The document discusses osteomyelitis, an infection of bone marrow and bone. It begins with a case study of a 7-year-old boy presenting with pain and swelling in his thigh. It then provides details on the classification, causes, pathogenesis, clinical features, investigations, treatment including antibiotics and possible surgery, and complications of osteomyelitis. The metaphysis is identified as the most common site of infection due to factors like increased vascularity and immature cells. Staphylococcus aureus is usually the causative organism in developed countries. Appropriate treatment involves antibiotics, splinting, and surgical drainage if the infection does not improve with antibiotics alone.

1. Osteomyelitis
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By:
Intern Dr Sunil Pathak

2. Case I
• A 7 year young boy came to Emergency with
sudden onset of pain and swelling of right
distal thigh.He has high grade of fever for 24
hours and is unable to bear weight. His knee
movement is relatively preserved.
Provisional diagnosis : Acute Osteomyelitis
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3. Introduction:
• Nelaton coined Osteomyelitis in 1834.
It includes three words
– Osteon = bone
– Myelo = marrow
– Itits = inflammation
– The clinical state in which bone is infected with
microorganisms
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4. 7/18/2019 4
Why Metaphysis is
most common site :

5. Reasons:
• Hairpin loop appearance of blood
vessel
• Increase vascularity to metaphysis
causing pooling of blood.
• Immature cells of metaphysis due to
high turnover.
• Presence of degenerating cartilge cells
which act as a good culture media.
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6. • Presence of end arteries in metaphysis.
• Relative lack of phagocytosis.
• More prone to trauma
• Presence of single endothelial linning in
metaphyseal arteries
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7. Classification
Duration Mechanism Host response to
disease
Acute
(<2 week)
Exogenous pyogenic
Subacute
(2 week -6 week)
Hematogenous
Non pyogenic
Chronic
(> 6 week)
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8. Etiology :
Staphylococcus aureus Most common/developed countries
Haemophilus influenzae In developing countries
pseudomonas Aids /iv drug abuse/DM
Salmonella Sickle cell disease
pasteurella Animal bite
Eikinella Human bite
Staphylococcus Epidermidis Hip replacement
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•Streptococcus pyogenes
•Streptococcus pneumoniae
•Group B streptococcus
•Gram negative organisms (Escherichia coli, Pseudomonas aeruginosa,
Proteus mirabilis)
•Bacteroids fragilis(anaerobes)

9. Pathogenesis:
• Most common route : Hematogenous route
• Most Common site: femur(27 %) and tibia
(26%)
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10. 1.Pre existing focus
/exogenous infection
2.Infective embolus
enters nutrient artery
3.Trapped in vessel of
metaphysis and block it
4.Active hyperemia +
PMN cells exudate
causes decalcification
5.Proteolytic
enzymes destroy
bacteria and
medullary elements
6.Debris increas and
intramedullary pressure
increases
7.Follows the path of
least resistance
8.Passes through
volksmann canal and into
subperiosteal space
9.Strips periosteum
and perforate it
10.Drains out
PATHOGENESIS
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11. Sequestrum:
• Piece of dead bone surrounded
by infected granulation tissue
• Lighter than normal bone and
normal pattern of bone is lost
• Appears pale and has smooth inner and rough
outer surface
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12. • Act as a nidus and cause of nonhealing sinus
in chronic osteomyelitis
• X ray : appear dense than surrounding bone
because demineralization doesn't take place
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13. Involucrum
• Dense sclerotic new bone
overlying a sequestrum
• Appears by the end of 2nd
week.
• If infection persist, pus may
continue to discharge through
a hole in involucrum which is
known as cloacae
• Cloacae are lined by infected
granulation tissue
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14. Cardinal features
• Pain
• Fever
• Refusal to bear weight
• Elevated WBC count
• Elevated ESR
• Elevated CRP
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15. Clinical feature
Infant Children
Failure to thrive Severe pain, malaise & fever
Drowsy & irritable Toxaemia
Pseudoparalysis Pseudoparalysis ‘Refusal to use a limb, or
even touch’
Metaphyseal tenderness Regional lymphadenopathy
History of birth difficulties, umbilical
artery catheterization, site of infection
such as inflamed IV infusion site, heel
puncture
Recent history of infection
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16. Investigation
• Plain x ray :
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1st week No abnormality of
bone
2nd week Faint extra cortical
outline due to
periosteal new
bone formation
Later periosteal thickening becomes more obvious and there is patchy
rarefraction of the metaphysis
Late sign: combination of regional osteoporosis with localized segment of
apparently increased density

17. ESR within 24-48 hrs after the onset of
symptom.
CRP elevated within 12 – 24 hrs
Wbc count rises
Antistaphylococcal antibody titres Rises
Aspiration of pus or fluid from
metaphyseal area
Gram stain help to identify type of
infection and assist with initial choice of
antibiotics
Blood culture Positive in less than half the cases of
proven infection.
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18. USG may detect subperiosteal collection of
fluid in early stage
MRI extremely sensitive and help in
differentiating soft tissue infection and
osteomyelitis
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•Bone scan
•CT
•Radionuclide scanning

19. Differential diagnosis
• Cellulitis
• Acute suppurative arthritis
• Streptococcal necrotizing myositis
• Acute rheumatism
• Sickle cell crisis
• Gaucher disease
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20. Treatment
• If suspected on clinical grounds treatment
must be started immediately without waiting
for final confirmation of diagnosis
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21. • 4 important aspect:
o Supportive treatment for pain and
dehydration: septicemia and fever can cause
severe dehydration.
o Splintage of affected part: for comfort and to
prevent joint contracture
o Appropriate antimicrobial therapy(duration 6
week)
o Surgical drainage
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22. Nade’s principles for treatment of
acute hematogenous osteomyelitis
1. Appropriate antibiotic is effective before pus
formation
2. Antibiotics do not sterilize avascular tissues or
abscesses, and such areas require surgical
removal
3. If such removal is effective, antibiotics should
prevent their reformation and primary wound
closure should be safe
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23. 4. Surgery should not damage further already
ischaemic bone and soft tissue
5. Antibiotics should be continued after surgery
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24. Neonate and infant upto 6 month patient
with sickle
Flucloxacillin +3rd generation
cephalosporin
6 month to 6 year Flucloxacillin + 2nd or 3rd generation
cephalosporin
Older children and previously fit adults Flucloxacillin plus fusidic acid/2nd or 3rd
generation cephalosporin
Elderly and previous unfit patient Flucloxacillin plus 2nd or 3rd generation
cephalosporin
Patient with sickle cell disease 3rd generation cephalosporin or a
fluoroquinolone like ciprofloxacin
Heroin addicts and immunocompromised
patients
3rd generation cephalosporins or a
fluoroquinolone
MRSA Vancomycin with a 3rd generation
cephalosporin; Linezolid
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25. Surgical drainage
• If antibiotics are given early: drainage is often
unnecessary
• Indication:
– do not improve within 36 hrs of starting treatment
– abscess is formed
– Severely ill and moribund child
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26. Complications
• Epiphyseal damage & altered bone growth
• Septic Arthritis
• Metastatic infection
• Pathological fracture
• Chronic osteomyelitis
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27. Reference:
• Apley_s system of orthopedics and fracture 9th
Edition
• Campbell’s operative orthopaedics 13th Edition.
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Thank you