Presentation on osteomyelitis for physiotherapy students
It includes the explanation along with the treatment for osteomyelitis which may be benefitial for the physiotherapy students
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2. DEFINITION OF OSTEOMYELITIS
Osteo=bone
Myelo=marrow
Itis=inflammation
So we can conclude that ostemyelitis is a disease in which
infection of bone marrow occurs.
Osteomyelitis is an infection of bone & bone
marrow that may be caused by direct
inoculation of an open traumatic wound or by
blood-borne organisms (hematogenous)
3. CLASSIFICATION
OfOSTEOMYELITIS
ACC TO DURATION-
ACUTE OSTEOMYELITIS(Less than 2 weeks)
SUB-ACUTE OSTEOMYELITIS(Between 2-6 weeks)
CHRONIC OSTEOMYELITIS(more than 6 week)
ACC TO ROUTE OF INFECTION(Acc toWaldogel’s)
HEMATOGENOUS(Most common)
DIRECT
CONTIGUITY
ACC TO HOST RESPONSE
PYOGENIC
NON PYOGENIC
7. INDIRECT ENTRY
Frequently affects growing bone in boys
<12 years old
Associated with increased incidence of blunt trauma
Most common sites of indirect entry ……
Distal femur
Proximal tibia
Humerus
Radius
8. Adults with increased risk
Vascular disorders
Genitourinary and respiratory infections
Spread infection from blood to bone
Vascular-rich bone sites
Pelvis
Tibia
Vertebrae
9. Direct Entry
Can occur at any age
Open wound where microorganisms can gain entry to
body
May also occur in presence of foreign body
Implant
Orthopedic prosthetic device
10. Direct Entry
After entry, microorganisms lodge in an area of bone
where circulation slows.
Usually the metaphysis
Microorganisms grow causing increased pressure
because most bone is nonexpanding
Increased pressure leads to ischemia and vascular
compromise of periosteum
11. Direct Entry
Eventually, infection passes through bone cortex and
marrow cavity
Results in cortical devascularization and necrosis
12. Direct Entry
Once ischemia occurs, bone dies
Sequestrum forms
Devitalized bone separates from living bone .
Part of periosteum that continues to have a blood
supply forms new bone called involucrum
13. Etiology and Pathophysiology
Caused by a variety of microorganisms
Most common infecting microorganism is Staphylococcus
aureus .
ORGANISM POSSIBLE PROBLEM
Staphylococcus aureus Pressure ulcer, penetrating
wound,
open fracture, orthopedic surgery
Staphylococc Epidermis Indwelling prosthetic device
Streptococcus viridans Abscessed tooth, gingvial disease
16. PATHOPHYSIOLOGY
Pus spreads into vascular channels
Raising intraosseous pressure
Impairing blood flow
Chronic ischemic necrosis
Separation of large devascularized fragment
New bone formation
(involucrum)
(Sequestra)
18. Acute Osteomyelitis
Types of Acute Osteomyelitis
I. Hematogenous Osteomyelitis
II. Direct Inoculation Osteomyelitis
19. Acute Osteomyelitis
Hematogenous Osteomyelitis:
Bacterial seeding from the blood.
Seen primarily in Children.
The most common site is the Metaphysis at the growing
end of Long Bones in Children, and The Vertebrae and
pelvic in Adults.
21. Acute Haematogenous Osteomyelitis
It is an endogenous form of the disease most often affecting
neonates.
Source of infection may be umblicus
Organisms – Staphlococci, Steptococci, E.Coli, Klebsiella,
Pasteurella, Proteus, etc :
Hematogenous-common in children .It is highest in the first
two decades of life. < 5 years of age. In adult-Haematogenous
is less common but they suffered due to debility
disease(diabetes mellitus)drugs(immunosuppresion
Clinical signs – Fever, malaise, non weight bearing lameness,
soft tissue swelling over the involved bone .
22. Pathophysiology
Septicaemia initiated from focus of infection (umblicus)
Infective emboli enters the nutrient arteries of long bones
The emboli gets entrapped in the end arteries and capillaries of the metaphyseal
area (epiphyseal plate)
Bacterial emboli causes inflammation, microthrombi formation, ischaemia,
bacterial proliferation & necrosis :
Hyperaemia, migration of leucocytes & pus formation
Purulent material travels under pressure in plane of least resistance
Reaches the outer cortex and elevates the periosteum
This compromise cortical blood supply Leads to sequestrum formation
23. SYMPTOMS
Temperature >102ºF long-lasting pain, Decreased range of motion in the case of joint
involvement. local warmth, tenderness, swelling .
CLINICAL FINDINGS
Within three to seven days- :
Interposed translucent fat planes within muscle are obliterated
by edema fluid.
