All about anatomy disease and treatment

1. OSTEOMYELITIS
IN BONES
PRESENTED BY : ANJALI SAINI
BAMS 4TH
YEAR

2. CONTENT
• Introduction
• Types
• Aetiopathogenesis
• Causes
• Pathophysiology
• clinical features
• Diagnosis
• investigation
• Treatment
• Complication
• Correlation with Ayurveda
• Case study

3. INTRODUCTION

4. OSTEOMYELTiS
Nelaton coined osteomyelitis in 1834
It includes three root words
• Osteon (bone)
• Myelo (marrow)
• Itis (inflammation)
DEFINITION
• Infection of bone and bone marrow is known as osteomyelitis.
But, it is almost occurs due to infective organism.
•it may remain localized, or it may spread through the bone to involve the
bone marrow, cortex periosteum and soft tissue surrounding the bone.

5. Anatomy of long bone

6. 1. Diaphysis (Shaft) 2.Epiphysis
(Ends of the Bone)
3.Metaphysis
(Between Diaphysis and
Epiphysis)
Parts of bone
*The long, cylindrical part
*central part of bone.
*Composed mainly of compact
bone
*Contains the medullary cavity,
( stores yellow bone marrow (fat
storage) in adults.)
*expanded ends of the
bone,
*covered with articular
cartilage
*Composed mostly of
spongy (cancellous) bone,
(red bone marrow)
*epiphyseal plate
(growth plate) in
children,
*which later becomes
the epiphyseal line in
adults.
Covering
*A dense fibrous
membrane covering
the outer surface
(except at joints).
*Contains blood vessels,
nerves, and osteoblasts
Endosteum
(Inner Lining of the
Bone)
*A thin membrane lining
the medullary cavity.
* Contains osteoblasts and
osteoclasts (bone-resorbing
cells), involved in bone
remodeling.
Periosteum
(Outer Covering)

7. microscopic structure of bone
Compact Bone
(Cortical Bone)
Osteons (Haversian Systems):
Structural units.
Haversian Canal: Contains blood
vessels & nerves
Lamellae: Concentric rings of
bone matrix
Lacunae: Small spaces housing
osteocytes.
Volkmann's Canals: Connect
osteons.
Trabeculae: honey comb -
like structure providing
strength.
Osteocytes in Lacunae:
Maintain bone tissue.
• Bone Marrow:
Fills spaces, aids blood cell
production.
Osteocytes: Maintain bone.
Osteoblasts: Form new bone.
Osteoclasts: Break down bone.
Osteoprogenitor Cells: Stem ce
for bone growth.
Spongy Bone
(Trabecular Bone)
Bone Cells

9. Relevant anatomy
• Metaphysis of long bone are highly
vascularized zones .
• From the diaphysis the medullary
arteries reach up to the growth Plate the
area of greatest activity and branch into
capillaries. The venous systems in this
area drains towards diaphysis.
• Thus the vessels in this zone are
arranged in the form of loop hair pin
arrangment .
• Blood stasis resulting from such an
arrangement is probably responsible for
the metaphysis being a favourite site for
bacteria settle . Thus, the common site of
osteomyelitis.

10. classification
1.Pyogenic/Suppurative
These are bacteria which are involved in microbe
Which lead to formation of pus
Most commonly caused by staphylococcus aureus.
2.Non-Pyogenic/NON-Suppurative
Those organism they damage tissues but do not produce
pus
Most commonly caused by mycobacterium tuberculli etc.

11. Classification on the
basis of duration
1. Acute Osteomyelitis
2. Subacute osteomyelitis
3. Chronic Osteomyelitis
Acute Subacute Chronic
<2 weeks 2 weeks – 3 months >3 months
Early acute
Late acute(4-5
days)
Less virulent- more
immune
Based on the duration and type of symptoms

12. 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.

13. The Cierny-Mader
classification
•TYPE 1
Medullary Osteomyelitis -Infection confined to medullary cavity.
•TYPE 2
Superficial Osteomyelitis Contiguous type of infection. Confined
to surface of bone.
•TYPE 3
Localized Osteomyelitis -Full-thickness cortical sequestration which
can easily be removed surgically.
• TYPE 4
Diffuse Osteomyelitis -Loss of bone stability, even after surgical
debridement.

15. ACUTe OSTEOMYELITIS
This can be primary (haematogenous) or secondary (following an open fracture
or bone operation). Haematogenous osteomyelitis is the commonest, and is often
seen in children.
Site of infection
Lower femoral metaphysis - commonest site.
other :
✓upper tibia
✓upper femoral
✓upper humeral metaphyses.

