Osteomyelitis and Suppurative Arthritis

• Etiology
– Bacteria are the most common pathogens in acute skeletal
infections
Osteomyelitis: Staphylococcus aureus is the most common infecting
organism in all age groups, including newborns
– Group B streptococcus and gram-negative enteric bacilli are also
prominent pathogens in neonates
– group A streptococcus is next in frequency but constitutes less than
10% of all cases
– Kingella kingae may be the second most common cause of
osteomyelitis in children <5 yr of age in some parts of the world.
– Nearly 90% of identified K. kingae infections have been in young
children
– After 6 yr of age, most cases of osteomyelitis are caused
by S. aureus, streptococcus, or Pseudomonas aeruginosa.
– Cases of Pseudomonas are related almost exclusively to
puncture wounds of the foot
– Salmonella and S. aureus are the two most common
causes of osteomyelitis in children with sickle cell anemia
suppurative arthritis:- S. aureus infection is most common.
Haemophilus influenzae type b before vaccine
– Group A streptococcus and S. pneumoniae historically
cause 10–20% of cases.
– In sexually active adolescents gonococcus is a common
cause
– Infection with atypical mycobacteria can occur after
penetrating injuries.
– Fungal infections usually occur as part of multisystem
disseminated disease
– Candida arthritis can complicate systemic infection in neonates
with or without indwelling vascular catheters
– Primary viral infections of bones or joints are exceedingly rare
– A microbial etiology is confirmed in about three fourths of
cases of osteomyelitis and two thirds of cases of suppurative
arthritis
– Blood cultures are positive in ∼50% of osteomyelitis patients.
– Prior antibiotic therapy and the inhibitory effect of pus on
microbial growth might explain the low bacterial yield
⁻ Epidemiology
⁻ The median age of children with musculoskeletal infections
is ∼6 yr.
⁻ Incidence of osteomyelitis in children is estimated to be 1 : 
5,000.
⁻ Bone infections are more common in boys than girls; the
behavior of boys might predispose them to traumatic
events.
⁻ Except for the increased incidence of skeletal infection in
patients with sickle cell disease, there is no predilection for
osteomyelitis based on race
– The majority of osteomyelitis cases in previously
healthy children are hematogenous.
– Minor closed trauma is a common preceding event in
cases of osteomyelitis, occurring in ∼30% of patients.
– Infection of bones can follow penetrating injuries or
open fractures.
– Bone infection following orthopedic surgery is
uncommon.
– Impaired host defenses also increase the risk of
skeletal infection
MOST COMMON CLINICAL ASSOCIATION
Frequent microorganism in any type of
osteomyelitis
Foreign body–associated infection
Common in nosocomial infections
Decubitus ulcer
Sickle cell disease
Exposure to kittens
Immunocompromised patients
Populations in which tuberculosis is
prevalent
Populations in which these pathogens are
endemic
MICROORGANISM
Staphylococcus aureus
Coagulase-negative staphylococci, other
skin flora, atypical mycobacteria
Enterobacteriaceae, P aeruginosa,
Candida.
S. aureus, streptococci and/or anaerobic
Salmonella spp., S. aureus, or S. Pneumoni
Bartonella henselae
Aspergillus , Candida, or Mycobacteria .
Mycobacterium tuberculosis
Brucella spp., Coxiella burnetii, fungi
found in specific geographic areas
(coccidioidomycosis, blastomycosis,
histoplasmosis)
– Septic arthritis is more common in young children.
– Half of all cases occur by 2 yr of age and three fourths of
all cases occur by 5 yr of age.
– Adolescents and neonates are at risk of gonococcal septic
arthritis
– The majority of infections in otherwise healthy children
are of hematogenous origin.
– Infection of joints can follow penetrating injuries or
procedures such as trauma, arthroscopy, prosthetic joint
surgery, intra-articular steroid injection, and orthopedic
surgery, although this is uncommon.
– Immunocompromised patients and those with
rheumatologic joint disease are also at increased risk of
joint infection
• pathogenesis
– ends of long bone (metaphysis) predilection for localization of
blood-borne bacteria due to blood supply and anatomy.
