Osteomyelitis is an infection of bone that can be acute, subacute, or chronic depending on duration of symptoms. Acute osteomyelitis typically involves the metaphysis and is caused by bacteria like Staphylococcus aureus entering through breaks in skin or bloodstream. It causes inflammation, pus formation, and bone necrosis. Treatment involves antibiotics, surgery if abscess forms, and immobilization. Chronic osteomyelitis results from inadequate treatment of acute osteomyelitis and is characterized by bone destruction, cavities containing pus and bone fragments, and draining sinuses. Surgical debridement along with long-term antibiotics is usually required to treat chronic osteomyelitis.

1. BONE INFECTIONS

2. OSTEOMYLITIS
INTRODUCTION
o Osteomyelitis is one of the most difficult and challenging
problems encountered in orthopedics.
o From the life-threatening acute osteomyelitis to the disabling
chronic osteomyelitis, it frustrates the best efforts of
orthopedic surgeons.
o The incidence of chronic osteomyelitis is on the rise. This is
primarily because of the rise in road traffic accidents (RTAs)
leaving a bizarre of compound fractures which are the major
cause of infection in bone

3. OSTEOMYLITIS
DEFINITION
osteon – bone myelo – marrow itis – inflammation
• Osteomylitis is the inflammation of bone caused by micro organism.
• It may be localized or can spread through the bone to involve the bone
marrow , cortex ,periosteum , and soft tissue sarrounding the bone.
Based on duration of symptoms
Acute osteomylitis - less than 2 weeks
Subacute osteomylitis – 2 weeks to 6 weeks
Chronic osteomylitis - more than six weeks
Begins in medullary cavity, spread to cortical bone then extend to periosteum

4. ROUTE OF SPREAD OF OSTEOMYLITIS
Directly - through
 break in skin,
 stab wounds,
 open fractures and surgery
Haematogenous from distant site,
 Tonsilitis
 Acute suppurative otitis media
 Dental abscess
 Boil or abscess
 Infected umbilical cord,
 Indwelling iv lines/urethral catheters
Lymphatics –
• Spread from neighboring infective sites like septic arthritis

5. CLASSIFICATION OF OSTEOMYLITIS
Acute osteomylitis - less than 2 weeks
Subacute osteomylitis – 2 weeks to 6 weeks
Chronic osteomylitis - more than six weeks
• Osteomylitis begins in medullary cavity, spread to
cortical bone then extend to periosteum
FACTORS THAT DETERMINE THE EXTENT OF INFECTION
 Virulence of infecting organisms
 Immune status of the host
 Underlying disease

6. ACUTE OSTEOMYLITIS
AETIOLOGY
• Staphylococcus aureus (60-85%) This is the most common organism
causing acute osteomyelitis.
• Streptococcus hemolyticus (8-10%)
• Salmonella
• Pseudomonas
• Pneumococcus
• Coliforms (E. coli)..
• Hemophilus influenza This is known to cause osteomyelitis in the age
group of 7 months to 4 years
• Treponema pallidum (syphilitic osteomyelitis)
Fungal osteomyelitis
• Actinomycosis
• Blastomycosis
• Cryptococcus's

7. PREDISPOSING FACTORS TO OSTEOMYLITIS
• Age – Affect children incidence is 88 percent because
they are more prone for injury and to fall.
• Affects adults due to
 Trauma(compound fractures or ORIF
immunosupression,underlying disease i.e. DM,
 Alcoholism
 malnutrition
• Sex Male preponderance (? more playful).
• Economic Status Low socioeconomic groups are more
susceptible

8. ACUTE OSTEOMYLITIS ,,,,,,,,,,
PATHOLOGY
• The microorganisms settle at metaphysis of the bone and therefore
initiate ;
 Inflammation,
 Suppuration,
 Necrosis(seguestrum)
 Reactive new bone formation(involucrum)
 Resolution and healing
WHY METAPHYSIS IS INVOLVED
 Highly vascularized and on injury there's a lot of bleeding
 U shaped end arteries from nutrient artery which twist back in hair pin
loops before entering the veins
 Vascular stasis due to looping of blood vessels thus favoring bacterial
colonization.
 There is presence of rapidly changing cells hence weakness

10. ACUTE OSTEOMYLITIS CONT…….
PATHOLOGY
• Organisms reach the bone from a septic focus elsewhere in
the body through blood stream (haematogenous)
• Settle in metaphysis of the bone(highly vascularized with a lot
of looping of blood vessels from nutrient artery.
• Organisms induce an acute inflammatory reaction with fluid
exudation resulting into pus formation(suppuration) .
• The exudates(pus) may spread outwards to involve the bone
cortex leading to periosteal stripping (periosteal reaction)
and elevation by pus. Bone dies due to lack a blood supply.
• Pus may extend to the adjacent joint to form pyogenic
arthritis
• Formed pus finds its way to the surface of the bone to form
sub periosteal abscess or it may spread towards bone
medullary cavity to affect the whole bone.

