Osteomyelitis

• First decade of life, younger than 13 y.o

• Common in boys
• Acute hematogenous osteomyelitis (AHO) is the most common type
• Risk factors :
– diabetes mellitus,
– chronic renal disease,
– hemoglobinopathies,
– rheumatoid arthritis,
– concurrent varicella infection,
– immunocompromise,
– sickle cell trait, and
– prematurity
 Pathophysiology
• Acute hematogenous osteomyelitis
• Bacterimia  slow blood flow in the metaphysis
 infetion (bacteria logde in the local bone in
sufficient numbers to overhelm local defence)
 osteoblast necrosis, activation of osteoclasts,
release of inflammatory mediators, blood vesel
thrombosis (purulent exudate)  subperiosteal
abscess (exudate penetrates the porous
metaphyseal cortex, in joint causes SA) 
 Chronic osteomyelitis
• Periosteal elevation (deprive the underlying
cortical bone of its blood supply, creating a
necrotic fragment of bone (sequestrum))
• The periosteum may form an outer layer of
new bone (involucrum)
 Bacteriology
• Staphylococcus aureus
• community-acquired methicillin-resistant S
aureus (CA-MRSA)
• MRSA  clyndamicin for empiric
• Kingella kingae is a gram-negative aerobe 
musculoskeletal infection in children 6 to 48
months of age
• mild to moderate clinical and laboratory signs
of inflammation
• low-grade or no fever, > CRP, > ESR, > WBC
• Blood culture
 Evaluation
• History
– fever,
– pain,
– limp,
– refusal to bear weight, and
– recent local trauma or infections.
 Examination
• Temperature and vital sign
• General appearance,
• The ability to bear weight,
• Point tenderness,
• Range of motion of adjacent joints (including
the spine), and
• Localized warmth, edema, and erythema.
 Laboratory findings
• The CRP is elevated in 98% of patients with AHO
and becomes abnormal within 6 hours of
infection.
• The ESR becomes elevated in 90% of patients
with osteomyelitis and peaks in 3 to 5 days.
• Blood cultures may yield an organism in 30% of
cases.
• The WBC count is elevated in only 25% of pa-
tients.
 Diagnostic imaging
• Plain radiographs  7 days after infection no
bone changes  soft tissue swelling
• Technetium Tc-99m bone scanning  focus
infection  92% accuracy  “cold” bone scran
(aggresuve infections)
• MRI  88% sensitivity  defect the marrow and
soft tissue edema in early infection
• CT  abcess formation and bony changes
(sequestra  chronic osteomyelitis)
 Differential diagnosis
• cellulitis,
• septic arthritis,
• toxic synovitis,
• fracture, thrombophlebitis,
• rheumatic fever,
• bone infarction,
• Gaucher disease, and
• malignancy (including leukemia)
 Treatment
• Aspiration
– Before initiating AB
– Dx aspiration
– Large bore needle  aspirate both subperiosteal
and intraosseous space
– After aspiration, AB started
 Nonsurgical
• No purulent material  IV AB
• Change IV AB  oral AB after clinical and lab
improvement
• For non resistant  AB given 3 weeks until
ESR, CRP normal
• For MRSA  AB giveb until 8 weeks
 Surgical
• Indications surgical drainage  pus aspiration,
failure to respond nonsurgical treatment
• Hemodynamic instability is contraindication
• Evacuation of all purulent material, débridement
of devitalized tissue, drilling of the cortex, and
débridement of intraosseous collections
• sent for culture and histol- ogy to rule out
neoplasm
• Chornic osteo  excision of sequestrum
 Complications
• 1. Meningitis
2. Chronic osteomyelitis
• 3. Septic arthritis
• 4. Growth disturbance
5. Pathologic fracture
• 6. Limb-length discrepancy
7. Gait abnormality
8. DVT and pulmonary embolism 9. Sepsis and
multiorgan failure
 Subacute osteomyelitis
• uncommon osseous infection  bone pain and radiographic
changes without systemic signs such as fever
• Similar bony neoplasm
• Different from AHO : increased host resistance, less virulent
pathogens, prior antibiotic exposure
• Bacteria : S. Aureus
• Lab : normal WBC, CRP, slight increase ESR, negative culture
• X ray : well-circumscribed radiolucency in the metaphysis or
epiphysis to periosteal new bone formation resembling that
in an aggressive malignancy
 Septic Arthritis
• surgical emergency  Delay in diagnosis
and/or treatment may result in permanent
joint damage, deformity and long term
disability
• Incidence  peaks the 1st few year of life
(younger than 2 y.o  hip and knee)
 Pathophysiology
• bacteremic seeding of a joint, direct
inoculation of a joint (trauma or surgery), or
contiguous spread from adjacent
osteomyelitis.
• Release proteolytic enzime from inflamatory
cells, synovial cells, cartilage and bacteria 
damage artic surface within 8 ho
• Increase joint pressure  osteonecrosis
 Bacteriology
• H in- fluenzae has decreased markedly since
the advent of H influenzae vaccine.
 Evaluation
• History
• PE :
– Fever
– Do not use affected extremity / refise to bear weight
– Effusion
– Tenderness
– Wamth
– Limited ROM
– For hip (FABER)
 Laboratory
• WBC : elevated
• ESR : elevated (normal in early case)
• CRP : elevated
• Blood culture: (+)
 Diagnostic imaging
• Plain x ray : joint space widening
• USG : hip effusion  guide to aspiration
• MRI : joint effusion (abcess for adjecent
osseous involvement)
 Aspiration
• Is nessesary for dx SA
• Taken for WBC count with differential, gram
stain and culture
 DD
• osteomyelitis,
• toxic synovitis,
• rheumatologic disorders
• tuberculosis (TB),
• Lyme disease,
• poststreptococcal arthritis,
• reactive arthritis,
• villonodular synovitis,
• leukemia,
• sickle cell disease,
• hemophilia,
• serum sickness, and
• Henoch-Schönlein purpura
 Diagnosis
Four of the following are present :
a. Fever higher than 38.5°C
b. Inability to bear weight
c. ESR greater than 40 mm/h
d. WBC count greater than 12,000/μL
CRP > 20mg/dl  increase risk
Fever > 38.5, elevated CRP, ESR, WBC, refusal to
bear weight  predictors factor
 Treatment
• Initial
– Joint aspiration (before AB empiric)
– IV AB until 3 weeks

• Non surgical
– Rare a role in SA
– AB IV
– Serial aspiration
 Surgical
• Indications :
• Surgical drainage  remove damaging enzyme
• Contraindications :
• Clinical status prevents it
• Procedures
• • Arthrotomy  remove all purulent fluid and irrigate the joint.
• • In the case of an infected hip, an anterolat- eral or medial
approach is performed emer- gently to decrease the risk of
osteonecrosis.
• • Drainage of the shoulder, elbow, knee, and ankle can be open
or arthroscopic.
 Complications
• Joint contracture
• Hip dislocation
• Growth disturbance
• Limb discrepancy
• Joint destruction
• Gait disturbance
• Osteonecrosis