OSTEOMYELITIS

Definition of Osteomyelitis
The root words osteon (bone) and myelo

(marrow)
are
(inflammation)

combined

with

itis

Osteomyelitis is an infectious process that

involves bone and its medullary cavity which

leads to a subsequent Inflammatory process.

Classification
Based on onset
Acute
Chronic

Source of

infection
Hematogenous
Contagenous
Direct Infection

Acute Osteomyelitis

Acute haematogenous osteomyelitis is mainly

a disease of children

Etiology: Staph. aureus, gram-negative bacili,

group B streptococcus

In infant:
There is still a free anastomosis
between metaphyseal and epiphyseal
blood vessel, infection can just as
easly lodge in epiphysis.

Acute Osteomyelitis in babies infection may

settle near the very end of bone: joint
infection and growth disturbance easly follow.
In older children, metaphyseal infection is
usual; the growth disc acts as a barrier to
spread

In children:
Organisme usually
settle in the methaphysis

Infection in the metaphysis may spread

towards the surface, to form a subperiosteal
abscess
Some of the bone may die, and is encased
in periosteal new bone as a sequestrum
The encasing involucrum is sometimes
perforated by sinuses

Pathology

Inflammation

Pathology of
acute ostemyelitis
Inflammation
acute inflammatory
reaction, vascular
congestion, exudation of
fluid, infiltration of PMN,
increase of intraosseus
pressure

Suppuration
Subperiosteal abscess, end
plate and intervertebral
disc infection

Pathology of
acute ostemyelitis
Necrosis

avascular necrosis of
growth plate in infant.
Bacterial toxins and
leucocytic enzymes
also may play their
part in the advancing
tissue destruction.
reactive new bone
formation
resolution and healing.

NEW BONE FORMATION

New bone forms from the deep layers of

the stripped periosteum.

This is typical of pyogenic infection and is
usually obvious by the end of the second
week. With rime the new bone thickens to
form an involucrum enclosing the
infected tissue and sequestra.

NEW BONE FORMATION

If the infection persists, pus and tiny

sequestrated splcules of bone may

continue to discharge through
perforations (cloacae) in the involucrum
and track by sinuses to the skin surfaces;
the condition is now established as a
chronic osteomyelitis.

RESOLUTION
Once common, chronic osteomyelitis

following on acute is nowadays seldom

seen.
If infection is controlled and intraosseous
pressure released at an early stage, this
dire progress can be aborted.
The bone around the zone of infection is
at first osteoporotic (probably due to
hypcraemia).

Sign & Symptoms

Signs and symptoms can vary significantly.
The patient, usually a child, presents with

severe pain, malaise and a fever

In
infants,
elderly
patients,
or
immunocompromised patients, clinical findings
may be minimal.
Pain and local tenderness are common
findings.

Laboratory
The most certain way to confirm the clinical

diagnosis is to aspirate pus from the

metaphyseal subperiosteal abscess or the
adjacent joint.
The WBC and CRP values are usually high.
Blood culture is positive in only about half the
cases of proven infection.

Imaging
PLAIN X-RAY
Standard radiographs

generally are
negative, but may
show soft-tissue
swelling.
Skeletal changes,
such as periosteal
reaction or bone
destruction, generally
are not seen on plain
films until 10 to 12
days into the infection

The first x-ray, 2 days after symptoms

began, is normal it always is;
metaphyseal mottling and periosteal
changes were not obvious until the
second film, taken 14 days later;
eventually much of the shaft was
involved.

Soft tissue swelling (early), bone demineralization

(10-14 days), sequestra (dead bone with

surrounding granulation tissue), and involucrum
(periosteal new bone) later.
MRI : extremely sensitive, even in the early phase

of bone infection, and can help to differentiate

between soft-tissue infection and osteomyelitis.
Radioscintigraphy

Sensitive but not specific.

Management

Supportive treatment for pain and

dehydration
Splintage of the affected part
Antibiotic therapy
Surgical drainage

Complication

Suppurative arthritis
Pathological fracture
Chronic osteomyelitis

Chronic Osteomyelitis
Chronic osteomyelitis represents a continuation of

unresolved acute infection

Now days, it more frequently follows an open

fracture or operation.

Usual

organisms are staphylococcus aureus,

Escherichia coli, Streptococcus pyogens, Proteus
and Pseudomonas.

Staging For Adult Chronic Osteomyelitis by

Cierny et al. (2003)

Pathology
Bone is destroyed or devitalized in a discrete area

at the focus of infection.

Cavities containing pus and pieces of dead bone

(sequestra) are surrounded by vascular tissue,

and beyond that by areas of sclerosis the result of
chronic reactive new bone formation.
The histological picture is one of chronic

inflammatory cell infiltration around areas of

acellular bone or microscopic sequestra.

Clinical features
Pain, pyrexia, redness and tenderness have

recurred, or with a discharging sinus.

There may be a sero-purulent discharge and

excoriation of the surrounding skin.

Laboratory
ESR and white blood cell count may be

increased
Organisms cultured from discharging sinuses
should be tested repeatedly for antibiotic
sensitivity.

Imaging
X-ray examination
Bone resorption with thickening

and sclerosis of surrounding bone

However, there are marked variation:
there may be no more than
localized loss of trabecculation,
or a area osteoporosis,
periosteal thickening, sequestra
show up as unnaturally dense fragments.

Radioscintigrapby with

Tc-HDP
reveals increased activity in both
the perfusion phase and the bone
phase.. It has relatively low
specificity and other inflammatory
lesions can show similar changes.
In doubtful cases, scanning with
Ga-citrate or In labelled
leucocytes may be more
revealing.
99m

MRI is extremely sensitive, even

in the early phase of bone

infection, and can help to
differentiate between soft-tissue
infection and osteomyelitis.
The most typical feature is a
reduced intensity signal in T1weighted images.

