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By P. J. Okoth
P.J. Okoth 1
 Define osteomyelitis
 Classify osteomyelitis
 Discuss acute osteomyelitis
 Discuss chronic osteomyelitis
P.J. Okoth 2
 Osteomyelitis is infection of bone by
pyogenic organisms
 It occurs in acute and chronic forms
P.J. Okoth 3
P.J. Okoth 4
 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
P.J. Okoth 5
 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
P.J. Okoth 6
 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)
P.J. Okoth 7
 The common causative organisms are:
 Staphylococcus aureus – commonest
 Streptococcus pyogenes
 Pneumococci
 Salmonella (mainly in sicklers)
 Brucella
 Klebsiella
 Haemophilus influenzae and Escherichia coli
in neonates.
P.J. Okoth 8
 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.
P.J. Okoth 9
 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.
P.J. Okoth 10
 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)
P.J. Okoth 11
 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
P.J. Okoth 12
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
P.J. Okoth 13
 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
P.J. Okoth 14
 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
P.J. Okoth 15
 Rheumatic fever
 Sickle cell disease crisis
 Vitamin C deficiency in infants (scurvy)
 Syphilitic metaphysitis in infants
 Osteogenic sarcoma
P.J. Okoth 16
 Septicaemia or pyemia
 Pyogenic arthritis
 Retardation of growth from damage of
epiphysial cartilage
 Chronic osteomyelitis
P.J. Okoth 17
 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
P.J. Okoth 18
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.
P.J. Okoth 19
 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
P.J. Okoth 20
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
P.J. Okoth 21
P.J. Okoth 22
 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.
P.J. Okoth 23
 Staphylococcus aureus is the usual causative
organism
 Other bacteria responsible include:
◦ Streptococci (haemolytic)
◦ Pneumococci
◦ Salmonella
◦ Staph albus
P.J. Okoth 24
 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.
P.J. Okoth 25
 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
P.J. Okoth 26
 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
P.J. Okoth 27
 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
P.J. Okoth 28
 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)
P.J. Okoth 29
 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
P.J. Okoth 30
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
P.J. Okoth 31
Supportive treatment:
 Rest the limb / splint
 Splintage after sequestrectomy/saucerisation
to prevent pathological fractures
 Analgesics
 Good nutrition
 Clinic follow-up
P.J. Okoth 32
Thank You
P.J. Okoth 33

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Osteomyelitis.pptx bbbbbbbbbbbbbbbhhhhhb

  • 1. By P. J. Okoth P.J. Okoth 1
  • 2.  Define osteomyelitis  Classify osteomyelitis  Discuss acute osteomyelitis  Discuss chronic osteomyelitis P.J. Okoth 2
  • 3.  Osteomyelitis is infection of bone by pyogenic organisms  It occurs in acute and chronic forms P.J. Okoth 3
  • 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 P.J. Okoth 5
  • 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 P.J. Okoth 6
  • 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) P.J. Okoth 7
  • 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. P.J. Okoth 8
  • 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. P.J. Okoth 9
  • 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. P.J. Okoth 10
  • 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) P.J. Okoth 11
  • 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 P.J. Okoth 12
  • 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 P.J. Okoth 13
  • 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 P.J. Okoth 14
  • 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 P.J. Okoth 15
  • 16.  Rheumatic fever  Sickle cell disease crisis  Vitamin C deficiency in infants (scurvy)  Syphilitic metaphysitis in infants  Osteogenic sarcoma P.J. Okoth 16
  • 17.  Septicaemia or pyemia  Pyogenic arthritis  Retardation of growth from damage of epiphysial cartilage  Chronic osteomyelitis P.J. Okoth 17
  • 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 P.J. Okoth 18
  • 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. P.J. Okoth 19
  • 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 P.J. Okoth 20
  • 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 P.J. Okoth 21
  • 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. P.J. Okoth 23
  • 24.  Staphylococcus aureus is the usual causative organism  Other bacteria responsible include: ◦ Streptococci (haemolytic) ◦ Pneumococci ◦ Salmonella ◦ Staph albus P.J. Okoth 24
  • 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. P.J. Okoth 25
  • 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 P.J. Okoth 26
  • 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 P.J. Okoth 27
  • 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 P.J. Okoth 28
  • 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) P.J. Okoth 29
  • 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 P.J. Okoth 30
  • 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 P.J. Okoth 31
  • 32. Supportive treatment:  Rest the limb / splint  Splintage after sequestrectomy/saucerisation to prevent pathological fractures  Analgesics  Good nutrition  Clinic follow-up P.J. Okoth 32