OSTEOMYELITIS OBJECTIVES The learner will be better able to: 1) Explain the principles reflected in the history and

discovery of osteomyelitis 2) Generate a differential diagnosis given a patient case 3) Describe the distinct features of a radiological image of a patient with osteomyelitis 4) Explain factors that influence the incidence of osteomyelitis in a given population 5) Identify classic features of osteomyelitis given a patient case INTRODUCTION Osteomyelitis is defined as an inflammation or an infection in the bone marrow and surrounding bone. The disease is classified as either acute or chronic, depending on the length of time the infection or symptoms persist. Symptoms include pain, warmth and/or swelling in the bone. Chronic osteomyelitis may last for years , with slow death of bone tissue from a reduced blood supply. Signs and symptoms may be absent, however, causing difficulty in diagnosing the chronic infection. Pathogens infect bone in posttraumatic osteomyelitis after a recent fracture. Bacteria, fungus and other microorganisms are typically the causative agents. The more susceptible a bone is to fracturing, the greater the chances of becoming infected and developing disease. Trauma from recent injuries and diabetes are major risk factors for osteomyelitis.The bone can be directly infected from the wound or indirectly via the blood from another site of infection, calledhematogenous osteomyelitis. The vertebrae and pelvis are often affected in adults in this blood-borne variety, while children are usually affected in long bones. EPIDEMIOLOGY The incidence of osteomyelitis after open fractures is reported to be 2% to 16%, depending significantly on the grade of trauma and the type of treatment administered. Prompt and thorough treatment help reduce the risk of infection, decreasing the probability of developing osteomyelitis. This is particularly important for patients with the following risk factors: diabetes, altered immune states and recent trauma. The tibia is the most frequent site of posttraumatic osteomyelitis , since it is the most vulnerable bone with the least vigorous blood supply in the body. The classification of osteomyelitis can be broken down into the following categories: exogenous ostemyelitis (47%), secondary to vascular insufficiency (34%) and hematogenous osteomyeltis (19%). The implantation of an orthopedic device (pins, plate, screws, artificial joint) can also seed infection as a nidus for pathogens, and therefore create post-operative osteomyelitis.

The growing skeleton is also at risk. Any bone can be affected but it is usually the weight-bearing bones before the physis has closed. At the physis on the metaphyseal side, end arteries form a capillar loop which may rupture following minor trauma. This region of blood stasis may attract circulating bacteria ("everybody has bacteria circulating, periodically" -HH Jones) . Once escaped through the vascular system, bacteria can set up shop in surrounding tissues. ETIOLOGY The presence of bacteria alone in an open fracture is not sufficient to cause osteomyelitis. In most cases, the body's immune system is capable of preventing the colonization of pathogens. The micro-environment determines whether infection occurs. The timing and extent of treatment are critical in determining whether infection develops. The likelihood of developing ostemyelitis increases with impaired immune function, extensive tissue damage, or reduced blood supply to the affected area. Patients with diabetes, poor circulation or low white blood cell count are at greater risk. Bacterial or fungal infection cause most osteomyelitis. Infection induces a large polymorphonuclear response from bone marrow, particularly staphylococcus aureus, streptococcus and haemophilus influenza. Staphylococcus infection predominates today and before the era of antiobiotics. CLINICAL DIAGNOSIS AND MANIFESTATIONS The diagnosis of osteomyelitis is made from clinical, laboratory and imaging studies. When the skeletal system is involved, pain, fever and leukocytosis (an increase in white blood cell count due to infection or inflammation) occur. The affected area is painful. Initial x-rays are typically normal. As early as 4 days, an area of lucency may be seen on x-ray. Usually, the changes are not recognized until 10 days or two weeks have passed. Subperiosteal new bone formation in the affected area is present, representing periosteal elevation from encroaching pus. If not successfully treated, pus enlarges the bone appearing as increased lucency, which surrounds sclerotic, dead bone . This inner dead bone is called the sequestrum (sequestered from blood supply), and the outer periosteal reaction laminates to form the involucrum. Draining sinuses develop when the pressure of pus exceeds the containment of the soft tissue. This further deprives the bone of its blood supply. This in turn harbors more bacteria, and the process cannot be reversed until extensive debridement of the area

occurs-until the environment changes to one that promotes healing.