16. Aetiopathogenesis
• Bacteria, viruses and fungi can all infect bone ,soft tissues and
joints. Generally, bacterial infections are more destructive
and move rapidly.
•
. Staphylococcus aureus is the commonest causative organism.
(40-60%) Others are Streptococcus and Pneumococcus.
• These organisms reach the bone via the blood circulation.
Primary focus of infection is generally not detectable
• The bacteria,as they pass through the bone, get settled in the
metaphysis

17. General factors
• Anaemia
• Debility
• Infection
• Poor nutrition
• Poor immune status
Local factors
• Hair pin bend vessels
• Metaphyseal haemorrhage
• Defective phagocytosis
• Rapid growth at metaphysis
• Vasospasm
Causes of
osteomyelitis
• more commonly in open fractures,
•The increasing use of operative methods
(i.e; osteotomy ,fusion ( joining of two or more bone) , reconstructive
surgery( repair of damaged bone)

18. Route of arrival of
organism

19. Three basic mechanisms allow an
infection to reach the bone;
1. Haematogenous spread
*commonest ,and is often seen in
children.
*Because children are more prone to
injury
. *Bacteria from distant focus (skin,
teeth, nose, etc.) will be carried by
blood hence the name Haematogenous
2.Contagious source of infection
3. Direct implantation

20. Haematogenous spread usually involves
the metaphysis of long bones in children
or the vertebral bodies in adults
Direct inoculation of
microorganisms into bone
penetrating injuries and
surgical contamination are
most common causes
Contiguous focus of infection seen in
patients with severe vascular disease
Osteomyelitis
Microorganisms in
bone

21. 1.Pathophysiology of
Osteomyelitis
Infectious Agent (Bacteria, Fungi, etc.)
|
2. Entry into Bone
• Haematogenous Spread (via bloodstream)•
• Direct Inoculation (trauma, surgery, implants)
• Contiguous Spread (from nearby infection)
↓
3. Inflammatory Response
• Neutrophils and inflammatory mediators activate
• Increased vascular permeability
↓
4. Pus Formation & Bone Necrosis
• Accumulation of inflammatory exudate
• Increased intraosseous pressure
• Compression of blood vessels. → Ischemia

22. 5. Sequestrum Formation (Dead Bone) • Loss of
blood supply Necrotic
→ Bone
(Sequestrum)
• Pus spreads to surrounding tissues
↓
6. Involucrum Formation (New Bone Formation)
• Periosteum lays down new bone around
necrotic area
• Attempt at healing but persistent infection
↓
7. Complications
• Chronic Osteomyelitis
• Sinus Tract Formation (Pus Drains Through Skin)
• Septic Arthritis (joint Infection)

23. Development of
osteomyelitis

24. • Fever
• Fatigue
• Irritability
• Malaise
• Restriction of movement of limb
• Local oedema
• Erythema and tenderness
symptoms

25. Clinical features
Early acute Febrile illness
Limping to walk
Avoidance of using the
extremity
Late acute Swelling
pain
Sub acute Cannot pinpoint onset
Fever/swelling-mild
Chronic Purulent drainage

26. Risk factor
• Trauma orthopaedic
surgery or open fracture
• Prosthetic
• Diabetes
• Peripheral vascular
disease
• Intravenous drug abuse
• Chronic steroid use
• Immunosuppression
• Tuberculosis
• HIV and AIDS
• Sickle cell disease

28. DIAGNOSIS
. Early diagnosis of acute osteomyelitis is critical because prompt antibiotics
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 degree of complications and morbidity.

29. Examination
• Febrile
• Dehydrated
• Signs of inflammation in Metaphyseal area (redness, heat)
• Abscess
• Swelling of adjacent joint

30. Investigation
ASPIRATE PUS OR FLUID: smear is examined for cells
and organism (to Identify a type of infection)
WBC Count : are elevated with increased
polymorphoneuclear leukocytosis Count.
C- REACTIVE PROTEINS :–level is elevated
ESR :usually elevate up to 90 percent
BLOOD CULTURE: results are positive with
haematogenous osteomyelitis

31. X-rays: Shows cortical irregularity and periosteal reaction.*
Bone scan: This is more advanced technique

32. ULTRASOUND
May detect a sub periosteal collection of fluid in the early stage of
osteomyelitis but it can not distinguish between hematoma and pus.
CT SCANNING
• CT is useful method to detect early osseous erosion and to
document the presence of sequestrum, foreign body, or
• 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.

33. 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.

