Osteomyelitis

Acute Osteomyelitis
• Definition: Bone infection

Causes

1. Staphylococcus aureus
2. Salmonella
3. Pseudomonas aeruginosa
4. Pasteurella multiocida
5. Eiknella corrodens
6. Anaerobes
• Most common pathogens in all age groups, HIV patients, post-
traumatic or post-surgical, open injuries
• Most common pathogens in Sickle cell disease
• Most common in drug addict, foot injuries
• Most common in animal bite
• Most common in human bite
• Most common in presence of diabetic ulcer

Site of infection

Children • Most common: Metaphysis of long bone (most common lower end femur)
Why most common in metaphysis?
• Defective phagocytosis in metaphysis
• Rich blood supply
• Mode of infection is hematogenous (blood)
Adult • Most common: Thoracolumbar spine

Pathogenesis & Course of disease

Mode of infection: Hematogenous (Most common)


Metaphyseal abscess formation (Suppuration)

Spread of infection (pus)
• Children: Spread to sub periosteum (because periosteum is loosely attached to bone)
• Adult: Spread to Medullary cavity involving diaphysis

Joint involvement
• Because metaphysis is intracapsular (ex: hip, shoulder, elbow)

Necrosis

Reactive new bone formation

Resolution & Healing

History & Examination

History
• High grade fever > 38C
• Acute onset of pain & swelling at the end of a bone
• Discharge
• Absent movement in pediatric age group
• History of injury

Physical examination
• High grade fever
• Dehydrated
• Classic signs of inflammation – redness, heat, swelling at metaphyseal area of bone
• Joint swelling – due to effusion

Diagnosis
“Any acute inflammatory disease at the end of a bone, in a child, should be taken as acute osteomyelitis
unless proved otherwise”
• Clinical diagnosis
• Disease of childhood
• More common in boys because boys more active & prone to get injury

Investigation

FBC  WBC (Leukocytosis)

ESR  ESR
Blood C&S
X-rays • Early sign: Periosteal new bone formation (periosteal reaction) – 7 –
10 days to form
Bone scan •  Uptake by bone in metaphysis
• Only perform when diagnosis in doubt

Differential diagnosis

Negative point
Acute septic arthritis • Tenderness & localized at joints only (not
metaphysis as osteomyelitis)
• Painful & restricted joint movement
Acute rheumatic arthritis • Tenderness & localized at joints only (not
metaphysis as osteomyelitis)
• Painful & restricted joint movement
•  ASO titer
•  CRP
Scurvy • Mimic acute osteomyelitis radiologically – due
to sub-periosteal hematomas formation
• Absence of pain, tenderness, fever
Acute poliomyelitis • Muscle tender
• No bone tenderness
Treatment

< 48 hours of onset of symptoms > 48 hours of onset of symptoms or

Important: Pus not yet formed & antibiotic can
stop inflammatory process
1. Rest – by splint or traction
2. Systemic antibiotics
• < 4 months old – Ceftriaxone + Vancomycin
• Older children – Ceftriaxone + Cloxacillin
• Adult – Cloxacillin + Rifampicin
• Change to specific antibiotic after get the blood
C&S result
• After 2 weeks of IV antibiotic, give Oral
antibiotic for 6 weeks
3. Rehydrated patients with IV fluid
4. Stop weight bearing for 6 -8 weeks
5. If all of these treatment failed to resolve
symptoms – Proceed with surgical intervention
(Next table)
Failed treatment when treated with <48 hours of
onset of symptoms
1. Ultrasound – for pus detection
2. Surgical exploration & drainage
• Drill hole in metaphysis of bone
• Enlarge the hole until there is free drainage of
pus, & take swab
• Wound is closed over a sterile suction drain
3. Rest – by splint or traction
4. Systemic antibiotics
• < 4 months old – Ceftriaxone + Vancomycin
• Older children – Ceftriaxone + Cloxacillin
• Change to specific antibiotic after get the blood
C&S result
• After 2 weeks of IV antibiotic, give Oral
antibiotic for 6 weeks
5. Rehydrated patients with IV fluid
6. Stop weight bearing for 6 -8 weeks

Complications
Main causes
• Delay diagnosis
• Inadequate treatment

General complications • Septicemia

Local complications
1. Chronic osteomyelitis (Most common)
• Causes: Delay in diagnosis + Poor host resistance  Sequestrum
formation (dead bone)  Confined pus in cavity inside bone
2. Acute pyogenic arthritis
• Occur in joints where metaphysis is intra-articular (hip, shoulder etc)
3. Pathological fracture
• Osteomyelitis or surgery weakens the bone
• Prevention: Adequate splinting of limb
4. Growth plate disturbances

Secondary Osteomyelitis

Causes
• Wound infection in open fracture
• Bone surgery

Symptoms
• Less severe than acute primary osteomyelitis
Chronic Osteomyelitis (chronic pyogenic osteomyelitis)

Types
• Chronic osteomyelitis secondary to acute osteomyelitis (Most common)
• Garre’s osteomyelitis
• Brodie’s abscess

