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Dr.Khaled Ata MD.

Department of Orthopedic Faculty of Medicine

Osteomyelitis
Definition:
 is an infection of bone

involving the periosteum,
cortical bone and the medullary cavity.

Osteomyelitis
Source of Infection:
 Hematogenous  Direct spread

 Exogenous

Classification:
 Acute hematogenous osteomyelitis (AHO)

 Subacute osteomyelitis
 Chronic osteomyelitis (recurrence)

AHO
 1/2 in < 5 y.o.
 boys > girls  1/3 report minor trauma  Metaphyses of long bones: 85%  Multiple locations: 5%,

AHO: sites
Radius 4% ulna 3%
Humerus 12%

Pelvis 9% Hands & feet 13%

Femur 27%

Tibia 22% fibula 5%

(AHO)
Source Of Infection

infected umbilical cord in infants
boils, tonsillitis, skin abrasions in adults UTI, in dwelling arterial line

(AHO)
Organism:
 Neonates:
Staph aureus, Strept, E coli

 Children:
Staph aureus, E coli, Pseudomonas, H inf

 Sickle-cell anemia:
Staph aureus, Salmonella

(AHO)

Pathology
 Primary focus and stage of

inflammation
 Spread of infection with pus

formation
 Formation of subperiosteal

abscess
 Pus tracks toward skin to form a

sinus
 Bone infarction (Sequestrum)  New bone formation

(involucrum)
 resolution

(AHO)
Clinical Pictures
History:

Skin lesion
Sore throat

Trauma

(AHO)
Clinical Features

 


severe pain reluctant to move fever malaise toxemia

(AHO)
Infant
 


 

failure to thrive drowsy irritable metaphyseal tenderness decrease ROM commonest around the knee

(AHO)
Adult
    

commonly thoracolumbar spine fever backache history of UTI or urological procedure old ,diabetic ,immunocompromised

(AHO)
Laboratory Tests:
 CBC  ESR+CRP  Blood culture (+ve in 50-70%)  Aspiration (Gram stain + culture and sensitivity)

(AHO)
Laboratory Tests:

 WBC elevated in 1/3
 CRP > 19 mg/L in 98%, peak on D # 2

(AHO)
Radiography
 Plain X-ray  Ultrasound  Bone & gallium scan (Sensitive but not specific)  CT scan  MRI

the earliest sign = soft tissue swelling on D # 3

periosteal elevation / lytic lesions on 2d- 3d week

Gallium67 scan : - uptake by
PMNs, in 24 hrs sensitivity: 91% -

AHO: imaging
 CT: - cortical destruction
- periosteal reaction - sequestra - intraosseeous gas

 MRI: T1 = low signal, T2 = high signal ,
sensitivity 97%, specificity: 92%

CT scan & MRI

CT scan

MRI

AHO: bacteriology
Needle aspiration: Bone culture (+) in 2/3 Blood culture (+) in 1/2 18 gauge spinal needle + Lidocaine “Needle is part of physical diagnosis”

(AHO)
Differential Diagnosis
 Acute Septic Arthritis  Acute monoarticular

rheumatoid arthritis  Sickle cell crisis  Cellulitis  Ewing’s Sarcoma

(AHO)
Treatment
General:
 Hospitalization

 Hydration
 Electrolyte replacement  Analgesia

 Immobilization

Empiric Tx of AHO
Age
< 3 mo.o. 1-st choice
Naf + Gent

Alternative
Naf + Cefotax

< 3 y.o.

Naf + Cephotax

Cefuroxime Van / Cld

> 3 y.o.

Naf

Cefazolin Cld

Definitive Tx of AHO
M/o
Staph. Aureus

1-st choice
Naf / Oxa (Dicloxa) Amp

Alternative
Cephazolin Cld / Van (MRSA) Cephotax Bactrim Cipro

Salmonella

AHO: indications for surgery
 Soft tissue or subperiosteal abscess  Purulent aspirate  Failure of Abx in 72 hrs  Sequestrum

**Debridement in proximity to the growth plate is risky

AHO: duration of Tx
Switch to PO: - resolution of symptoms and fever - CRP approaching NL

Duration of Tx: - asymptomatic - CRP NL - min 3 weeks *Get an X-ray at the end of Tx (sequestrum?)

