1) Osteomyelitis is an infection of bone tissue that can be acute or chronic. Acute osteomyelitis is commonly caused by Staphylococcus aureus and presents with pain, swelling, and fever. 2) If not treated adequately within 48 hours, surgical drainage and antibiotics are needed. Chronic osteomyelitis can develop if treatment is delayed and causes long-term bone changes seen on x-ray like sequestra and involucrum. 3) Specific types include Brodie's abscess, where infection is contained in the bone, and Garre's osteomyelitis, which is nonsuppurative. Surgical debridement is usually needed to treat chronic cases.

1. OSTEOMYLITIS
BY- DR. ALOK VERMA

2. Defination
 Inflammation of bone tissue or/& bone marrow
due to pyogenic infection.

3. CLINICAL PRESENTATION
 ACUTE
 CHRONIC

4. ACUTE
Can be primary (Hematogenous) or
secondary (following an open fracture or
operation).
Hematogenous is commonest and often seen in
children.

5. AETIOLOGY
 Mainly two cause
 1 – Low Immunity of individual.
 2 – High virulence of causative organism.

6. CAUSETIVE ORGANISM
Age group Most common organisms
 Newborns (younger than 4 mo) ----- S. aureus, Enterobacter
species, and group A and B Streptococcus species.
 Children (aged 4 mo to 4 y) ---------- S. aureus, group A
Streptococcus species, Haemophilus influenzae, and
Enterobacter species.
 Children, adolescents (aged 4 y to adult) -------- S. aureus
(80%), group A Streptococcus species, H. influenzae, and
Enterobacter species.
 Adult --------S. aureus and occasionally Enterobacter or
Streptococcus species.
 Sickle Cell Anemia Patients ---------------Salmonella species.

7. COMMON SITE
 METAPHYSIS OF LOWER END FEMUR ,
UPPER END OF TEBIA , UPPER FEMUR ,
UPPER HEUMERUS.
 IN SOME JOINT METAPHYSIS IS
INTRACAPSULAR LEADS PYOGENIC
ARTHRITIS.

8. ANATOMY OF BONE

9. PATHOGENESIS
HOST INFLAMMATORY RESPONSE TO BACTERIA
LEADS DESTRUCTION OF BONE TISSUE FOLLOWED BY
FORMATION OF EXUDATION AND PUS CELLS
ONCE SUFFICIENT AMOUNT OF PUS IS FORM IT SPREAD IN
FOLLOWING DIRECTION
MEDULLARY CAVITY OUT OF CORTEX JOINT
CAPSULE

10. TOWARDS MEDULLARY CAVITY
 THROMBOSIS OF VEIN AND ARTERIES
 CUT OFF BLOOD SUPPLY OF PERTICULAR
THAT SEGMENT

11. TOWARDS CORTEX
 PUS GOES TO SUBPERIOSTEAL SPACE
 LIFTING OF PERIOSTIUM LEADING TO
DAMAGE THE BLOOD SUPPLY OF THAT
PERTICULAR PART
 THAT SEGMENT RENDERED AVASCULAR
K/A SEQUESTRUM

12. TOWARDS CORTEX…………..
 PERIOSTIUM GENRATES NEW BONE
SUBPERIOSTIALY (INVOLUCRUM)
 PERIOSTIUM PERFORATES AND PUS
COME INTO SUBCUTANEOUS PLANE ,AS
ABSCESS
 BURSTING OF ABSCESS ,LEADING
DISCHARGING SINUS.

13. TOWADRS EPIPHYSEAL
PLATE
 RESISTENT TO PUS
 LATER ON MAY CAUSE PYOGENIC
ARTHRITIS.

16. CLINICAL FEATURE
 IN CASE OF PRIMARY O.M. CHILDREN OR
ADOLESCENTS ARE USUALLY VICTIM
 HISTORY OF TRAUMA MAY OR MAY NOT
BE FOUND.
 SIGN OF INFLAMMATION AS PAIN ,
SWELLING, REDNESS,WARMNESS WILL
BE PRESENTS.
 AFFECTED REGION IS TENDER.
 SIGN OF TOXAEMIA AS CHILD BECOMES
FEBRIL ALONG WITH RIGORS ,CHILLS,
HEADACHE , BACKACHE.