DIFFERENTIAL DIAGNOSIS Ewing sarcoma Osteosarcoma Reactive bone marrow edema Traumatic or stress fractures Inflammatory arthritis Gout SUMMARY Osteomyelitis is an infection involving the bone. The bones usually affected are the weight-bearing bones, particularly before the physis has closed. Exogenous osteomyelitis occurs from open trauma, sometimes relatively minor in nature. Hematogenous osteomyelitis occurs from bacteria circulating in the bloodstream. Acute and chronic subtypes are classified according to the timing and duration of the infection. REFERENCES 1. Dirschl DR, Almekinders LC. Osteomyelitis. Drugs. 1993; 45: 29-43. 2. Ehara S. Complications of skeletal trauma. Radiol Clin North Am. 1997; 35: 767-781. 3. Sammak B, Abd El Bagi M, Al Shahed M, et al. Osteomyelitis: a review of currently used imaging techniques. Eur Radiol. 1999; 9: 894-900.

4. Waldvogel F, Medoff G, Swartz M. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (I). N Engl J Med. 1970; 282: 198-206. 5. Widmer AF. New developments in diagnosis and treatment of infection in orthopedic implants. Clin Infect Dis. 2001; 33: S94-S106.

----

Osteomyelitis Gale Encyclopedia of Medicine, 3rd ed. | 2006 | Carson-DeWitt, Rosalyn Osteomyelitis Definition Osteomyelitis refers to a bone infection, almost always caused by a bacteria. Over time, the result can be destruction of the bone itself. Description Bone infections may occur at any age. Certain conditions increase the risk of developing such an infection, including sickle cell anemia, injury, the presence of a foreign body (such as a bullet or a screw placed to hold together a broken bone), intravenous drug use (such as heroin), diabetes,kidney dialysis, surgical procedures to bony areas, untreated infections of tissue near a bone (for example, extreme cases of untreated sinus infections have led to osteomyelitis of the bones of the skull). Causes and symptoms Staphylococcus aureus, a bacterium, is the most common organism involved in osteomyelitis. Other types of organisms include the mycobacterium which causes tuberculosis, a type of Salmonella bacteria in patients with sickle cell anemia, Pseudomonas aeurginosa in drug addicts, and organisms which usually reside in the gastrointestinal tract in the elderly. Extremely rarely, the viruses which cause chickenpox and smallpox have been found to cause a viral osteomyelitis. There are two main ways that infecting bacteria find their way to bone, resulting in the development of osteomyelitis. These include:
y

Spread via the bloodstream; 95% of these types of infections are due to Staphylococcus aureus. In this situation, the bacteria travels through the bloodstream to reach the bone. In children, the most likely site of infection is within one of the long bones, particularly the thigh bone (femur), one of the bones of the lower leg (tibia), or the bone of the upper arm (humerus). This is because in children these bones have particularly extensive blood circulation, making them more susceptible to invasion by bacteria. Different patterns of blood circulation in adults make the long bones less well-served by the circulatory system. These bones are therefore unlikely to develop osteomyelitis in adult patients. Instead, the bones of the spine (vertebrae) receive a lot of blood flow. Therefore, osteomyelitis in adults is most likely to affect a vertebra. Drug addicts may have osteomyelitis in the pubic bone or clavicle. Spread from adjacent infected soft tissue; about 50% of all such cases are infected by Staphylococcus aureus. This often occurs in cases where recent surgery or injury has result in a soft tissue infection. The bacteria can then spread to nearby bone, resulting in osteomyelitis. Patients with diabetes are particularly susceptible to this source of osteomyelitis. The diabetes interferes with both nerve sensation and good blood flow to the feet. Diabetic patients are