11. PATHOLOGY OF OSTEOMYLITIS CONT……..
• The abscess can find its way into the soft tissues and reach the skin
surface to form a sinus.
• The intraosseous pressure rises rapidly, causing intense pain, obstruction
to blood flow and intravascular thrombosis resulting to bone ischemia
• The ischemic bone dies and separates from the surrounding living bone as
seguestra.
• A new bone is laid down around the seguestra called an involucrum
RESOLUTION AND HEALING
• If infection is controlled and intraosseous pressure released at an early
stage the infection is arrested .
• With efficient treatment, the infection can be prevented in early phase
from complicating to chronic osteomylitis
• Bone around the zone of infection is osteoporotic.
• With healing, there is fibrosis and new bone formation this, together with
the periosteal reaction, results in sclerosis and thickening of the bone.

13. CLINICAL FEATURES
Symptoms
• Acute in onset
• Pain
• Swelling
• Fever (95%) •
• Local swelling (80%)
• malaise
• Sweating
•Chills
• Rigors
• Dehydrated/shock
On examination
• Local swelling
• limitation of movement
• Tenderness over affected bone
• Raised temperature
• Fluctuating mass
• Local erythema
• Increased pulse rate
• Anemic
• Failure to thrive

14. DIAGNOSIS OF ACUTE OSTEOMYLITIS`
• By history taking ,clinical presentation, and physical examination
LAB FINDINGS
FBC - leucocytosis
pus culture – positive
Gram staining – positive
RADIOLOGY
XRAYS
less than 2 weeks - normal but only soft tissue swelling
After 2 weeks –periosteal thickening/elevation
- New bone formation - involucrum
- Bone destruction/necrosis -sequestrum
- Regional osteoporosis
- Bone rare faction at metaphysis
- Bone sclerosis
• With early and effective treatment the above radiological features are absent.
BONE SCAN – Confirms diagnosis

16. MANAGEMENT OF ACUTE OSTEOMYLITIS
• Acute osteomyelitis is an orthopedic emergency which needs in patient admission.
Conservative mnx
• Rest in bed
• Nutritional support
• protect affected part with splints to reduce pain and muscle spasm.
• Elevation of the part, warm and moist packs to reduce the swelling.
• Analgesics to relieve pain
Treatment—
• Admit patient
• Blood transfusions,
• Intravenous fluids to correct shock and hypovolemia caused by fever and sepsis.
• Treatment with antibiotics helps to reduce toxicity.
• Surgery— Timed to prevent complications
INDICATION OF SURGERY
• Abscess formation
• Failure to respond to antibiotics
• Very sick

17. MANAGEMENT OF ACUTE OSTEOMYLITIS
Antibiotic therapy
• To prevent chronic osteomyelitis , broad spectrum
bactericidal agent given intravenous for the first 2 weeks
and oral for the next 4 weeks
• intravenous flucloxacillin and fusidic acid till child show
improvement then per oral for 3-6 weeks
• Children under 4 years(gram negatives) give cefuroxime or
cefotaxime(BSA)
• SCD(salmonella) give chloramphencal, or septrin
• Immunocompromised ( pseudomonas, proteus ) give
flucloxacillin and gentamycin
• Local antibiotics: Antibiotics impregnated with cement
beads provide high dose of antibiotics locally.

18. MNX OF ACUTE OSTEOMYLITIS CONT………..
Surgical Methods
• Aspiration: it helps in decompression and pus obtained
is cultured to identify the organism and check for
antibiotic sensitivity.
• Incision and drainage helps to drain the abscess.
• Multiple drill holes helps to drain the pus by making
multiple holes in the cortex.
• Small bone window If the multiple drill holes do not
drain the pus, a small window of bone is removed
from the cortex and the pus is evacuated

19. ACUTE OSTEOMYLITIS CONT……….
DDX
• Septic arthritis
• Cellulitis
• Osteoid osteoma
• Ewings sarcoma
• Soft tissue infection
COMPLICATIONS
• Septicemia to brain and lungs
• Septic arthritis due to extension of the neighboring foci of infection into the joint.
• Chronic osteomyelitis develops due to improper and inadequate treatment.
• Pathological fractures
• growth disturbances
• Pulmonary embolism
• Deep venous thrombosis
PROGNOSIS
• Ninety percent resolve due to early diagnosis and effective antibiotic therapy.
• Eight percent show morbidity.
• Two percent have mortality