• In the metaphysis, nutrient arteries branch into
nonanastomosing capillaries under the physis, which make
a sharp loop before entering venous sinusoids draining into
the marrow.
• Blood flow in this area is thought to be “sluggish,”
predisposing to bacterial invasion
• As the inflammatory exudate progresses, pressure increases
spread through the porous metaphyseal space via the
haversian system and Volkmann canals into the
subperiosteal space.
• Purulence beneath the periosteum may lift the periosteal
membrane of the bony surface, further impairing blood
supply to the cortex and metaphysis
– In newborns and young infants, transphyseal
blood vessels connect the metaphysis and
epiphysis, so it is common for pus from the
metaphysis to enter the joint space.
– During the latter part of the 1st year of life, the
physis forms, obliterating the transphyseal blood
vessels.
– Joint involvement, once the physis forms, can
occur in joints where the metaphysis is intra-
articular (hip, ankle, shoulder, and elbow), and
subperiosteal pus ruptures into the joint space
• In later childhood, the periosteum becomes
more adherent, favoring pus to decompress
through the periosteum.
• Once the growth plate closes in late
adolescence, hematogenous osteomyelitis
more often begins in the diaphysis and can
spread to the entire intramedullary canal
– The synovial membrane has a rich vascular supply
and lacks a basement membrane, providing an
ideal environment for hematogenous seeding.
– The cytokines stimulate chemotaxis of neutrophils
into the joint space, where proteolytic enzymes
and elastases are released by neutrophils,
damaging the cartilage.
– Proteolytic enzymes released from the synovial
cells and chondrocytes also contribute to
destruction of cartilage and synovium.
• Bacterial hyaluronidase breaks down the hyaluronic acid in
the synovial fluid, making the fluid less viscous and
diminishing its ability to lubricate and protect the joint
cartilage.
• Damage to the cartilage can occur through increased
friction, especially for weight-bearing joints.
• The increased pressure within the joint space from
accumulation of purulent material can compromise the
vascular supply and induce pressure necrosis of the
cartilage.
• Synovial and cartilage destruction results from a
combination of proteolytic enzymes and mechanical factors
• SITE
– The femur and tibia are equally affected and together
constitute almost half of all cases.
– The bones of the upper extremities account for one fourth of
all case
– joints of the lower extremity constitute three fourths of all
cases of suppurative arthritis
– The elbow, wrist, and shoulder joints are involved in about
one fourth of cases, and small joints are uncommonly infected.
– There is usually only a single site of bone or joint involvement.
– Several bones or joints are infected in fewer than 10% of cases;
notable exceptions are gonococcal in 50% more than one
Clinical Manifestations
• The earliest signs and symptoms of osteomyelitis, often
subtle and nonspecific, are generally highly dependent on
the age of the patient.
• Neonates might exhibit pseudoparalysis or pain with
movement of the affected extremity (e.g., diaper changes).
• Half of neonates do not have fever and might not appear
ill.
• Older infants and children are more likely to have fever,
pain, and localizing signs such as edema, erythema, and
warmth.
• With involvement of the lower extremities, limp or refusal
to walk is seen in approximately half of patients
• Focal tenderness over a long bone can be an important
finding.
• Local swelling and redness can mean that the infection has
spread out of the metaphysis into subperiosteal space,
representing a secondary soft-tissue inflammatory response.
• Pelvic osteomyelitis can manifest with subtle findings such
as hip, thigh, or abdominal pain.
• Back pain with or without tenderness to palpation overlying
the vertebral processes is noted in vertebral osteomyelitis
• Children with subacute symptoms and focal finding in the
metaphyseal area (usually of tibia) might have a Brodie
abscess, with radiographic lucency and surrounding reactive
bone
Diagnosis
• The diagnosis of osteomyelitis is clinical; blood cultures
should be performed in all suspected cases
• Aspiration of the infected site for Gram stain and culture
• Polymerase chain reaction appears to be the most
sensitive technique to detect K. kingae, with detection
up to 6 days after antibiotics are initiated.
• WBC and differential, ESR, and C-reactive protein (CRP)-
may be normal during the first few days of infection
– Monitoring response to therapy or identifying complications
• Normal synovial fluid  —
– Highly viscous
– Clear
– Essentially acellular
– Protein concentration approximately one-third that of plasma
– Glucose concentration similar to that in plasma
• Cell count — Normal synovial fluid is nearly acellular.
