3. ACUTE OSTEOMYELITIS
• A severe infection of the bone and surrounding tissues.
• Can occur in any age, but common to children younger than 12 years
of age.
• Duration of acute osteomyelitis is less than 1 month after onset of
symptoms
5. INCIDENCE
• 1 in 5000 children younger than 13 years old
• mean age 6.6 years
• 2.5 times more common in boys
• more common in the first decade of life due to the rich
metaphyseal blood supply and immature immune system
• typically metaphyseal via hematogenous seeding
7. CONT…..
• illicit IV drug use
• poor vascular supply
• systemic conditions such as diabetes and sickle cell
• peripheral neuropathy
• recent trauma or surgery
8. Causes
• Staphylococcus aureus in 80% to 90% of cases
• Kingella kingae is becoming more common nowadays
• E.coli, Pseudomonas, and Klebsiella in patients with
genitourinary tract infections and IV drug abusers.
• In neonates: Hemophilus influenza and group B streptococci
• In patients with sickle cell disease –Salmonella infection
9. Risk factors
• recent trauma or surgery
• immunocompromised patients
• illicit IV drug use
• poor vascular supply
• systemic conditions such as diabetes and sickle cell
• peripheral neuropathy
10. • Hematogenous
• Through the bloodstream
• Contiguous focus
• Extension from adjacent tissue infection
• Direct infection
into the bone such as penetrating injuries,ooen fractures or surgical
contamination.
Mechanism of spread
11. • Predominantly occur in children, middle-aged, and older adults.
• There is usually a single organism that enters a bone via the
bloodstream from a site of infection (most commonly S. aureus).
• Common sources of infection: skin infection, URTI, and acute otitis
media.
Hematogenous Osteomyelitis
12. • Onset is insidious.
• Infection spreads to adjacent bone through the soft tissue.
• Greater risk for clients with Diabetes Mellitus and severe
atherosclerosis.
Osteomyelitis 2⁰ to Contiguous Infection
13. • Microbes gain entry to the bone through open fractures, penetrating
wounds, or contamination in a surgical procedure.
• Implanted items may also cause infection.
Direct Bone Infection
14. Pathophysiology
Organisms once localized in bone
Bacteria proliferate and induce inflammatory reaction and cause cell
death.
Bone undergoes necrosis within first 48 hours
Bacteria and inflammation spread within the shaft of the bone and may
percolate throughout the haversian systems and reach the periosteum
Subperiosteal abscess
Segmental bone necrosis sequestrum (dead piece of bone)
Rupture of periosteum leads to an abscess in the surrounding soft tissue
and the formation of draining sinus.
15. v
• Over time, host response develops
• After first week of infection chronic inflammatory cells become more
numerous
• Cytokines from leukocytes stimulates osteoclastic bone resorption
ingrowth of fibrous tissue deposition of reactive bone in the periphery
• Reactive woven or lamellar bone which forms sleeve of living tissue
surrounding dead bone is called as involucrum.
17. Clinical Manifestations
Acute Osteomyelitis
• Systemic
• Chills
• High fever
• Rapid pulse
• General Malaise
• Local
Constant bone pain that worsens with activity
Swelling, tenderness, warmth at infection site
Restricted movement of affected part
Later signs: drainage from sinus tracts
18.
19. DIAGNOSIS
The diagnosis of acute osteomyelitis is basically
clinical. It is a disease of childhood, more common
in boys, probably because they are more prone to
injury
20. INVESTIGATION
WBC count
elevated in 25% of patients and correlates poorly with treatment response
C-reactive protein
elevated in 98% of patients with acute hematogenous osteomyelitis,becomes elevated within 6 hours
most sensitive to monitor therapeutic response , declines rapidly as the clinical picture improves
CRP is the best indicator of early treatment success and normalizes within a week
failure of the C-reactive protein to decline after 48 to 72 hours of treatment should indicate that treatment
may need to be altered
ESR
elevated in 90% of patients with osteomyelitis
rises rapidly and peaks in three to five days, but declines too slowly to guide treatment
less reliable in neonates and sickle cell patients
21. CONT…
• blood culture
is positive only 30% to 50% of the time and will likely be negative
soon after antibiotics are administered, even if treatment is not
progressing satisfactorily
22. IMAGING
• X-rays :
The earliest sign to appear on the X-ray is a periosteal new bone
deposition (periosteal reaction) at the metaphysis. It takes
about 7-10 days to appear
23.
24.
25. Cont..
• MRI
detects abscesses and early marrow and soft tissue edema
indications
can assist with decision making when a poor clinical response to
antibiotics or surgical drainage considered
26.
27. Cont..
• Bone scan:
• A bone scan using Technetium-99 may show increased uptake by the
bone in the metaphysis. This is positive before changes appear on X-
ray. This may be indicated in a very early case where diagnosis is in
doubt.
• Indium-111 labelled leucocyte scan is most specific for diagnosis of
bone infection.
28. MEDICAL TREATMENT
• CLOXACILLIN 1-2g 6hourly then continue with ampicillin and
cloxacillin 500mg 8hourly to complete 3-6weeks or until CRP and X-
RAY become negative
• For SCD pts if salmonella spp is considered , give ciproflaxin iv 400mg
12hourly for 2weeks then orally to complete 4-6weeks
29. SURGICAL TREATMENT
• Sequestrectomy: This means removal of the sequestrum. If it lies
within the medullary cavity, a window is made in the overlying
involucrum and the sequestrum removed. One must wait for
adequate involucrum formation before performing sequestrectomy
• Saucerisation: A bone cavity is a ‘non-collapsing cavity’, so that there
is always some pentup pus inside it. This is responsible for the
persistence of an infection. In saucerisation, the cavity is converted
into a ‘saucer’ by removing its wall. This allows free drainage of the
infected material.
30. Cont…
Curettage:
The wall of the cavity, lined by infected granulation tissue, is curetted
until the underlying normal-looking bone is seen. The cavity is
sometimes obliterated by filling it with gentamycin impregnated
cement beads or local muscle flap
31. Clinical Manifestations
of Chronic Osteomyelitis
• Chronic – an infection that persists for longer than 1 month
• Infection that has failed to respond to initial course of antibiotic therapy
• Systemic signs
• Signs and Symptoms
Constant bone pain
Swelling
Tenderness
Warmth at site
Continuous Drainage
33. • If with current infection, postpone orthopaedic surgery
• Strict aseptic technique during orthopaedic surgery
• Prophylactic antibiotics
• Urinary catheters and drains are removes as soon as possible
Prevention
34. • Pharmacologic
• IV Antibiotic Therapy for 3-6 weeks
• Then, oral ATB for 3 months
• Direct application
• Surgical
• Surgical Debridement
• Sequestrectomy
• Saucerization
• Internal fixation or external supportive devices
Management
35. Complications of chronic osteomyelitis:
1) Deformities of bones.
2) Pathological fractures.
3) Systemic effects such as chronic fever & fatigue.
4) Amyloidosis of the AA type (secondary amyloidosis).This can get further deposited in the
kidney, liver & blood vessels.
5) Squamous cell carcinoma of the skin: The skin at the edges of the draining sinus tracts
may undergo malignant transformation over time.
6) Sepsis
7) Rarely sarcoma in the infected bone
