Hematogenous Osteomyelitis Hematogenous osteomyelitis is typically seen in childrenin the metaphyseal ends of long bones in the lower extremities.The proximal end of the tibia is the most common site. Staphaures bacteria arising from a peripheral site such as the skin ornose and throat gain access to the peripheral circulation wherethey travel to the terminal end-arterial circulation just beneaththe growth plate where a primary focal abscess will arise. Theabscess will then increase in size resulting in local thrombosisfollowed by bone necrosis as the purulent mass works its waythru the adjacent cortex gaining access to the subperiostealspace thus lifting the periosteum which then goes on to forma healing involucrum. In the early days prior to antibiotics,osteomyelitis was a very aggressive disease process associatedwith severe local pain, high fevers and septacemia resultingin high white counts and sed rates. The disease was frequently
multi focal in bones as well as in various organs such as thelung, liver and brain resulting in death in a high number ofcases. However, since the advent of antibiotics the modernform of osteomyelitis is far less aggressive and may presentwith minimal symptoms of pain with a minimal elevation ofthe white count or sed rate and for this reason my go onwithout diagnosis or treatment.
8/17/39 8/26/3910 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
Musculoskeletal Tubrculous Infections Tuberculous infection of the musculoskeletal system is seen inabout 5% of patients with pulmonary TBc. The problem is morecommon in Asian and Mexican populations of the world. In theUSA musculoskeletal TBc is rare in children but is more commonin adults with immunodeficiency conditions related to IV drugabuse, alcoholism, HIV disorders and patients on corticosteroidmedication. The most common skeletal site for TBc infection isthe spine followed next by the hip and knee. The TB mico-bacterial organism enters the blood stream in the lung and travelsto a metaphyseal bone site in the spine, hip or knee area whichthen results in discitis or psoas abscess of the spine or tuberculousarthritis of the hip or knee. The tuberculous micobacteriumstimulates the formation of a caseating granulomatous lesionmade up of epithelioid cells, Langhans giant cells and lymphs.A similar granuloma is seen in sarcoidosis which is none infectiousand none caseating. Antituberculous drugs include streptomycin,PAS, INAH, myambutol, and rifampin.
Tuberculous Osteomyelitis9 year old male with knee pain and swelling 1 yr
TBc Dactylitis4 yr Eskimo with TBc dactylitis (spina ventosa)
Tuberculous Tenosynovoitis Epithelioid granuloma27 yr male with 1 yr historyof carpal tunnel syndrome2nd to TBc tenosynovitis
Sarcoidosis Sarcoidosis is a nonspecific noncaseating epithelioid granuloma-tous process that affects the reticuloendothelial system of youngadults that pathologically resembles the histology of TBc, fungusinfections, viruses and even low grade lymphomas such asHodgkin’s disease. In the US it is seen more commonly in thesoutheastern states and is ten times more common in blacks thenwhites. 90% will have pulmonary infiltrates or hialar adenopathyalong with systemic symptoms of fever, coughing, inflammatoryarthropathy and iritis. Other systemic symptoms include weightloss, lymphadenopathy and hepatosplenomegaly as seen inlymphomas. Granulomatous skin lesion similar to erythemanodosum can be seen. Hypercalcemia can be seen in 25% of casesecond to an increase of calcium absorption at the gut level. 70%of cases will have a positive Kveim skin test to help separate outother granulomatous disorders such as TBc. 5% of cases involvethe middle and distal phalanges of the hand (most common) and
feet associated with overlying subcutaneous nodularities thatmight suggest the diagnosis of TBc, gout, Ollier’s disease ortuberous sclerosis. The homeycomb or latticework lytic patternof sarcoidosis will help differentiate from these other diagnosticconsiderations. The bony lesions are asymptomatic unlessassociated with a pathologic fracture. Bony changes in large bonesare very rare and can present with a sclerotic pattern seen in lowgrade lymphomas such as Hodgkin’s disease. The prognosisfor minor lesions of the hands and feet is excellent but withgreater reticuloendothelial involvement of multi organ systemsthe prognosis is more guarded like that of a low gradelymphoma.
