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Osteomyelitis
1. • Osteomyelitis - an inflammation of the bone
caused by an infecting organism.
• The infection may be limited to
- single portion of the bone
- may involve numerous regions
• The infection generally is due to
-a single organism
- polymicrobial infections
3. ACUTE HEMATOGENOUS OSTEOMYELITIS
• The most common bone infection
• Usually is seen in children
• More common in males in all age groups
affected.
• Caused by a bacteremia.
4. Bacteriological seeding of bone-associated with
-Localized trauma
-Malnutrition
-An inadequate immune system
In many cases-the exact cause not identified.
5. Aetiology
Staphylococcus aureus- most common
-Older children and adults
Gramnegative -vertebral body infections in
adults.
Pseudomonas
-Intravenous drug abusers
6. Aetiology
Fungal osteomyelitis
-Chronically ill patients
-Longterm intravenous therapy
-Parenteral nutrition.
Salmonella osteomyelitis- tends to be diaphyseal rather than
metaphyseal
- Sickel cell anaemia
- SC hemoglobinopathies
9. Aetiology
Healthy infants 2 to 4 weeks old
- Group B Streptococcus
Children 6 months to 4 years old
-Haemophilus influenzae
10. The incidence of this infection –reduced dramatically
-A higher standard of living
-Improved hygiene
11. Pathogenesis
Shows characteristic progression -marked by
-Inflammation
-Suppuration
-Bone necrosis
-Reactive new bone formation and
-Ultimately, resolution and healing
-Else intractable chronicity
12. Pathogenesis
Acute osteomyelitis in children:
-The ‘classical’ picture is seen in children
between 2 and 6 years
The infection generally involves
-The metaphysis of rapidly growing long bone
13. Bacterial seeding leads
An acute inflammatory reaction with
-Vascular congestion
-Exudation of fluid
-Infiltration by polymorphonuclear leucocytes.
14. Ultimately cause
Local ischemic necrosis of bone
subsequent abscess formation.
the abscess enlarges
intramedullary pressure increases ,vascular stasis,small vessels thrombosis
cortical ischemia,
allow purulent material to escape through the cortex into the subperiosteal
space.
A subperiosteal abscess then develops
If left untreated
extensive formation of sequestra
chronic osteomyelitis
15. Pathophysiology of hematogenous seeding. When under pressure, exudate or abscess
can extend through Volkmann canals into subperiosteal region and from there into
medullary cavity or epiphysis
16. Infection in the metaphysis may spread towards the surface, to form a subperiosteal abscess
17. Some of the bone may die, and is encased in periosteal new bone as a sequestrum
19. If the infection is
controlled and
intraosseous pressure
released at an early stage
Dire progress can be
halted
The bone around the zone
of infection becomes
increasingly dense-results
in thickening of the bone.
The normal anatomy may
eventually be
reconstituted
The bone is left
permanently deformed.
20. In adults
.The vertebral bodies -affected generally.
-A vertebral infection spread through
.The end-plate the intervertebral disc
an adjacent vertebral body
21. Clinical features
Clinical features differ in the three groups
Children
usually a child over 4 years
presents with
severe pain
Malaise
a fever;
In neglected cases-toxaemia may be marked.
22. Clinical features
Joint movement - restricted (‘pseudoparalysis’)
Typically the child looks- ill and feverish
The pulse rate-over 100
The temperature is raised.
The limb is held still
23. Clinical features
Acute tenderness near one of the larger joints
.above or below the knee
.in the popliteal fossa
.in the groin
Gentlest manipulation -painful
27. Clinical features
In the very elderly and immune deficiency
.Systemic features- mild
.The diagnosis is easily missed.
28. DIAGNOSIS
Evaluation -begin with a history and physical
Examination
Evaluation of Acute Hematogenous Osteomyelitis
■ Historyand physical examination
■ Laboratory tests:
White blood cell count
Erythrocyte sedimentation rate
C-reactive protein
■ Plain radiographs
■ Technetium- 99 m bone scan ± MRI
■ Aspiration for suspected abscess
29. DIAGNOSIS
• Signs and symptoms can vary significantly
• clinical findings may be minimal
-In infants
-Elderly patients
-Immunocompromised patients-
• In the early stages- Fever and malaise may or may
not be present
• Pain and local tenderness- are common findings.