• Bacterial joint infections typically are purulent with leukocyte
counts (most of which are neutrophils) of 50,000 to 150,000
cells/mm 3
• In nongonococcal bacterial arthritis, the sensitivity of Gram stain
has been estimated to range from 50 to 70 percent
• synovial fluid to detect acid-fast bacilli is often negative with an
estimated sensitivity of only 20 percent
• Plain Radiographs
– Within 72 hr of onset of symptoms of
osteomyelitis, can show displacement of the deep
muscle planes from the adjacent metaphysis
caused by deep-tissue edema.
– Lytic bone changes are not visible on radiographs
until 30-50% of the bony matrix is destroyed.
– Tubular long bones do not show lytic changes for
7-14 days after onset of infection.
– Infection in flat and irregular bones can take
longer to appear
• CT and MRI
– CT can demonstrate osseous and soft-tissue abnormalities
and is ideal for detecting gas in soft tissues
– MRI is more sensitive than CT or radionuclide imaging in
acute osteomyelitis and is the best radiographic imaging
technique for identifying abscesses and for differentiating
between bone and soft-tissue infection.
– MRI provides precise anatomic detail of subperiosteal pus
and accumulation of purulent debris in the bone marrow
and metaphyses for possible surgical intervention
– Gadolinium administration can also enhance MRI
– MRI can also demonstrate a contiguous septic arthritis,
pyomyositis, or venous thrombosis
• Radionuclide Studies
– Radionuclide imaging can be valuable in suspected,
especially early in the course of infection and/or if
multiple foci are suspected or an unusual site is
suspected, as in the pelvis.
– Technetium-99 methylene diphosphonate (99mTc),
which accumulates in areas of increased bone turnover,
is the preferred agent for radionuclide bone imaging
(three-phase bone scan).
– Any areas of increased blood flow or inflammation can
cause increased uptake of 99mTc in the first and second
phases, but osteomyelitis causes increased uptake of
99mTc in the third phase (4-6 hr).
• Three-phase imaging with 99mTc has excellent sensitivity (84-
100%) and specificity (70-96%) in hematogenous osteomyelitis
and can detect osteomyelitis within 24-48 hr after onset of
symptoms.
• The sensitivity in neonates is much lower, due to poor bone
mineralization.
• Advantages include:
– infrequent need for sedation,
– lower cost, and
– the ability to image the entire skeleton for detection of
multiple foci
Treatment
Antibiotic Therapy
• The initial empirical antibiotic therapy is based on:
– ages,
– the results of the Gram stain of aspirated material, and
– additional considerations
• vancomycin is substituted for nafcillin.
• If the neonate is a small premature infant or has a central
vascular catheter, the possibility of nosocomial bacteria
(Pseudomonas or CONS) or fungi (Candida) should be
considered.
• In older infants and children, the principal pathogens are S.
aureus and streptococcus
• A major factor influencing the selection of empirical therapy is
the rate of methicillin resistance among community S. aureus
isolates.
• If MRSA accounts for ≥10% of community S. aureus isolates,
including an antibiotic effective against CA-MRSA in the initial
empirical antibiotic regimen is suggested
• Vancomycin is the gold standard agent for treating invasive
MRSA infections, especially when the child is critically ill.
• Clindamycin is also recommended when the rate of
clindamycin resistance is ≤10% among community S. aureus
isolates and the child is not severely ill.
• Cefazolin or nafcillin is the agent of choice for parenteral
treatment of osteomyelitis caused by methicillin-susceptible
S. aureus.
• Penicillin is first-line therapy for treating osteomyelitis due to
susceptible strains of S. pneumoniae as well as all group A
streptococcus.
• Cefotaxime or ceftriaxone is recommended for pneumococcal
isolates with resistance to penicillin or for most Salmonella
spp
• In patients with sickle cell disease with osteomyelitis, a
broad-spectrum cephalosporin such as cefotaxime is used in
addition to vancomycin or clindamycin.
• Clindamycin is a useful alternative drug for patients allergic
to β-lactam drugs.