Case #1 Sarcoidosis of Hand 46 yr male with recent path fracture ring finger
Biopsy specimenNone caseating epithelioid granuloma with Langhans giant cells Schaumann’s body
Tuberculous Spondylitis About 60% of all TBc involves the spine and is frequentlyseen in Asian or Mexican patients. In Hong Kong where thisdisease is common they see over 100 cases per year, 70% ofwhich are seen in children. L-1 is the most common vertabrainvolved and from there it can spread up and down the spineunder the anterior longitudinal ligament or thru the Batson’spara vertebral plexes. In China multiple vertabrae are involvedcompared to only one or two vertabrae in mid aged adults inthe USA. As with pyogenic spondylitis it is felt that thetuberculous organism gains access to the vertebral body thruthe blood supply to the spine. Even though there is no primaryinfection of the avascular disc space, extensive destruction ofthe vertebral body with collapse of the disc into the bodyresults in significant gibbus deformity not common in pyo-genic spondylitis.
TBc Spondylitis Dorsal Spine45 yr female with mid dorsal back pain for 6 mos
Leprosy Leprosy is not very common in the USA but is seen in othercountries such as South America, Africa, southern EuropeIndia and China. There are two clinical types of leprosy. Themore common and non infectious form is the neural ortuberculoid form that is of interest to orthopedic surgeonsbecause of the peripheral neuropathies and neuropathic jointsthat are seen in this form. The lepromatous form which isinfectious because of the draining skin ulcerations has a poorchance for survival. In the neural form of leprosy the micobacterium lepri organ-ism finds its way into periperal nerves causing them to enlargeresulting in a loss of both motor and sensory components. Theloss of sensation results in trophic skin changes including lossof pigmentation, hair and ulcerations. Neuropathic joints areseen in 27% of cases.
Neural or tuberculoid form of leprosy Short fingerNeurotrophic foot ulcers and Gynecomastia 2nd to claw hand deformities testicular leprosy
Neural leprosy Combined median & ulnar N involvement with trophic skin changes, clawing, lack of sweating, and short finger tips from terminal phylangeal osteolysisLoss of skin pigmentation in areas of anesthesia
Neural leprosy Social stigma of eyebrow alopeciaNeuropathic feet with deformityand shortening due to osteolysisand neuropathic joints
Neural leprosyShortening from terminal osteolysis Neuropathic joint shortening
Lepromatous (infectious) form of leprosyDraining facial sores of infectious form of leprosy with micobacterium lepri organisms seen to right
Leutic Infections Syphilis is a disease caused by the treponema pallidumorganism which was first introduced to America by ChristopherColumbus. 50% of cases will involve bone. The two major clinicaltypes include the adult and congenital forms. The acute form ofthe disease is a soft tissue problem and the late or tarda formof the disease is the type that involves bone and joints thatwould be of interest to an orthopedic surgeon . The two mostcommon bones affected with syphilis include the cranium andthe tibia.
Congenital lues3 mo female with luetic metaphysitis & facial snuffles
Congenital lues6 mo. male with luetic metaphysitis
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
Coccidiomycosis The two most common fungus infections seen by orthopedicsurgeons are coccidiomycosis and blastomycosis. Coccidio-mycosis is most common and seen in the south western part ofthe USA whereas, blastomycosis has no special location.coccidiomycosis is usually seen in the San Joaquin Valley areawhere it starts with an upper respiratory infection and afever known as valley fever followed in a few weeks by anacute pneumonitis which usually heals without recurrence.In a very small percent of cases a granulomatous response isseen in joints, bone, muscle and skin that can lead to the deathof the patient. The granulation tissue is similar to that seen inTBc except for the presence of endospores seen in the cytoplasmof the Langhans type giant cells. Coccidiomycosis replicatesthru a process of endosporulation within the mother cell where-as in blastomycosis the reproduction takes place thru a processof external budding from the mother spore.
Coccidiomycosis of knee 82 yr old farmer from Fresno with mild painful swelling of kneewith lytic epiphyseal lesion like GCT except for anterior breakout
Surgical clean outYellow arrow sinus track lead tonecrotising cavitary abscess spacewith granulomatous granulationtissue revealing Langhans typegiant cells with blue arrowendospore of coccidiomycosis
Coccidiomycosis of Knee Bone scan40 yr old farmer from Stockton with pain and swelling of knee 3 mos
Coccidiomycosis arthritis23 year Asian male with painful swollen knee 2 years