17. ON PALPATION
 IF MAXIMUM TENDERNESS IS OVER THE
METAPHYSIS OF LONG BONE THEN
DIAGNOSIS IS O.M.
 IF MAXIMUM TENDERNESS IS OVER JOINT
LINE THEN DIAGNOSIS IS SUPPURATIVE
ARTHRITIS.
 THERE MAY BE SOME EFFUSION IN
ADJACSENT JOINT.
 WHEN ABSCESS IS BURST INTO
SUBCUTANEOUS TISSUE FLCTUAT
ABSCESS MAY BE PALPATED.

18.  PATIENT MAY NOT PERMIT MOVENENT OF
NEARBY JOINT.
 ONLY WHEN METAPHYSIS IS
INTRACAPSULAR ACUTE OM MAY TURN
INTO ACUTE SUPPURATIVE ARTHRITIS.

20. INVESTIGATION
1- BLOOD EXAMINATION WITH CULTURE
(REVEALS LEUCOCYTOSIS AND RAISED
ESR AND CAUSETIVE ORGANISM).
2-ASPIRATION OF PUS WITH THICK
NEEDLE TO CONFERM PRESESNCE OF
PUS WITHIN BONE.

21. X-RAY
 NO ROLE IN FIRST FEW DAYS
 PATCHY RAREFRACTION AT SITE ON 10TH
DAY DUE TO HYPARAEMIA AND LATER
NEW BONE FORMATION BY PERIOSTIUM.
 SOMETIME SMALL SEQUESTRUM MAY BE
SEEN.

25. DIFFRENTIAL DIAGNOSIS
 1 Acute septic arthritis.
 2 Acute rheumatic arthritis.
 3 Scurvy
 4 Acute poliomyelitis

26. Acute septic arthritis.
 Tenderness and swelling localized to joint
rather than metaphysis
 Movement of joint is restricted and painful.
 In case of doubt joint fluid may e aspirated, but
under full antiseptic condition.

28. Acute rheumatic arthritis.
 Most feature are similar to ASA but fleeting
character of joint pain, elevated ASLO titre and
CRP values , positive RA factor may help in
diagnosis.

30. Scurvy
 There is formation of subperiosteal
heamatoma in scurvy also.
 Absence of fever , tenderness and pain along
with other feature of malnutrition may help in
diagnosis.

33. Acute poliomyelitis
Fever may be present.
Tenderness is present in muscles not in bone.

34. TREATMENT
 EARLY, ADEQUATE TREATMENT IS THE
KEY OF SUCCESS IN ACUTE OM
CASES CAN BE DEVIDED IN TWO GROUPS
1. CHILD BROUGHT WITHIN 48 HRS.
2. CHILD BROUGHT AFTER 48 HRS.

35. CHILD BROUGHT WITHIN 48
HRS.
 REST
 IMPROOVE GC OF PATIENT
 AQEQUATE ANTIBIOTICS
 PROPER REHYDRATION OF PATIENT BY IV
FLUIDS
 IF CHILD RESPOND TO TREATMENT AND
AREA OF TENDERNESS IS REDUCED LIMB
MAY BE PUT TO USE.
 IF CHILD DOSEN’T RESPOND TO TREATMENT
WITHIN 48 HRS , SURGICAL INTERVENTION
MAY BE RUQUIRED.

36. CHILD BROUGHT AFTER 48
HRS.
 SURGICAL EXPLORATION AND DRAINAGE
IS THE MAINSTAY OF TEATMENT.
 A DRILL HOLE IS MADE IN THE REGION OF
METAPHYSIS AREA.
 A SWAB OF PUS IS TAKEN FOR CULTURE
AND SENSTIVITY.
 WOUND IS CLOSED OVER STERLISE
SUCTION DRAIN.
 REST ANTIBIOTICS AND HYDRATION IS
CONTINUED POSTOPRATIVLY.