• In addition to good antistaphylococcal activity, clindamycin
has broad activity against anaerobes and is useful for
treating infections secondary to penetrating injuries or
compound fractures.
• For immunocompromised patients, combination therapy is
usually initiated, such as with vancomycin and ceftazidime,
or with
• piperacillin-tazobactam and an aminoglycoside.
• K. kingae usually responds to β-lactam antibiotics,
including cefotaxime.
• Duration of antibiotic therapy is individualized depending on
the organism isolated and clinical course.
• For most infections including those caused by S. aureus, the
minimal duration of antibiotics is 21-28 days, provided that
– the patient shows prompt resolution of signs and
symptoms (within 5-7 days) and
– the CRP and ESR have normalized
• a total of 4-6 wk of therapy may be required.
• For group A streptococcus, S. pneumoniae, or H. influenzae
type b, treatment duration maybe shorter.
• A total of 7-10 postoperative days of treatment is adequate
for Pseudomonas osteochondritis when thorough curettage
of infected tissue has been performed.
• Immunocompromised patients generally require prolonged
courses of therapy, as do patients with mycobacterial or
fungal infection
• Changing antibiotics from the intravenous route to oral
administration when a patient's condition clearly has
improved and the child is afebrile for ≥48-72 hr, may be
considered.
• In children with venous thrombosis complicating
osteomyelitis, anticoagulants generally are administered
Surgical Therapy
• When frank pus is obtained from subperiosteal or
metaphyseal aspiration or is suspected based on MRI findings,
a surgical drainage procedure is usually indicated.
• Surgical intervention is also often indicated after a penetrating
injury and when a retained foreign body is possible
• Treatment of chronic osteomyelitis consists of surgical
removal of sinus tracts and sequestrum, if present.
• Antibiotic therapy is continued for several months or longer
until clinical and radiographic findings suggest that healing has
occurred.
• Monitoring the CRP or ESR is not helpful in most cases of
chronic osteomyelitis
Physical Therapy
• The major role of physical medicine is a preventive one.
• If a child is allowed to lie in bed with an extremity in flexion,
limitation of extension can develop within a few days.
• The affected extremity should be kept in extension with
sandbags, splints, or, if necessary, a temporary cast.
• Casts are also indicated when there is a potential for
pathologic fracture.
• After 2-3 days, when pain is easing, passive range of motion
exercises are started and continued until the child resumes
normal activity.
• In neglected cases with flexion contractures, prolonged
physical therapy is required
Septic arthritis:
• In older infants and children with septic arthritis, empirical
therapy to cover for S. aureus, streptococci, and K. kingae
includes cefazolin (100-150 mg/kg/24 hr divided q8h) or
nafcillin (150-200 mg/kg/24 hr divided q6h)
• Ten to 14 days is usually adequate for streptococci, S.
pneumoniae, and K. kingae; longer therapy may be needed
for S. aureus and gram-negative infections.
• Normalization of ESR and CRP in addition to a normal
examination supports discontinuing antibiotic therapy.
• Oral antibiotics can be used to complete therapy once the
patient is afebrile for 48-72 hr and is clearly improving
• Infection of the hip is generally considered a surgical
emergency because of the vulnerability of the blood supply to
the head of the femur.
• For joints other than the hip, daily aspirations of synovial fluid
may be required.
• Generally, one or two subsequent aspirations suffice.
• If fluid continues to accumulate after 4-5 days, arthrotomy or
video assisted arthroscopy is needed.
• At the time of surgery, the joint is flushed with sterile saline
solution.
• Antibiotics are not instilled because they are irritating to
synovial tissue, and adequate amounts of antibiotic are
achieved in joint fluid with systemic administration
• Acute-phase reactants may be useful as monitors.
• The serum CRP typically normalizes within 7 days after
start of treatment, whereas the ESR typically rises for 5-
7 days, and then falls slowly, dropping sharply after 10-
14 days.
• Failure of either of these acute-phase reactants to follow
the usual course should raise concerns about the
adequacy of therapy.
• Recurrence of disease and development of chronic
infection after treatment occur in <10% of patients
• It appears that initiation of medical and surgical therapy
within 1 wk of onset of symptoms provides a better
prognosis than delayed treatment
THANK YOU