Joints

1. Osteomyelitis
Dr.punita adajania
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2.  NELATON (1834) : coined osteomyelitis
 The root words osteon (bone) and myelo
(marrow) are combined with itis (inflammation)
to define the clinical state in which bone is
infected with microorganisms.
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3. Defination of Osteomyelitis
Osteomyelitis is defined as an
acute or chronic inflammatory
process of bone, bone marrow
and its structure secondary to
infection with micro organisms.
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4. CLASSIFICATION
 Duration , Mechanism & Host response.
 Duration - Acute / Subacute / Chronic
 Mechanism - Heamatogenous(Blood)
- Exogenous (open fractures)
 Host response - Pyogenic / Granulomatous
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5.  Duration of infection
1. Acute ( <2 WEEKS)
2. Subacute (2-3 WEEKS)
3. Chronic ( >3 WEEKS)
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6. ACUTE OSTEOMYELITIS
 Age : Infancy and childhood.
 Sex : Males predominate 4:1
 Location : Metaphysis of long bone.
 Cause: Poor nutrition, unhygienic surroundings.
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7. Etiological Agents
 Infants < 1 year – Group B streptococci
Staph aureus
E.coli
 1- 16 years – S. aureus , S. pyogens , H. Influenza
 > 16 years – S.aureus , S.epidermidis , Gram –ve bacteria
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8. Pathogenesis
Introduction of bacteria from :
 Outside through a wound or continuity from a
neighboring soft tissue infection
 Hematogenous spread from a pre existing focus (most
common route of infection)
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9. PATHOLOGY OF ACUTE
OSTEOMYELITIS
 Staph. aureus is the commonest causative organism.
 Others: strepto and pneumococci
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10. 10
MICRO ORGANISMS
REACH BONE VIA BLOOD
CIRCULATION
BACTERIA GET LODGED IN THE
METAPHYSIS

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HOST BONE INITIATES AN
INFLAMMATORY REACTION
LEADS TO BONE DESTRUCTION
AND PRODUCTION OF
INFLAMMATORY EXUDATE
(PUS)
AFTER SUFFICIENT PUS
FORMATION,IT SPREADS INTO
DIFFERENT
DIRECTIONS(MEDULLARY
CAVITY, CORTEX)

12. CLINICAL FEATURES
 Fever (High Grade)
 Child refuses to use limb (pseudoparalysis)
 Local redness , swelling , warmth , oedema
 Newborn – failure to thrive , drowsy , irritable.
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13. Laboratory Tests
 Elevations in the peripheral white blood cell count (WBC)
 Erythrocyte sedimentation rate (ESR) is elevated.
 The C-reactive protein level usually is elevated.
 Blood culture is positive in most of the cases.
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14.  X-RAYS: Earliest sign to appear is periosteal new bone
deposition at metaphysis.(7-10 days)
 BONE SCAN
 Aspiration of bone using thick needle: for pus removal
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16. Differential Diagnosis
 Acute septic arthritis(tenderness and swelling at joint rather
than at metaphysis)
 Acute rheumatic arthritis( features same as septic arthritis but
blood levels helps in diagnosis)
 Scurvy(mimics O.M, but absence of pain, tenderness and fever
points towards scurvy)
 Acute poliomyelitis(presence of fever and muscle tenderness but
bones are not tender)
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17. Management of acute osteomyelitis.

