Acute Osteomyelitis. Infection in bone Osteomyelitis l acute (subacute) l chronic l specific (eg TB) l non specific(most common)

Acute Osteomyelitis

Infection in bone

Osteomyelitis

acute (subacute) chronic

specific (eg TB) non specific(most common)

Acute haematogenous OM

mostly children

boys> girls

history of trauma

Acute OsteomyelitisOrganism

Gram +ve staphylococus aureus strep pyogen strep pneumonie

Gram -ve haemophilus influnzae (50% < 4 y) e .coli pseudomonas auroginosa, proteus mirabilis

Acute Osteomyelitis Source Of Infection

infected umbilical cord in infants

boils, tonsilitis, skin abrasions

in adults UTI, in dwelling arterial line

Acute OsteomyelitisAcute Osteomyelitis

Source of Infection:

Hematogenous Direct spread Exogenous

Acute Osteomyelitis Pathology

starts at metaphysis ?trauma vascular stasis acute inflammation suppuration necrosis new bone formation resolution

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Pathology:

Primary focus and stage of inflammation

Spread of infection with pus formation

Formation of subperiosteal abscess

Pus tracks toward skin to form a sinus

Bone infarction (Sequestrum)

New bone formation (involucrum)

Acute Osteomyelitis

Acute Osteomyelitis

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Age variation

Neonates:

Extensive bone necrosis

Increased ability to absorb large

sequestrum

Increased ability to remodel

Epiphysio-metaphyseal vascular connection

leading to secondary septic arthritis

Acute Osteomyelitis Clinical Features

severe pain reluctant to move fever malaise toxemia

Acute OsteomyelitisAcute Osteomyelitis

Clinical PicturesHistory:

Skin lesion

Sore throat

Trauma

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Clinical PicturesSymptoms:Pain, restlessMalaise and fever The limb is held

still (pseudo paralysis)

Sometimes mild or absent (neonates)

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Clinical PicturesSigns:

General and LocalLaboratory Tests:

CBC ESR+CRP Blood culture (+ve in 50-70%) Aspiration (Gram stain + culture and

sensitivity)

Acute Osteomyelitis Infant

failure to thrive drowsy irritable metaphyseal tenderness decrease ROM commonest around the knee

Acute Pyogenic OsteomyelitisAcute Pyogenic Osteomyelitis

Age variation

Adults:

No subperiosteal abscess due to

adherent periosteum

Soft tissue abscess

Vascular connection with the joint

leading to secondary septic arthritis

Acute OsteomyelitisAdult

commonly thoracolumbar spine fever backache history of UTI or urological procedure old ,diabetic ,immunocompromised

Acute Osteomyelitis Diagnosis

History and clinical examination FBC, ESR, B.C. X-ray (normal in the first (10-14) days Ultrasound Bone Scan Tc 99, Gallium 67 MRI Aspiration

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RadiographyPlain X-ray

Ultrasound

Bone & gallium scan (Sensitive but not specific)

CT scan

MRI

Acute Osteomyelitis

Acute OsteomyelitisAcute Osteomyelitis

Differential DiagnosisAcute Septic ArthritisAcute monoarticular

rheumatoid arthritis Sickle cell crisisCellulitisEwing’s Sarcoma

Acute OsteomyelitisAcute Osteomyelitis

Treatment Antibiotics:

Type?Route?When to start?When to stopMonitoring?

Acute OsteomyelitisAcute Osteomyelitis

Treatment

Surgical Drainage:Indications?

Procedure?

Drilling?

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Treatment General:HospitalizationHydrationElectrolyte replacementAnalgesiaImmobilization

Acute Osteomyelitis Treatment

supportive treatment for pain and dehydration

splintage antibiotics surgery

Acute OsteomyelitisTreatment

Antibiotics: Start blindly after taking blood culture.

Older child & previously fit adults.(staph inf): I/V flucloxacillin and fusidic acid. 2-3 wks. Then orally 3-6 wks.

Child under 4 (haemophilus inf.): Cefuroxime or cefotaxime or co-amoxiclav.

Immunocompromised pts: Third generation cephalosporins.

Acute OsteomyelitisTreatment

Neonates and infants up to 6 months of age :penicillin-resistant Staphylococcus aureus, Group B streptococcus and Gram-negative organisms.

flucloxacillin plus a third-generation cephalosporin like cefotaxime.

Children 6 months to 6 years of age :Haemophilus influenzae. combination of intravenous flucloxacillin and cefotaxime or cefuroxime.

Acute OsteomyelitisTreatment

Elderly and previously unfit patients, Gram-negative infections, combination of flucloxacillin and a second- or third-generation cephalosporin.

Heroin addicts and immunocompromised patients

Unusual infections (e.g. with Pseudomonas aeruginosa,

Proteus mirabilis or anaerobic Bacteroides species)

third-generation cephalosporins or a fluoroquinolone

preparation, depending on the results of sensitivity tests.

Acute OsteomyelitisTreatment

Drainage:1. CF do not improve within 36 Hrs.2. Signs of deep pus.( swelling,

oedema, fluctuation).3. If pus is aspirated.

Acute Osteomyelitis Complications

septicemia metastatic infection septic arthritis altered bone growth chronic osteomyelitis

Acute OsteomyelitisAcute Osteomyelitis

PrognosisFactors affecting

prognosis:Organisms Infected Bone Age of the PatientTreatment

Subacute OsteomyelitisClinical features

long history (weeks, months)

pain, limp

swelling occasionally

local tenderness

Subacute OsteomyelitisPathology

Brodies abscess

a well defined cavity in cancellous bone

Subacute OsteomyelitisInvestigation

X ray

Bone scan

Biopsy(50%) grow organism

Subacute OsteomyelitisTreatment

antibiotics for 6 months

surgery