Periosteal elevation or thickening may represent new bone
formation, pus, or reactive edema from adjacent soft tissue infection .
24. DIAGNOSIS
Aspiration of pus and send for culture W.B.C. CRP and ESR
Blood for culture Plain films, bone scintigram, ultrasound,
CT Scan and MRI Even a biopsy all show positive results
Elevations in the peripheral white blood cell count (WBC),
Erythrocyte sedimentation rate (ESR), and C-reactive
protein (CRP) in children with hematogenous
osteomyelitis are variable and nonspecific Blood culture is
positive in half of cases.
Laboratory findings: Lytic and sclerosis, indicating chronic
infection. Periosteal new bone formation, with compatible
25. CLINICAL FINDINGS
Within three to seven days- :
Interposed translucent fat planes within muscle are
obliterated by edema fluid.
Periosteal elevation or thickening may represent new bone
formation, pus, or reactive edema from adjacent soft tissue
infection .
26. In acute osteomyelitis-
principle of treatment are-
General supportive treatment Analgesic for relieve pain I/V
fluid(fever with shock, septicaemia)
Spintage of the affected part
Antibiotics(oral/intravenous)-It should be started
immediately not waiting for culture of blood and pus
management.
Drainage-if necesssary
27. Management and Treatment Of
Acute Osteomyelitis:
Acute osteomyelitis is an orthopaedic emergency which needs in
patient admission. The management can be discussed as general and
local
GENERAL MANAGEMENT
• Conservative management is mainstay of treatment. The mneomics
RESTS sums up the conservative line of treatment
• Rest in bed, protect affected part with splints to alleviate pain and
spasm.
• Elevation-of part ,warm and moist packs to reduce swelling.
• Systemic treatment-blood transfusion, iv fluid to correct shock and
hypovolaemia.
• Treatment-with antibiotics to reduce toxicity . Antibiotics given are
penicillins, ciprofloxacin etc.
Surgery
28. LOCAL MANAGEMENT
Focus here is on well timed surgery if one of
following indication are present
•Abscess formation
•Severely ill
•Failure to respond to intravenous antibiotics for
more than 48 hrs.
• Exact treatment varies according to the bones
involved, the severity of the infection and the
immune status of the patient.
29. During acute osteomyelitis following measures are suggested
•Proper splinting of affecting joints in functional positions.
•Limb elevation to control oedema.
•Cryotherapy in initial stages followed by thermotherapy in later
stages .These measure help to reduce pain and spasm.
•Unaffected joints put in active vigorous exercises
•After complete cessation of pain, mild isometrics exercise are
prescribed for affected joints.
•Mobilise joint and strengthen the muscles like active assisted ,
active and resisted exercise after disease is completely arrested.
•Ambulation and weight transfer done slowly commenced
initially with help of assistive advice.
PHYSIOTHERAPY MANAGEMENT
30. SUB-ACUTE OSTEOMYELITIS
Is caused by staphylococcus aureus.
Patient complaint of pain without constitutional
symptoms.
Temperature may be increased or normal.
It is not detected until at least two weeks has elapsed.
Blood culture is positive in 60% of cases
WBC and ESR raised in 50 % of cases
CAUSES
Increased host resistances
Lowered bacterial resistances
If Anti-biotics are administrated before symptom appear.
31. A Brodie abscess
is a subacute osteomyelitis with a predilection for the
ends of long bones and the carpus and tarsus. Plain
radiographic findings include the following:
(1) a central area of radiolucency with a surrounding
thick rim of reactive bone sclerosis, which may
persist for months;
(2) pathognomonic tortuous parallel lucent channels
extending toward the growth plate;
(3) a variable degree of periosteal new-bone formation;
and
(4) associated soft-tissue swelling.
32. A Brodie abscess is characterized
by a double line at the site of the
lesion due to the high signal
intensity of granulation tissue
surrounded by low signal
intensity of bone sclerosis on T2-
weighted MRIs. The lesion has
low-to-intermediate signal
intensity that is outlined by a
hypointense rim on T1-weighted
MRIs.
Treatment of Brodie’s
abscess in the
metaphysis includes
surgical curettage
33. CLINICAL FEATURES
pain, limp
swelling occasionally
local tenderness
INVESTIGATION
X ray
Bone scan
Biopsy(50%) grow organism
TREATEMENT
Antibiotics given for 6 month
Surgery
35. Chronic osteomyelitis
Is a severe, persistent, and sometimes incapacitating
infection of bone and bone marrow. It is often a
recurring condition because it is difficult to treat
definitively. May arise as a result of an
inappropriately treated acute trauma, soft tissue
spread in the immunosuppressed patient,
diabetics, and i.v drug abusers.