18.  Bone abscess
 Septic Arthritis
 Septicemia
 Fracture
 Growth arrest
 Overlying soft-tissue cellulitis
 Chronic infection
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19. Chronic Osteomyelitis
 Definition:
“ A severe, persistent and incapacitating infection of
bone and bone marrow ”
Term used for chronic pyogenic osteomyelitis.
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20. 3 types:
 Chronic osteomyelitis secondary to acute osteomyelitis
 Garre’s osteomyelitis
 Brodie’s abscess
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21. Aetiological Agents
Usual organisms (with time there is always a mixed
infection)
 Staph.aureus(commonest)
 Staph.pyogenes
 E.coli
 Pseudomonas
 Staph.epidermidis
(commonest in surgical implant)
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22. Clinical Features
a) Pain
b) Pyrexia
c) Redness
d) Tenderness
e) Discharging sinus
(seropurulent discharge
to thick pus)
Lower end of
femur(commonest site)
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23. Pathogenesis
Inadequate treatment of acute OM /Foreign
implant /
Open fracture
Inflammatory process continues with time
together with persistent infection by
Staphylococcus aureus
Persistent infection in the bone leads to
increase in intramedullary pressure due
to inflammatory exudates (pus)
stripping the periosteum
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24. Pathogenesis (Contd.)
Vascular thrombosis
Bone necrosis (Sequestrum formation)
New bone formation occur (Involucrum)
Multiple openings appear in this involucrum, through
which exudates & debris from the sequestrum pass via
the sinuses
(Sinus formation)
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25. Radiographic Findings
1) X-ray examination
 Thickening and irregularity of the cortex
 Patchy sclerosis (honey combed appearance)
 Sequestrum seen. Appears denser than the
surrounding normal bone.
2) CT scan & MRI
- Show the extent of bone destruction, reactive
oedema, hidden abscess and sequestra
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26.  BLOOD: ESR may be slightly elevated.
Total blood counts are increased.
 Pus culture
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27. Treatment - Antibiotics
- Chronic infection is seldom
eradicated by antibiotics alone.
- Bactericidal drugs are important
to:
a) Stop the spread of infection to
healthy bone
b) Control acute flares
- Antibiotics used in treating
chronic osteomyelitis
(Fusidic acid, Clindamycin,
Cefazolin)
- Antibiotic (IV route) is given for 10
days prior to surgery.
- After the major debridement
surgery, antibiotic is
continued for another 6 weeks
(min) but usually >3months.
[treat until inflammatory
parameters (ESR) are normal]
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28. Surgical Treatment
 SEQUESTRECTOMY: Removal of sequestrum.
A window is made in the overlying involucrum
and the sequestrum is removed.
 SAUCERIZATION: Bone cavity is converted
into a “saucer” by removing its wall.
Allows free drainage of the infected material.
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29.  CURETTAGE: The wall of the cavity, lined by
infected granulation tissue is curetted until the
underlying normal-looking bone is seen.
 EXCISION OF AN INFECTED BONE: Excision
of the infected bone segment without
compromising the functions of the limb, and
building up the gap by transporting a segment of
the bone from adjacent part.
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30.  AMPUTATION: Very rarely done. Preferred in
case of long standing discharging sinus (
especially when the sinus undergoes a
malignant change).
 In many cases, combination of these procedures
are also performed.
 After surgery, wound is closed over a
“continuous irrigation system”.
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31. Complications
1) Pathological Fracture
- This occurs in the bone weakened by chronic
osteomyelitis
2) Deformity
– In children the focus of osteomyelitis destroys part of
the epiphysis growth plate.
3) Shortening/ lengthening
- Destruction of growth plate arrest growth.
- Stimulation of growth plate due to hyperemia.
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32. PHYSIOTHERAPY MANAGEMENT
 The type of rehabilitation for osteomyelitis depends on
the location of the infected bone and the underlying cause
of infection.
 Splinting or cast immobilization: This may be
necessary to immobilize the affected bone and nearby
joints in order to avoid further trauma and to help the
area heal adequately.
 Splinting and cast immobilization are frequently done in
children, although motion of joints after initial control is
important to prevent stiffness and atrophy.
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33.  Rehabilitation is aimed at restoring normal range
of motion, flexibility, strength, and endurance.
 The goal of rehabilitation for progressive
osteomyelitis is to maintain function and
enhance mobility.
 Active range of motion initially helps maintain
flexibility and strength and relieves the
musculoskeletal pain associated with muscular
weakness, paralysis, and immobility.
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34.  As the therapy progresses, passive range of motion
exercises are preferable to avoid overexertion or possible
damage to the muscles.
 In the event of muscle weakness to the legs, balance
exercises may be utilized.
 As strength continues to progress, endurance becomes a
focus in the individual's rehabilitation program for
osteomyelitis.
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35.  Aerobic exercises that increase cardiovascular
fitness are recommended.
 The American Heart Association recommends 30 to
60 minutes of aerobic activity 3 or 4 times a week.
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