30. • The white blood cell count -often normal
But the erythrocyte sedimentation rate and C-
reactive protein level- elevated
• The Creactive protein
A measurement of the acutephase response
31. CARDINAL FEATURES OF ACUTEOSTEOMYELITIS IN CHILDREN
Pain
Fever
Refusal to bear weight
Elevated white cell count
Elevated ESR
Elevated CRP
32. • PLAIN X-RAY
-During the first week- no abnormality of the
bone.
-Standard radiographs -generally are negative
but may show soft tissue swelling(1 to 3 days
after the start of the infection)
- Displacement of the fat planes
33. Skeletal changes(10 to 12 days after the start of
infection)
-Faint extra cortical outline :Periosteal reaction
-Bony destruction
34. The first x-ray 2 days
after symptoms began,
is normal –
It always - metaphyseal
mottling and periosteal changes
were not obvious until the
second film, taken 14 days later
Eventually much of the
shaft was involved.
38. • RADIONUCLIDE SCANNING
Technetium 99m bone scans -confirm the
diagnosis
A negative technetium99m bone scan -rules out the
diagnosis of osteomyelitis.
Gallium scans and indium111labeled
leukocyte scans
40. MAGNETIC RESONANCE IMAGING
Show early inflammatory changes in
-bone marrow
-soft tissue
Very useful for detecting
-Intraosseous and
-Subperiosteal abscesses.
41. LABORATORY INVESTIGATIONS
-Pus or Fluid aspirate
.The metaphyseal subperiosteal abscess
.The extraosseous soft tissues or
.An adjacent joint
42. Performed with a 16 or 18gauge needle in the
area of :
-Maximal swelling and tenderness
-Usually the long bone metaphysis.
43. Patients with suspected osteomyelitis-the hip or
vertebra
-CT- assisted aspiration
-Ultrasoundassisted aspiration.
The sample is sent to the laboratory
-Gram Stain
-Culture, and sensitivities.
45. TREATMENT
If osteomyelitis is suspected on clinical grounds
-Blood and fluid samples should be taken for
laboratory investigation
-Treatment started immediately without
waiting for final confirmation of the
diagnosis.
46. TREATMENT
There are four important aspects to the
managementof the patient:
• Supportive treatment for pain and
dehydration.
• Splintage of the affected part.
• Appropriate antimicrobial therapy.
• Surgical drainage.
47. TREATMENT
The choice of antibiotic is based on:
-The highest bactericidal activity
-The least toxicity and
-The lowest cost.
49. TREATMENT
Nade(1983) -five principles for the treatment of
Acute hematogenous osteomyelitis
1. An appropriate antibiotic is effective before abscess
formation
2. Antibiotics do not sterilize avascular tissues or
abscesses, and such areas require surgical removal
50. TREATMENT
3.If such removal is effective, antibiotics should
prevent their reformation, and primary wound
closure should be safe
4.Surgery should not damage further already
ischemic bone and soft tissue
5.Antibiotics should be continued after surgery.
51. TREATMENT
The patient should receive
-General supportive care
.Intravenous fluids
.Appropriate analgesics and
.Comfortable positioning of the affected
limb.
52. TREATMENT
An abscess requiring surgical drainage –
.Not found by MRI or ultrasound
.Empirical intravenous antibiotic therapy
should be started
.The patient should be carefully monitored
53. TREATMENT
The Creactive protein value -checked every 2 to
3 days
If no appreciable clinical response to
.Antibiotic treatment within 24 to 48 hours
-Occult abscesses :suspected
-Surgical drainage should be considered
54. TREATMENT
The two main indications for surgery
-An abscess requiring drainage
-Failure of the patient to improve
The objective of surgery
-Drain any abscess cavity
-Remove all nonviable or necrotic tissue
57. TREATMENT
Once the signs of infection subside
-Movements are encouraged
-The child is allowed to walk with the aid of
crutches
-Full weightbearing : after 3–4 weeks.
58. TREATMENT
While patients are on oral antibiotics -
-The serum antibiotic levels in order
.To ensure that the minimal inhibitory
concentration (MIC) :maintained or
exceeded.
59. TREATMENT
CRP, ESR and WBC values-checked at regular
intervals
Treatment can be discontinued –ESR/CRP
remain normal.
