Medical

1. By P. J. Okoth
P.J. Okoth 1

2.  Define osteomyelitis
 Classify osteomyelitis
 Discuss acute osteomyelitis
 Discuss chronic osteomyelitis
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3.  Osteomyelitis is infection of bone by
pyogenic organisms
 It occurs in acute and chronic forms
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4. P.J. Okoth 4

5.  Define acute haematogenous osteomyelitis
 Discuss the aetiology of acute haematogenous
osteomyelitis
 Describe the pathology of acute haematogenous
osteomyelitis
 Outline the clinical features of acute haematogenous
osteomyelitis
 State the investigations in acute haematogenous
osteomyelitis
 State the differential diagnosis
 State the complications of acute haem. Osteomyelitis
 Outline the management of acute haem osteomyelitis
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6.  Recognize the importance of having a high
index of suspicion for osteomyelitis
 Recognize the value of blood cultures to
isolate an organism before starting
antibiotics
 Realize the importance of giving high-dose
intravenous antibiotics
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7.  Acute haematogenous osteomyelitis is an
infection of bone by pyogenic organisms
which have gained access to bone through
the bloodstream.
 It is one of the most important diseases of
childhood.
 Acute implies that infection has been present
for a short period (less than 2 weeks)
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8.  The common causative organisms are:
 Staphylococcus aureus – commonest
 Streptococcus pyogenes
 Pneumococci
 Salmonella (mainly in sicklers)
 Brucella
 Klebsiella
 Haemophilus influenzae and Escherichia coli
in neonates.
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9.  Organisms enter the bone via bloodstream
from a septic focus, e.g. boil, furuncle,
carbuncle, cellulitis, intravenous canula or I.V
line
 Infection begins at the metaphysis where the
organisms have settled. A minor injury to a
bone may render it vulnerable to infection by
organisms circulating in the blood.
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10.  The organisms induce an acute inflammatory
reaction, producing pain and swelling.
 Pus is formed in the medullary cavity. It finds
its way to the surface of bone to form a sub-
periosteal abscess.
 Later the abscess may burst into soft tissues
and may lead to formation of a sinus.
 Sequestrum (dead bone) formation results
from septic thrombosis of vessels and
periosteal stripping cutting off blood supply
to the bone.
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11.  New bone is laid down beneath the stripped-
up periosteum, forming a layer of new bone
called involucrum
 The epiphysial cartilage is a barrier to spread
of infection to the joint.
 However, joint may be infected if the
metaphysis lies partly within a joint cavity,
causing acute pyogenic arthritis.
 Even when a joint is not infected it may swell
from an effusion of clear fluid (sympathetic
effusion)
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12.  Mainly a disease of children, especially boys
 Most commonly affects the tibia, femur and
humerus.
 Onset is rapid
 May be history of recent boils or minor injury
 Severe pain over the affected bone
 Swelling of affected limb
 Inability to use the limb/ child failing to move
one limb
 Fever
 Other constitutional symptoms: malaise, refusal
to feed, vomiting, diarrhoea
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13. On examination:
 Febrile 39-40 degrees Celcius
 Exquisite tenderness over the affected bone,
over the metaphysial area
 Overlying skin is warmer than normal
 The soft tissues are indurated
 Fluctuant abscess may be present
 Sympathetic effusion in neighbouring joint
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14.  Blood for culture and sensitivity – must be
done immediately, before any antibiotic is
given.
 Local X-ray
◦ No alteration from normal in early stages
◦ After two or three weeks there may be diffuse
rarefaction of metaphysis and new bone outlining
the raised periosteum
 Full haemogram + ESR
– marked polymorphonuclear leucocytosis
◦ High ESR
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15.  Pyogenic arthritis of adjacent joint
◦ Acute osteomyelitis is distinguished from pyogenic
arthritis by the following features:
 The point of greatest tenderness is over the bone
rather than the joint
 A good range of joint movement is retained
 Distended joint (sympathetic effusion) does not
contain pus.
 Cellulitis
 Trauma – fracture or STI
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16.  Rheumatic fever
 Sickle cell disease crisis
 Vitamin C deficiency in infants (scurvy)
 Syphilitic metaphysitis in infants
 Osteogenic sarcoma
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17.  Septicaemia or pyemia
 Pyogenic arthritis
 Retardation of growth from damage of
epiphysial cartilage
 Chronic osteomyelitis
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18.  The key to successful treatment is a high
index of suspicion, leading to early diagnosis
by blood culture.
 Efficient treatment must be begun at the
earliest possible moment
 Treatment is categorized as:
◦ General treatment
◦ Local treatment
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19. General treatment:
 Systemic high-dose intravenous antibiotics
 Antibiotics must be started blind after cultures
have been taken because if the disease can be
sterilized within the first 48 hours of onset,
complete resolution can be guaranteed.
 A combination of flucloxacillin and fusidic acid is
recommended.
 Antibiotics should be continued for at least 4
weeks even when the response has been rapid.
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20.  For children under 5 and neonates,
flucloxacillin (250mg/kg per day in 4 divided
doses) and ampicillin (150mg/kg per day in
divided doses to cater for Haemophilus
influenzae) are recommended.
 Treatment is changed according to culture
and sensitivity results as soon as the
causative organism is identified and
sensitivity ascertained.
 Bed rest
 Analgesics/ antipyretics
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21. Local treatment:
 Operation: if the diagnosis is reached more than
48 hours after onset of symptoms, it should be
assumed that there is a collection of pus and
surgery is required to drain it.
 Done under GA. Skin is opened over most tender
red area. Incision is made down to the bone and
subperiosteal pus is evacuated.
 One or two drill holes may be made into the
cortex to improve medullary drainage
 Wound may safely be sutured in most cases
 Splint the limb until infection is overcome
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22. P.J. Okoth 22