20. SUBACUTE OSTEOMYLITIS
• Subacute osteomylitis – 2 weeks to 6 weeks
• Insidious and not severe because organism is less virulence or host more
resistance,
• It is caused by
 Staphylococcus aureus
 Staph Epidermis.
• The patient complains of pain, limping ,slight swelling, temperature may be
increased or normal.
• Blood culture is positive , and WBC and ESR are raised,
IMAGING
• Oval cavity with sclerosis containing seropurulent fluid
TREATMENT
• Immobilize
• antibiotics

21. CHRONIC OSTEOMYLITIS (CHRONIC PYOGENIC OSTEOMYLITIS)
Osteomyelitis lasting for more than three weeks is termed as chronic.
Chronic osteomyelitis can arise from any one of the following ways:
 Sequelae of acute osteomyelitis (5-10%)
 Following compound fractures
 Following surgery on bones and joints
 Fungal osteomyelitis
Chronic osteomylitis is denoted by;
o Abscess cavities
o Sequestrium/involucrum
o Multiple scars and sinuses tract
o Cavity,
o Irregular thickening of bone,
o Sprouting granulation tissue,
o Discharge of bony spicules - involucrum and pus

23. PATHOLOGY OF CHRONIC OSTEMYLITIS
• Follows acute osteomylitis
• Cavities containing pus and pieces of dead bone (sequestra)
are surrounded by involucrum
• Involucrum is dense and sclerotic with multiple openings
called cloacae through which exudate , bone debris and
sequestra find exit and pass through the sinus.
• The sequestra act as substrates for bacterial adhesion.
• Sinuses may seal off for weeks or even months, giving the
appearance of healing, only to reopen or appear somewhere
else.
• Constant bone destruction, leads to a pathological fracture.

25. CLINICAL FEATURES
• Fever, pain, swelling
• Night sweats
• Malaise
• Restlessness
ON EXAMINATION
• Irregular thickening of bone develops due to unequal pace of destruction
of bone and new bone formation.
• Bone deformity seen
• Multiple sinuses ,some draining and others healing.
• Scars and muscle contractures develope due to the spread of infection
from the bones to the muscles and the consequent fibrosis.
• There is flare up or reappearance of a sinus that had already healed.

26. DIAGNOSIS OF CHRONIC OSTEOMYLITIS
• From history and physical examination
LAB FINDINGS
• FBC – Elevated ESR/WBC
• Blood culture reveals bacteremia
• Aspiration of pus for C/S and gram straining
• Biopsy(gold standard) for histology to R/o malignancy change
X-RAYS
• show bone resorption or as frank excavation with thickening and sclerosis
of the surrounding bone.
• Area of osteoporosis, or periosteal thickening
• Sequestra show up as dense fragments
 Radioisotope scintigraphy is sensitive and are useful for showing up
hidden foci of infection.
 CT and MRI together will show the extent of bone destruction and
reactive oedema, hidden abscesses and sequestra.

28. MANAGEMENT OF CHRONIC OSTEOMYLITIS
SURGERY –
• Bone debridement – repeat several times
• Sequestrectomy is done next then the cavity is curetted until fresh
bleeding occurs.
• Saucerization - is removal of adjacent bone cortex on debridement
then open packing done to allow healing.
• Local closure if the space left is very small.
• Myoplasty for slightly larger space, surrounding muscles can be
packed into the cavity.
• Cancellous bone grafts for a space less than 2.5 cm.
• Free vascularized bone graft for larger areas
• Amputation is done If the patient’s life is endangered by infection
,malignant change has formed ,arterial insufficiency or neuropathy
It should be the last choice and not the first.

30. COMPLICATIONS
Pathological fractures
Malignancy change
Deformity
Growth disturbances due to muscle and soft
tissue contracture's
Joint stiffness
Septic arthritis

31. BRODIES ABCESS
• Brodie’s abscess is a localized form of chronic osteomyelitis,
involves metaphyseal and epiphyseal area, and is common in young adults
• Age 11- 20 yrs and affect metaphysis.
Clinical Presentation
• The patient complains of intermittent pain of long duration and local tenderness.
Etiology
• Causative organism is low virulence Staph. aureus in 50 percent of the cases.
Radiograph
• It shows circular or oval appearance. Usually, a cavity with a rim of sclerotic bone
is seen at the metaphysio epiphyseal junction.
Treatment
• Rest
• Antibiotics,
• Curettage and bone grafting, and the wound is Loosely closed over a drain
• surgery

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