40. COMPLICATION
 GENERAL
 LOCAL

41. GENERAL COMPLICATION
 SEPTICAEMIA
 PYAEMIA
 EITHER COMPLICATION IF LEFT
UNCONTROLLED MAY BECOME FATAL.

42. LOCAL COMPLICATION
 1 CHRONIC OSTEOMYELITIS
 2 ACUTE PYOGENIC ARHRITIS
 3 PATHOLOGICAL FRACTURE
 4 GROWTH PLATE DISTURBENCES

43. CHRONIC OSTEOMYELITIS
1- Chronic osteomyelitis secondary to acute
osteomyelitis( most common)
2- Garre’s osteomyelitis.
3- Brodie’s abscess

44. PATHOLOGY
 Acute changes into chronic due to one or more
following reason-
 1 Delayed and inadequate treatment.
 2 Type and virulence of organism.
 3 Reduced host resistence.

45. Conti….
In response to persistence infection bone genrating
more and more sub-periosteal new bone.
This deposition is in very irregular fashion so that
osteomyelitic bone has very irregular surface.
Continuous discharging sinus get fibrosed and become
fixed to bone.
This all leading big sequestrum , involucrum and big size
cloacae

46. DIAGNOSIS
 Diagnosis suspected clinically but can be
confirmed radiologically
 Clinical examination is most important—
 1 Chronic discharging sinus
 2 Thickened irregular bone
 3 Tenderness on deep palpation
 4 Adjacent joint may be stiff

47. INVESTIGATION
 A-X-RAY
 Reavels
 1- Thickening and irregularity of bone cortices.
 2- Patchy sclerosis gives honey comb
appearences.
 3- Bone cavity shows area of rarefaction
sarrounded by sclerosis
 4- Sequestrum ( appears denser than
sarrounding bone)
 5 –Involucrum and cloaca may be visible.

48. BLOOD EXAMINATON
ESR may be raised other no significant changes
seen usualy
PUS CULTURE
May grow causative organism.

49. DIFFRENTIAL DIAGNOSIS
 1- TUBERCULAR OSTEOMYELITIS
 2- SOFT TISSUE INFECTION
 3- EVEING SARCOMA

50. TREATMENT
 Primarily surgical ,antbiotics may be used in
acute excerbation and in postoprative period.
 Aim of surgery is-
 1- Removal of dead bone
 2- Elimination of dead space
 3- Removal of infected granulaton tissue and
sinus.

51. SURGICAL PROCEDURE
 A-SEQUESTRECTOMY
 B- SAUCERIZATION
 C- CURETTAGE
 D- EXCISION OF INFECTED BONE
 E- AMPUTATION
 Most of cases combination of procedure may
be required.

52. COMPLICATIONS
 An acute excerbation
 Growth abnormality
 Pathological fracture
 Joint stiffness
 Sinus tract malignancy
 Amyloidosis

53. GARRE’S OM
 Sclerosing , Nonsuppurative chronic
osteomylitis
 May begins with Acute local pain ,pyrexia, and
swelling . There is tenderness on deep
palpation.
 There is no discharging sinus.
 Shaft of femur and tebia are commonly
involved
 Importance lies in diffrentiating it from bone
tumor.

54. BRODIE’S ABSCESS
 This is a special type of O.M. in which body’s
defence mechanism has been able to contain
the infection so as to create a chronic bone
abscess containing pus or jelly like granulation
tissue , sarrounded by zone of sclerosis.

55. CLINICAL FEATURE
 Patient are usually b/w 11- 20 yr. of age.
 Commonest site are usually upper end of tibia
and lower end of femur , located of
metaphysis.
 The deep boring pain is predominant symptom
that become worse at night.
 On examination tenderness and thickening of
bone along with transient effusion in adjacent
joint may be present.

56. DIAGNOSIS
 Radiological feature
is diagnostic.
 X-ray shows circular
or oval lucent area
sarrounded by zone
of sclerosis. Rest of
bone is normal.

58. TREATMENT
Surgical evacuation and curattage is performed
under good antibiotic cover.
If cavity is very large cancellous bone chips may
be packed.