36. This disease may result from
(1) inadequately treated acute OSM (2) a
hematogenous type of osteomyelitis; (3)
trauma, (4) iatrogenic causes such as joint
replacements and the internal fixation of
fractures; (5) compound fractures; (6)
infection with organisms, such as
Mycobacterium tuberculosis and Treponema
species (syphilis); and (7) contiguous spread
from soft tissues, as in diabetic ulcers or
ulcers in peripheral vascular disease
37. Clinical presentation
chronic forms of osteomyelitis usually occur in adults.
Generally, these bone infections are secondary to an open
wound, most often an open injury to bone and
surrounding soft tissue. Localized bone pain, erythema
and drainage around the affected area are frequently
present. The cardinal signs of subacute and chronic
osteomyelitis include draining sinus tracts, deformity ,
shortening or lengthning of bones and local signs of
impaired vascularity, range of motion and neurologic
status. The incidence of deep musculoskeletal infection
from open fractures has been reported to be as high as 23
percent.6 Patient factors, such as altered neutrophil
defense, humoral immunity and cell-mediated
immunity, can increase the risk of osteomyelitis
38. Other forms of chronic osteomyelitis
Tuberculous osteomyelitis of the bone is
secondary spread from a primary source in
the lung or GI tract. It most commonly
occurs in the vertebrae (body) and long
bones. Once established, the bacilli provoke
a chronic inflammatory reaction. Small
patches of caseous necrosis occur, and these
coalesce to form larger abscesses. The
infection spreads across the epiphysis into
the joints. The infection may track along soft
tissue to appear as a cold abscess
39. TUBERCULOUS
OSTEOMYELITIS
It is rare in the developed country and common in the
developing and underdeveloped countries of world.
This disease effect the adolescent and young adult more
often Most frequently involved are spine and bones of
extremities.
Tuberculosis lesion appear as the focus of bone destruction .
Tuberculosis of spine,potts disease often commences in
vertebral body may be aasociated with compression fracture
and destruction of intervertebral discs producing permanent
damage and paraplegia.
Extension of caseous material along with pus from the
lumbar vertebrae to the sheaths of psoas muscle produce
psoas abscess or lumbar cold abscess .This abscess when
burst out they form sinus.
Tuberculosis of spine,Pott’s disease often commense in
vertebral body and may be associated with compression
fracture and destruction of the intervertebral discs,produce
permanent damage and paraplegia.
Extension of caseous material alongwith pus from the
lumbar vertebrae to sheath of psoas muscle produce psoas
abscess or lumbar cold abscess,this abscess may burst
through skin and form sinus.Long standing cases may
develop systemic amyloidesis.
42. Management of
chronic
osteomyelitis
g
GOAL
Eradication of the infection by achieving a
viable and vascular envoirnment This can
be done by radical debridement by way of
sequestrectomy and resection of scarred
and infected bone and soft tissue.
Appropriate antibiotic required.
Reconstruction of both bone and soft
tissue defect may be needed
Principal of treatment
Surgery to be undertaken only when fever
and infection has subsided,when living
bone is distinguished from the dead bone .
When surgery is indicated ,culture is done
and antibiotics is started at least four days
before surgery and is continued for two
weeks.
Surgery method include Sequestrectomy
and saucerisation.Other methods of
treatment are Open Grafting,hyperbaric
oxygen therapy,closed suction
drainage,amputation is done in very rare
cases.
43. PHYSIOTHERAPY MANAGEMENT
Measure for chronic osteomyelitis
Here disease has run its course and left back various sequlae like
limb length discrepancies
deformities,scarring etc.Efforts are made to combat these problem
Limb length discrepancies-corrected by shoe raise and other
method
Deformities-Corrected by various orthotic devices
For scar,contractures etc,sustained passive streching of scarred
and contracted tissue.
Deep ultrasonic massage for adherant scars.
Strengthening isometrics and isokinetic exercises for the
muscles
Range of motion exercises like active and passive ones for
affected and non-affected joints
Assistive devices used for ambulation,weight transfers.
44. Manifestations of Osteomyelitis
Cardiovascular effects
Tachycardia
GI effects
Nausea and vomiting
Anorexia
MS effects
Limp in involved extremity
Localized tenderness
Integumentary effects
Drainage and ulceration at involved site
Swelling, erythema, and warmth at involved site Lymph node
involvement
Other effects
High temperature with chills
Abrupt onset of pain
Malaise
45. COMPLICATIONS
Osteomyelitis may result in following complications
Septicemia
Acute bacterial arthritis
Pathologic fractures
Development of squamous cell carcinoma in
longstanding cases
Secondary amyloidosis in long standing cases
Vertebral osteomyelitis may cause vertebral
collapse with paravertebral abscess,cord
Compression and neurological deficits.