34. DIFFRENTIAL DIAGNOSIS Of acute OM
(a)ACUTE SEPTIC ARTHRITIS
• tenderness and swelling localised to the joint rather
than metaphysis
• movement at the joint is painful and restricted
• in case of doubt fluid may be aspirated.
(b)ACUTE RHEUMATIC ARTHRITIS
•Similar as acute septic arthritis
(c)SCURVY
• formation of sub periosteal hematomas
•radiologically mimic acute osteomyelitis
•absence of pain ,tenderness,fever.
(d)ACUTE POLIOMYELITIS
•fever and muscle are tender.
•but there is no tenderness on the bones.

35. General 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

36. •Clindamycin and vancomycin have good bone penetration.
• if the child is brought within 48 hours of the onset of symptoms:
• Rest: splint or traction (until improves)
• Antibiotics:
Ceftriaxone + Vancomycin,
Ceftriaxone + Cloxacilllin (6-8 weeks)
• Adequate rehydration with IV fluids
Response after 48 hours
Precautions
wt. bearing restricted – 4 to 8 w
• if child is brought after 48 hours of onset of symptoms
• Collection of pus -> USG
• Surgical exploration and drainage
Rest, antibiotics (6 weeks), hydration
Treatment of acute osteomyelitis

37. COMPLICATIONS of
acute OM
•Chronic osteomyelitis
• Septic arthritis
• Growth plate disturbance
• Septicemia
• Pathological fracture
• Metastatic infection

39. SUB ACUTE Osteomyelitis
treatment
Conservative:
a) Immobilization
b) Antibiotics (flucloxacillin + fusidic acid) for 6weeks
Surgical
(if the diagnosis is in doubt / failed conservative treatment):
c) a) Open biopsy)
d) Perform curettage on the lesion

40. Chronic Osteomyelitis
“A severe, persistent and incapacitating
infection of bone and bone marrow”
( More than 6 weeks)
Acute osteomyelitis becomes chronic due to following reason:
• improper drainage of pus •formation of undrained cavity
• presence of Sequestra • presence of foreign bodies in case of
open injuries

41. cardinal features chronic om
There are 3 cardinal features
❖ Sequestrum: It is a piece of dead bone. It
appears pale and has a smooth inner and rough outer
surface.
❖ Involucrum : It is the dense sclerotic bone
overlying a sequestrum.
❖Cloaca : there may be some holes in the
involucrum for pus to drain out.
Types of chronic osteomyelitis:
3 types
a) Chronic osteomyelitis secondary to acute osteomyelitis
b)Garre's osteomyelitis.
c) Brodie's abscess.

43. CLINICAL FEATURES of
chronic om
◆ A chronic discharging sinus is the commonest presenting symptom.
• Thickened, irregular bone.
• Tenderness on deep palpation.
• Generalized symptoms like fever, malaise etc.

44. examinations in chronic Osteomyelitis:
• chronic discharging sinus
• thickened, irregular bone
Tenderness
Adjacent joint may be stiff
Investigation:
Radiological features
• Thickening and irregularity of the cortices
• Patchy sclerosis
• Bone cavity
• Sequestrum – appears denser than the surrounding normal bone
because the decalcification which occur in normal bone ,doesn’t
occur in dead bone.
Granulation tissue surrounding the sequestrum gives rise to a
radiolucent zone around it.
• Involucrum and cloacae may be visible
• Sinogram
• CT scan and MRI
• Blood examination

45. • A SEQUESTRUM ( IS A PIECE
OF DEAD BONE)AND AN
INVOLUCRUM( IS THE NEW
BONE THAT FORMS AROUND
IT DURING THE HEALING
PROCESS )
• CLOACAE

46. DIFFERENTIAL DIAGNOSIS of
chronic om
✓Tubercular osteomyelitis
• discharge thin , watery
•oderless and light yellow With blood tinged
b) Soft tissue infection
A longstanding soft tissue infection with a discharging sinus may mimic
osteomyelitis.
Absence of thickening of underlying bone, and absence of sinus.
c)Ewing's sarcoma:
A child with Ewing’s sarcoma sometimes presents with a rather sudden onset
pain and swelling, mostly in the diaphysis. Radiological appearance often
resembles that of osteomyelitis. A biopsy will settle the diagnosis.