Investigations
The most certain way to confirm the

clinical diagnosis is to aspirate pus from

the metaphyseal subperiosteal abscess or
the adjacent joint.
The white cell count and C-reactive

protein values are usually high and the

haemoglobin concentration diminished;

Investigations
The ESR also rises but it may take several

days to do so and it often remains

elevated even after the infection
subsides.
Blood culture is positive in only about half

the cases of proven infection.

Differential diagnosis
Cellulitis
Streptococcal necrotizing myositis
Acute suppurative arthritis
Acute rheumatism
Sickle-cell crisis
Gaucher's disease

Treatment
Supportive treatment for pain and

dehydration;
Splintage of the affected part;
Antibiotic therapy 3 6 weeks; and
Surgical drainage

ANTIBIOTIK TREATMENT
Older children and fit adult :

Staphylococcus group
Flucloxacillin and fusidic acid i.v 1 2

weeks
Orally antibiotics 3 6 weeks

Children < 4 years ; Haemophilus group

and gram negatife organisms

Cephalosporins (cefuroxime or cefotaxime)

i.v or orally
Amoxicillin-clavulanic acid combination
(co-amoxiclav, a -lactamase inhibitor)

Management
Antibiotics
Local Treatment
Operation :
Debridement
Dealing with the dead space
Soft tissue cover

Complication
A pathologic fracture
Non union or segmental bone loss

SUBACUTE OSTEOMYELITIS
Relative mildness
The organism being

less virulent
(Staphylococcus
aureusor ) and the
patient more
resistance (or both);

SUBACUTE OSTEOMYELITIS
More variable in

skeletal distribution
than acute
osteomyelitis
The Distal femur and
the proximal and
distal tibia are
favorite sites.

PATHOLOGY
Well defined cavity in cancellous bone

glairy seropurulent fluid (rare pus)

Cavity is lined by granulation tissue of
mixture of acute and chronic
inflammatory cells.
The surrounding bone trabeculae are
often thickened

Clinical features
The patient : child or adolescent
Pain near one of the larger joints for

several weeks or even months

A limp or slight swelling, muscle wasting
and local tenderness
Normal temperature to slight higher
White cell count may be normal but ESR
is raised

IMAGING
Plain X-Ray
A circumscribed, oval or round cavity 1 2
cm in diameter on tibia or femoral
metaphysis or in epiphysis or in cuboidal
bone (calcaneus)
Cavity surrounded by halo of sclerosis (the
classic Brodies abscess)
Metaphysis lesion little or no periosteal
reaction
Diaphysial lesion periosteal new bone
formation and cortical thickening
Radioisotope scan

DIAGNOSIS
Differential diagnosis : Osteoid osteoma

with appearance as malignant bone

tumour
Certain examination by Biopsy for
bacteriological culture.

TREATMENT
Conservative
Immobilization and antibiotics

(flucloxacillin and fusidic acid) for 6

weeks than thereafter for 6 12 months
Curretage; indicate for lesion after biopsy
and also for the case with no healing with
conservative treatment. Antibiotics

CHRONIC OSTEOMYELITIS
The usual organisms (and with time there

is always a mixed infection) are Staph.

aureus, E. coti, S. pyogenes, Proteus and
Pseudomonas;
In the presence of foreign implants
Staph. cpidermidis, which is normally
non-pathogenic, is the commonest of all.

Pathology

Bone is destroyed or devitalized in a

discrete area at the focus of infection or

more diffusely along the surface of a
foreign implant.
Cavities containing pus and pieces of

dead bone (sequestra) are surrounded by

vascular tissue, and beyond that by areas
of sclerosis -the result of chronic reactive
new bone formation.

Pathology

The sequestra act as substrates

The histological picture is one of chronic

inflammatory cell infiltration around areas

of acellular bone or microscopic
sequestra.

Chronic osteomyelitis chronic bone infection, with a persistent

sequestrum, may be a sequel to acute osteomyelitis (a). More
often it follows an open fracture or operation (b). Occasionally it
presents as a brodie's abscess (c).

Clinical features
The patient presents because pain,

pyrexia, redness and tenderness have

recurred (a 'flare'), or with a discharging
sinus.
In long-standing cases the tissues are

thickened and often puckered or folded in

where a scar or sinus is attached to the
underlying bone.

Clinical features
There may be a sero-purulent discharge

and excoriation of the surrounding skin.

In post-traumatic osteomyelitis the bone

may be deformed or non-united.

Imaging
X-ray examination
Bone resorption with thickening and
sclerosis of surrounding bone, loss of
trabeculation, area osteoporosis,
periosteal thickening, sequestra, or the
bone crudely thickened and misshapen

Imaging

Radioisotope scintigraphy
Sensitive but not specific. Using 99m Tc-HDP
for showing increased activity of perfusion
and bone phase and 67 Ga-Citrate or Inlabelled leucocytes for showing hidden foci of
infection

CT and MRI
Show the extent of bone destruction and
reactive edema, hidden abscess and
sequestra

Investigations
ESR and blood white cell

count may be
increased; are helpful
in assessing the progress
of bone infection but they
are not for diagnostic.

Investigations
Organisms cultured from

discharging sinuses
should be tested
repeatedly for antibiotic
sensitivity; with time,
they often change their
characteristics and
become resistant to
treatment.

Treatment
Antibiotics ; Fucidic acid,

clindamycin and
cephalosporins
Local treatment :
incision and drainage
Operation

THANKS

Greene,W. Netters Orthopaedic 1st ed

Apley, Apleys System Of Orthopaedics And

Fractures 8th Edition

Salter, Robert B, MD, Textbook of Disorders
and Injuries of the Musculoskeletal system