteomyelitis is treated with
all except :
A.antibiotics B.splinting
C.anelgesics D. surgery
49. 3)Chronic osteomyelitis is diagnosed mainly by:
A.Sequestrum
C. Deformity
B. Bone fracture
C.Brodie’ abscess
4) Osteomyelitis of spine most common organism
is:
A.Staphylococcus aureus B. pseudomonas
C.Tuberculosis C. Streptococcus
50. 6)When does the boney lesion of osteomyelitis
appear on x-ray:
A.2week B.24hours
C.1week D.2hours
7)Osteomyelitis most commonly starts at:
A.Metaphysis B.Epiphysis
C.Diaphysis D. None
8)The most common causing osteomyelitis in drug
abusers is:
A.Pseudomonas B.staphylococcus Aureus
C. E.coli D. Kiebsiella.