48. tREAtment OF chronic
Osteomyelitis
Principles of treatment:
•Treatment of chronic osteomyelitis is primarily surgical.
Antibiotics are useful only during acute exacerbations and during post-
operative period
. Aim of surgical interventions is:
(i) removal of dead bone;
(ii) elimination of dead space and cavities;
(iii) removal of infected granulation tissue and sinuses.
Operative procedures:
1.Sequestrectomy
( Surgical removal of the sequestrum )

49. (3)Amputation
It is defined as the surgical removal of a part or whole of a
limb.
(4) Curretage
The wall of the cavity ,lined by infected granulation tissue , is
curetted until the underlying normal – looking bone is seen . The
cavity is sometimes obliterated by filling it with gentamicin
impregnated bed cement beads or local muscle flap.
After surgery the wound is closed
over a continuous suction irrigation
system.
This system has an inlet tube going to the
medullary cavity, and an outlet tube
bringing the irrigation fluid out. A slow
suction is applied to the outlet tube. The
irrigation fluid consists of suitable
antibiotics and a detergent. The
medullary canal is irrigated in this way
for 4 to 7 days.

51. Complications of
chronic om
1.An acute exacerbation
2. Growth abnormalities
• Shortening
• Lengthening
• Deformities
3. Pathological fracture
4.Joint stiffness
5. Sinus tract malignancy
6. Amyloidosisis

52. GARRE'S OSTEOMYELITIS
This is a sclerosing, non-suppurative chronic osteomyelitis.
It may begin with acute local pain, pyrexia and swelling.
Pyrexia and pain subside but the fusiform osseous enlargement
persists
There is tenderness on deep palpation. There is no discharging sinus.
Shafts of the femur or tibia are the most commonly affected
• The importance of Garre's osteomyelitis lies in differentiating it
from bone tumors, which commonly present with similar features e.g.,
Ewing's tumour or osteosarcoma.
Treatment is guarded. Acute symptoms subside with rest and broad-
spectrum antibiotics. Sometimes, making a gutter or holes in the bone
bring relief in pain.

53. BRODIE'S ABSCESS
It is a special type of osteomyelitis in which the body's defense mechanisms
have been able to contain the infection so as to create a chronic bone
abscess containing pus or jelly-like granulation tissue surrounded by a zone
of sclerosis.
Clinical features: The patient is usually between 11to 20 years of
age. Common sites are the upper-end of the tibia and lower-end of the
femur. It is usually located at the metaphysis. A deep boring pain is the
predominant symptom. It may become may worse at night.

54. In some instances, it becomes worse on walking and is relieved by rest.
Occasionally, there may be a transient effusion in the adjacent joint
during exacerbation of symptoms. An examination may reveal
tenderness and thickening of the bone
Radiological features: The radiological picture is diagnostic. It shows a
circular or oval lucent area surrounded by a zone of sclerosis. The rest of
the bone is normal .
treatment is by operation. Surgical evacuation and curettage is
performed under antibiotic cover. If the cavity is large, it is packed with
cancellous bone chips.

55. Ayurveda management:
Wound cleaning by vra a śodhana kw tha
ņ ā followed by vra a
ņ basti with certain
oils like j ty di
ā ā oil, kampillak di
ā oil etc.
It is effective in some of cases.
A Brodie abscess is a subacute osteomyelitis, which may persist for years before
converting to a frank osteomyelitis

56. अस्थिमज्जागत विद्रधि से आधुनिकशास्त्र में
Osteomyelitis or Brodie abscess का
ग्रहण किया जा सकता है।
Modern correlation

57. अस्थिमज्जागत विद्रधि
(OSTEOMYELITS)
अथमज्जपरीपाको घोरः समुपजायते ।
सोऽस्थिमांसनिरोधेन द्वारं न लभते यदा ।
ततः स व्याधिना तेन ज्वलनेनेव दह्यते ।
अस्थिमज्जोष्मणा तेन शीर्यते दह्यमानवत् ।
विकारः शल्यभूतोऽयं क्लेशयेदातुरं चिरम् ।
अथास्य कर्मणा व्याधिर्दारं तु लभते यदा ।
ततो मेदः प्रभं स्निग्धं शुक्लं शीतमथो गुरु ।
भिन्नेऽस्थिन निःस्त्रवेत् पूयमेतदस्थिगतं विदुः ।
विद्रधिं शास्त्रकुशलाः सर्वदोषरुजावहम् ।
(सु. नि. 9/36-40)

58. • जब अस्थि में विद्रधि उत्पन्न होती है तब चिकित्सा
न करने से मज्जा का भयंकर पाक होता है और जब
यह पाक बाहर नहीं निकल पाता तब रोगी को
ज्वलनवत् वेदना (burning pain) होती है।
• इस व्याधि में रोगी को चिरकाल तक कष्ट सहना
पड़ता है। जब इस अवस्था में शल्य कर्म द्वारा पूय
(Pus) को बाहर निकलने के लिए मार्ग मिल जाता है,
तब मेदप्रभ स्निग्ध, श्वेत, शीत, गुरू, स्राव, अस्थि भेदन
करने पर निकलता है। यह व्याधि सर्व दोषयुक्त होती
है।