Chronic osteomyelitis secondary to acute osteomyelitis

How acute osteomyelitis cause chronic osteomyelitis

1. Delayed and inadequate treatment (Most common)
• This cause pus to spread within medullary cavity & sub-periosteally  Sequestrum formation (dead
bone tissue)  Destruction of cancellous bone  Formation of cavity within bone
2. High virulent organism
• Immune system couldn’t control the high virulent organism, so infection persist
3. Reduced host immune resistance
• Ex: Immunocompromised patient, malnutrition

Pathogenesis
Acute osteomyelitis

Factors
• Delayed and inadequate treatment
• High virulent organism
• Reduced host immune resistance

Chronic osteomyelitis

Host bone generate more & more sub-periosteal new bone

Bone thickening

Sub-periosteal new bone is deposited in irregular fashion

Irregular surface of osteomyelitic bone

Continuous pus discharge

Sinus formation

Sinus tract get fibrosed & become fixed to the bone

Diagnosis
• Clinical
• Confirm by radiological
• Most common in children
• Most common site: Lower end of femur

History taking & examination

History taking
• Chronic sinus discharge
• Discharge – purulent to thick pus
• Small bone fragment extrude out from sinus
• Pain – during exacerbation only
• Fever – during exacerbation only

Physical examination
• Chronic sinus discharge
• Sprouting granulation tissue at opening (indicate sequestrum within the bone)
• Sequestrum visible at mouth of sinus
• Sinus surrounded by healed puckered scars (indicate previous healed sinus)
• Thickened, irregular bone
• Tenderness on palpation
• Stiff adjacent joint – associated arthritis of joint

Investigations

FBC •  WBC – during acute exacerbation only

ESR • Normal or mildly increase
Pus C&S • Identify causative organism
• To select specific antibiotic
X-ray • Thickening & irregularity of cortices
• Patchy sclerosis
• Bone cavity – surrounded by sclerosis
• Sequestrum – appear denser than surrounding
bone because decalcification occur in normal
bone, not dead bone
• Radiolucent zone around sequestrum – due to
granulation tissue surrounding it
• Involucrum & cloacae visible
Sinogram • Perform if doctor cannot see on x-rays here
the pus may be coming from
CT • If diagnosis is in doubt
MRI • CT scan better in defining cavity & sequestra
which difficult to see on routine x-ray

Differential diagnosis

1. Tubercular osteomyelitis • Discharge: Thin & watery

• Undermined margin & bluish surrounding the skin

2. Soft tissue infection
3. Ewing’s sarcoma
• Multifocal
• Previous TB infection
• Absence of thickening of underlying bone
• Absence of sinus fixed to the bone (because infection not coming
from bone)
• Absence of radiological changes in bone
• Present with sudden onset of pain & swelling

Treatment
• Primarily surgical: To remove dead bone, dead space & cavity, infected granulation tissue & sinuses
• Antibiotic: Useful only during acute exacerbations & during pos-surgery period
• After surgery, the wound is closed over Continuous suction irrigation system

1. Sequestrectomy • Removal of sequestrum

• Must wait for adequate involucrum formation first
• If sequestrum lies within medullary cavity, a window is made in
overlying involucrum & sequestrum is removed
2. Saucerisation • Bone cavity is converted into saucer by removing its wall – to allow free
drainage of infected material
3. Curretage • Currete wall of bone cavity that lined by infected granulation tissue
4. Excision of infected bone • Remove affected bone altogether without compromise function of limb
5. Amputation • Very rarely used
• Preferred in case of long standing discharging sinus that undergo
malignant changes – Sinus tract malignancy

Complications

1. Growth abnormality • Bone shortening – because damaged growth

plate
• Bone lengthening – because  vascularity of
growth plate nearby osteomyelitis
• Bone deformity – Part of growth plate is
damage but remaining normal growth plate
continue growing
2. Pathological fracture • Chronic osteomyelitis weakened the bone
3. Joint stiffness • Secondary to scarring of soft tissue around the
joint or joint is secondarily involved
4. Sinus tract malignancy • Rare, usually squamous cell carcinoma
• Treatment: Amputation

Garre’s Osteomyelitis
About
• Definition: Sclerosing, non-suppurative chronic osteomyelitis
• Most common site: Shaft of femur or tibia
• Must differentiate with bone tumor (Ewing’s sarcoma or Osteosarcoma)
History
• Acute local pain
• Fever
• Swelling

Examination
• Tender on palpation
• No discharge sinus

Treatment
• Guarded
• Broad spectrum antibiotic – To relive acute symptoms

Brodie’s abscess
About
• Type of osteomyelitis where immune system contain (wall of) the infection, creating a chronic bone
abscess containing pus or jelly like granulation tissue that surrounded by zone of sclerosis
• Most common age group: 11 – 20 years old
• Most common site: Upper end of tibia, Lower end of femur
• Most common at Metaphysis of bone

History
• Deep boring pain
• Pain worse at night, walking
• Pain relieve by rest
• Transient effusion (swelling) in adjacent joint

Examination
• Tenderness of affected site
• Thickening of bone on affected site

Investigation

X-ray Diagnosis • Circular or oval lucent area

surrounded by zone of sclerosis

Treatment
• Surgical evacuation & curettage + Antibiotic