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 Ewings 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.

Ewings, 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