59. चिकित्सा (MANAGEMENT)
पर्यागते विद्रधौ तु सिद्धिनैकान्तिकी स्मृता । प्रत्याख्याय तु
कुर्वीत मज्जजाते तु विद्रधौ । स्नेहस्वेदोपपन्नानां
कुर्याद्रक्तावसेचनम् ।
विद्द्ध्युक्तां क्रियां कुर्यात् पक्वे वाऽस्थि तु भेदयेत्।
(सु. चि. 16/39, 40)
विद्रधि में पाक होने पर चिकित्सा की सफलता में अनिश्चितता बनी रहती है
अतः अस्थिमज्जागत विद्रधि को प्रत्याख्येय (असाध्य) समझकर चिकित्सा
करनी चाहिए।
NOTE: According to modern aspect, the osteomy elitis is very
difficult to treat and still there is not any established management.
• स्नेहन व स्वेदन के पश्चात् रक्तमोक्षण ।
• पाक होने पर अस्थि भेदन।

60. निःशल्यमथ विज्ञाय कर्तव्यं व्रणशोधनम् ।
धावेत्तिक्तकषायेण तिक्त सर्पिस्तथा हितम् ।
(सु.चि. 16/41)
• विद्रधि व्रण के शल्यरहित (पूयरहित) होने पर व्रण का शोधन करना चाहिए।
• तिक्त द्रव्यों के क्वाथ से व्रणप्रक्षालन (wound toileting) करना चाहिए।
• तिक्त द्रव्यों के क्वाथ से सिद्ध घृत का पान करवाना चाहिए।
यदि मज्जपरिस्त्रावो न निवर्तेत देहिनः ।
कुर्यात् संशोधनीयानि कषायादीनि बुद्धिमान् ।
(सु।16/12)
• यदि रोगी की विद्रधि से मज्जा का स्त्राव बन्द न हो तो संशोधनीय क्वाथों का प्रयोग करना
चाहिए।

61. Case Presentation: Osteomyelitis Patient Information
Name: rakesh Age: 45 years
Sex: Male
Occupation: Construction Worker
Chief Complaint: Pain and swelling in the right lower leg for two weeks
History of Present Illness
The patient presented with progressive pain, swelling, and redness over the
right tibia for the past two weeks. He reported fever, chills, and difficulty
bearing weight on the affected limb. No recent trauma, but he had a history
of untreated diabetes mellitus.
Past Medical History Diabetes Mellitus (Type 2) – Poorly controlled
Hypertension – On medication No history of tuberculosis, malignancy, or
prior osteomyelitis
Physical Examination
Vital Signs:Temperature: 38.5°C (febrile)Pulse: 102 bpmBP: 130/85
mmHg
Local Examination:Swelling, tenderness, and warmth over the right tibia
Overlying skin: Erythematous, mildly edematous No open wounds or sinus
tracts Restricted range of motion due to pain

62. Differential Diagnoses
Osteomyelitis
Cellulitis
Septic arthritis
Bone malignancy (e.g., osteosarcoma)Investigations Laboratory
Tests: 16,500/mm³ ( )ESR: 90 mm/hr ( )CRP: 120 mg/L ( )Blood glucose:
↑ ↑ ↑
250 mg/dL ( , uncontrolled diabetes)Blood culture: Staphylococcus aureus
↑
(positive)
Radiological Findings:
X-ray (Right Tibia): Periosteal reaction and lytic lesions
MRI: Bone marrow edema, abscess formation
Bone Biopsy & Culture: Confirmed Staphylococcus aureus
infection
Diagnosis
Chronic osteomyelitis of the right tibia secondary to
Staphylococcus aureus infection, associated with poorly controlled
diabetes.

63. Management Plan1.
Medical Treatment:IV antibiotics (Vancomycin + Piperacillin-Tazobactam)Blood sugar
control (insulin therapy)Pain management (NSAIDs)
2. Surgical Intervention:
Debridement of necrotic bone Drainage of abscess if present Possible Sequestrectomy
(removal of dead bone)
3. Supportive Care: Wound care Physiotherapy for limb function Patient education on
diabetes control and infection prevention
Prognosis & Follow
-Up Regular follow-up to monitor infection resolution Repeat MRI if
symptoms persist Long-term glycemic control to prevent recurrence

64. Thank you