(AHO)
Complications
 Septicemia & metastatic abscesses

 Septic arthritis
 Growth disturbance (children)  Pathological fracture

 Chronic osteomyelitis

Subacute Osteomyelitis
 Longer history and less virulent organism
 Insidious onset, Mild symptoms  Pain is the most consistent symptom  Usually no constitutional symptoms

Subacute Osteomyelitis
 Abnormal initial radiographs
 Inconclusive laboratory data  NL WBC count and CRP  Difficult to distinguish from bone tumors e.g.

Ewing’s, osteosarcoma
 Dx: biopsy culture

subacute osteomyelitis
 Staph. aureus, GNRs (incl. Pseudomonas), anaerobes

>1/2 = polymicrobial
 Recurrence rate: 40%  Tx: Timentin + Gent  Duration: > 7 d. IV, total 3 – 4 we.

Chronic Osteomyelitis
Factors responsible for chronicity
 Local factors: Cavity, Sequestrum, Sinus, Foreign
body, Degree of bone necrosis

 General: Nutritional status of the involved tissues,
vascular disease, DM, low immunity

 Organism: Virulence  Treatment: Appropriateness and compliance  Risk factors: Penetrating trauma, prosthesis, Animal
bite

Chronic Osteomyelitis
Types
 A complication of acute Osteomyelitis  Post traumatic  Post operative

Chronic Osteomyelitis
Clinical picture
 Continuous or intermittent suppuration and sinus

formation with acute exacerbations.
 Pain, fever, redness, and tenderness during acute

exacerbations.
 Discharging sinus with +ve/-ve culture.  Pathological fracture.

Chronic Osteomyelitis
Investigation
 Lab tests/ culture  Plain X-ray:

   

Bone rarefaction surrounded by the dense sclerosis, sequestration and cavity formation Sinogram Bone scan & gallium scan To detect chronic multifocal osteomyelitis CT Scan & MRI Biopsy

Chronic Osteomyelitis
Treatment
 Antibiotics  Surgical treatment
Derbridement Sequestrectomy Local antibiotics Stability Treatment of bone cavity

Chronic Osteomyelitis
Complications
 Recurrence & Recurrence & Recurrence  Pathological fractures  Growth disturbance  Amyloid disease

 Epidermoid carcinoma of the fistula

Septic Arthritis
 Septic arthritis is an infection of the joint

usually bacterial, as viral arthritis is usually self limiting and treatment is supportive.  50% of cases in children <3 years  The hip joint is the common site in <3years, whereas the knee joint is more common in older children.

Septic arthritis
 > 90% monoarticular ( multiple in N.gon)  Staph. aureus >> GAS > Pneumococcus ( in < 5 y.o.)

Septic arthritis: pathogenesis
 Highly vascular synovial tissue, no basal membrane  Hematogenous spread, adhesion to sialoprotein in synovial

fluid
 Chondrocytes and synovial WBCs release proteases that

destroy ground substance of articular surface
 Bacterial endotoxins stimulate release of IL-1 & TNF that

induce release of proteases

Acute Septic Arthritis
Clinical Pictures
 General manifestations:
constitutional symptoms and signs of acute infection

 Local manifestation:
Swelling, hotness and redness Deformity with muscle spasm Restriction of all movements of the joint The joint is fixed in the position of ease

Acute Septic Arthritis
Investigations
 Lab tests/ cultures  Plain X-ray  Bone scan & Gallium scan  Ultrasound  Aspiration: if WBC >50,000with >90% PMNLs

suspect septic arthritis even if culture is negative.

 Aspirate culture (+) in > 2/3, Gram stain (+) in 1/2 Blood culture (+) in 1/3

Imaging

Marked widening of the medial joint space in the R hip as compared to the left hip (arrows)
Michael Richardson, 1994, University of Washington

Acute Septic Arthritis
Differential Diagnosis
 Acute osteomyelitis  Transient synovitis of the hip (<10)  Acute rheumatic fever  Haemoarthrosis  Haemophilic arthritis

Acute Septic Arthritis
Treatment
 Aspiration  Antibiotics  Splintage  Surgical drainage  Treatment of complications

Sequalae
 stiff joint (cartilage damage)  unstable joint (chronic dislocation)  arrest of bone growth