23.  This is infection of bone by pyogenic
organisms present for more than 2-3 weeks.
 It is nearly always a sequel of acute
osteomyelitis
 Ocasionally the infection is subacute or
chronic from the beginning.
 Infected compound fractures often become
chronic.
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24.  Staphylococcus aureus is the usual causative
organism
 Other bacteria responsible include:
◦ Streptococci (haemolytic)
◦ Pneumococci
◦ Salmonella
◦ Staph albus
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25.  Commonest in the long bones
 Often confined to one end of long bone, but it
may affect the whole length.
 The bone is thickened and generally denser than
normal. May be honeycombed with granulation
tissue, fibrous tissue, or pus.
 Sequestra are commonly present within cavities
in the bone
 There may be a sinus track leading to the
surface. The sinus tends to heal and break down
recurrently. Never heals completely if sequestrum
is present.
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26.  Main symptom is usually a purulent discharge
from a sinus over the affected bone.
 Discharge may be continuous or intermittent
 Pain may be the predominant feature that
brings patient to hospital.
 Flare-up of infection – local pain, pyrexia,
and the formation of an abscess, then
reappearance of a sinus.
 May present with pathological fracture
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27.  O/E
◦ May be pale from chronic illness
◦ May be febrile in flare-up
◦ bone is palpably thickened, with overlying scars or
sinuses
◦ May be obvious limb deformity
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28.  Radiographic examination:
◦ Thickened bone
◦ Irregular and patchy sclerosis (may give a
honeycombed appearance)
◦ Periosteal reaction (involucrum)
◦ Irregular cortex
◦ Sequestrum (seen as a dense loose fragment,with
irregular but sharply demarcated edges, lying
within a cavity in the bone)
◦ Obliterated medullary cavity
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29.  Haemogram + ESR – high ESR and Hb may be
low.
 Radioisotope scanning – may show increased
uptake in the vicinity of the lesion
 CT scanning – may be of value in diffuse
disease for localisation of abscess cavities
and sequestra (allowing for accurate planning
of operative treatment)
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30.  Pathological fracture
 Amyloid disease – may follow long-continued
chronic osteomyelitis with persistent
discharge of pus
 Development of squamous celled carcinoma
in a sinus
 Joint stiffness and contractures
 Anaemia of chronic illness
 Bone deformity leading to limb deformity
 Growth disturbance
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31. Specific treatment:
◦ Surgery
◦ Antibiotics
 Acute flare-up – antibiotics as in acute
osteomyelitis with incision and drainage of
abscess
 Sequestrectomy / saucerisation to remove
sequestra and to open up abscess cavities.
 Irrigate through vacuum drainage with rifocin
for 7-14 days
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32. Supportive treatment:
 Rest the limb / splint
 Splintage after sequestrectomy/saucerisation
to prevent pathological fractures
 Analgesics
 Good nutrition
 Clinic follow-up
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33. Thank You
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