therefore prone to developing poorly healing wounds to their feet, which can then spread to bone, causing osteomyelitis. Acute osteomyelitis refers to an infection which develops and peaks over a relatively short period of time. In children, acute osteomyelitis usually presents itself as pain in the affected bone, tenderness to pressure over the infected area, fever and chills. Patients who develop osteomyelitis, due to spread from a nearby area of soft tissue infection, may only note poor healing of the original wound or infection. Adult patients with osteomyelitis of the spine usually have a longer period of dull, aching pain in the back, and no fever. Some patients note pain in the chest, abdomen, arm, or leg. This occurs when the inflammation in the spine causes pressure on a nerve root serving one of these other areas. The lower back is the most common location for osteomyelitis. When caused by tuberculosis, osteomyelitis usually affects the thoracic spine (that section of the spine running approximately from the base of the neck down to where the ribs stop). When osteomyelitis is not properly treated, a chronic (long-term) type of infection may occur. In this case, the infection may wax and wane indefinitely, despite treatment during its active phases. An abnormal opening in the skin overlaying the area of bone infection (called a sinus tract) may occasionally drain pus. This type of smoldering infection may also result in areas of dead bone, called sequestra. These areas occur when the infection interferes with blood flow to a particular part of the bone. Such sequestra lack cells called osteocytes, which in normal bone are continuously involved in the process of producing bony material. Diagnosis Diagnosis of osteomyelitis involves several procedures. Blood is usually drawn and tested to demonstrate an increased number of the infection-fighting white blood cells (particularly elevated in children with acute osteomyelitis). Blood is also cultured in a laboratory, a process which allows any bacteria present to multiply. A specimen from the culture is then specially treated, and examined under a microscope to try to identify the causative bacteria. Injection of certain radioactive elements into the bloodstream, followed by a series of x-ray pictures, called a scan (radionuclide scanning), will reveal areas of bone inflammation. Another type of scan used to diagnose osteomyelitis is called magnetic resonance imaging, or MRI When pockets of pus are available, or overlaying soft tissue infection exists, these can serve as sources for samples which can be cultured to allow identification of bacteria present. A long, sharp needle can be used to obtain a specimen of bone (biopsy), which can then be tested to attempt to identify any bacteria present. Treatment Antibiotics are medications used to kill bacteria. These medications are usually given through a needle in a vein (intravenously) for at least part of the time. In children, these antibiotics can be given by mouth after initial treatment by vein. In adults, four to six weeks of intravenous antibiotic treatment is usually recommended, along with bed-rest for part or all of that time. Occasionally, a patient will have such extensive ostemyelitis that surgery will be required to drain any pockets of pus, and to clean the infected area. Alternative treatment General recommendations for the treatment of infections include increasing vitamin supplements, such asvitamins A and C. Liquid garlic extract is sometimes suggested. Guided imagery can help induce relaxation and improve pain, both of which are considered to improve

healing. Herbs such as echinacea(Echinacea spp.), goldenseal (Hydrastis canadensis ), Siberian ginseng (Eleutherococcus senticosus ), and myrrh (Commiphora molmol ) are all suggested for infections. Juice therapists recommend drinking combinations of carrot, celery, beet, and cantaloupe juices. A variety of homeopathic remedies may be helpful, especially those used to counter inflammation. Prognosis Prognosis varies depending on how quickly an infection is identified, and what other underlying conditions exist to complicate the infection. With quick, appropriate treatment, only about 5% of all cases of acute osteomyelitis will eventually become chronic osteomyelitis. Patients with chronic osteomyelitis may require antibiotics periodically for the rest of their lives. Prevention About the only way to have any impact on the development of osteomyelitis involves excellent care of any wounds or injuries. Resources PERIODICALS Calhoun, Jason H., et al. "Osteomyelitis: Diagnosis, Staging, Management." Patient Care 32 (January 30, 1998): 93+. KEY TERMS Abscess A pus-filled pocket of infection. Femur The thighbone. Humerus The bone of the upper arm. Thoracic Pertaining to the area bounded by the rib cage. Tibia One of the two bones of the lower leg.

Image Gallery Osteomyelitis Image 1 (Plain Radiograph): Osteomyelitis of the left distal radius (arrow).

2. Image 2 (Bone Scan): Focal area of increased uptake representing osteomyelitis in the region of the left iliac crest (arrow). 3. Image 3 (Computed Tomography): Coronal image of chronic osteomyelitis showing cortical thickening of proximal humerus (arrow)

4.Image 4 (Magnetic Resonance Imaging): T1 image showing chronic osteomyelitis of proximal humerus (arrow).

Coronal

chronic osteomyelitis