CONTENTS
Bone & Joint Infections
Dr. CS Kumar
Senior Lecturer/Orthopaedic Surgeon
Head of Orthopaedic Trauma Unit
University Malaya Medical Centre
29th April 2014
Osteomyelitis
 The term osteomyelitis does not
specify the causative organism or
the disease process
 Definition
 Acute Pyogenic Osteomyelitis
 Sub-acute Osteomyelitis
 Chronic Osteomyelitis
 Septic Arthritis
Osteomyelitis
Classification:
 Duration Acute, Subacute or Chronic
 Route of infection Hematogenous or Exogenous
 Host response Pyogenic or Granulomatous
 Acute Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis

Definition:
Incidence:
 AO is an infection of bone
 Age more in children
involving the periosteum,  Sex boys > girls
cortical bone and the  Bone affected all bones
medullary cavity.  Site of infection metaphysis

Acute Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis

Organism: Source of Infection:

 Neonates:  Hematogenous
Staph aureus, Strept, E coli
 Children:  Direct spread
Staph aureus, E coli, Serriata, Pseudomonas, H inf
 Sickle-cell anemia:  Exogenous
Staph aureus, Salmonella
 Acute Pyogenic Osteomyelitis

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 Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis
Age variation Age variation
Neonates: Adults:
 Extensive bone necrosis  No subperiosteal abscess due to adherent

 Increased ability to absorb large sequestrum periosteum

 Increased ability to remodel  Soft tissue abscess

 Epiphysio-metaphyseal vascular connection  Vascular connection with the joint leading to

leading to secondary septic arthritis secondary septic arthritis

Acute Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis

Clinical Pictures Clinical Pictures

History: Symptoms:
 Pain, restless
Skin lesion  Malaise and fever
 The limb is held still
Sore throat (pseudo paralysis)
 Sometimes mild or
Trauma
absent (neonates)
 Acute Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis
Clinical Pictures
Radiography
Signs:
 Plain X-ray
General and Local
 Ultrasound
Laboratory Tests:
– CBC  Bone & gallium scan (Sensitive but not specific)
– ESR+CRP  CT scan
– Blood culture (+ve in 50-70%)  MRI
– Aspiration (Gram stain + culture and sensitivity)
Acute Pyogenic Osteomyelitis
Differential Diagnosis
 Acute Septic Arthritis
 Acute monoarticular
rheumatoid arthritis
 Sickle cell crisis
 Cellulitis
 Ewing’s Sarcoma
Acute Pyogenic Osteomyelitis
Treatment
General:
 Hospitalization
 Hydration
 Electrolyte replacement
 Analgesia
 Immobilization
 Acute Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis

Treatment Treatment
Antibiotics: Surgical Drainage:
 Type?
 Indications?
 Route?
 Procedure?
 When to start?
 Drilling?
 When to stop
 Monitoring?

Acute Pyogenic Osteomyelitis Acute Pyogenic Osteomyelitis

Prognosis Complications
Factors affecting prognosis:  Septicemia & metastatic abscesses
 Organisms  Septic arthritis
 Infected Bone  Growth disturbance (children)
 Age of the Patient  Pathological fracture
 Treatment
 Chronic osteomyelitis
Subacute Osteomyelitis Subacute Osteomyelitis

 Longer history and less virulent organism  Abnormal initial radiographs

 Insidious onset, Mild symptoms  Inconclusive laboratory data

 Negative cultures/ biopsy

 Pain is the most consistent symptom
 Difficult to distinguish from bone tumors
 Usually no constitutional symptoms
e.g. Ewing’s, osteosarcoma
 Chronic Osteomyelitis Chronic Osteomyelitis

Factors responsible for chronicity

 Local factors: Cavity, Sequestrum, Sinus, Types
Foreign body, Degree of bone necrosis  A complication of acute Osteomyelitis
 General: Nutritional status of the involved
tissues, vascular disease, DM, low immunity  Post traumatic
 Organism: Virulence
 Treatment: Appropriateness and compliance  Post operative
 Risk factors: Penetrating trauma, prosthesis,
Animal bite
 Chronic Osteomyelitis

Clinical picture
 Continuous or intermittent suppuration and sinus
formation with acute exacerbations.
 Pain, fever, redness, and tenderness during
acute exacerbations.
 Discharging sinus with +ve/-ve culture.
 Pathological fracture.

Chronic Osteomyelitis
Investigation
 Lab tests/ culture
 Plain X-ray:
Bone rarefaction surrounded by the dense
sclerosis, sequestration and cavity formation
 Sinogram
 Bone scan & gallium scan
To detect chronic multifocal osteomyelitis
 CT Scan & MRI
 Biopsy
 Chronic Osteomyelitis
Treatment
 Antibiotics
 Surgical treatment
Preoperative assessment & preparation
Derbridement
Sequestrectomy
Local antibiotics
Stability
Treatment of bone cavity

Chronic Osteomyelitis

Complications
 Recurrence & Recurrence & Recurrence
 Pathological fractures
 Growth disturbance
 Amyloid disease
 Epidermoid carcinoma of the fistula

Acute Septic Arthritis
 Organism?
 Route of infection?
 Pathology:
Serous or acute synovitis
Serofibrinous
Suppurative (purulent) arthritis
Septic Arthritis
 Septic arthritis is an infection of the joint
usually bacterial, as viral arthritis is
usually self limiting and treatment is
supportive.
 50% of cases in children <3 years
 The hip joint is the common site in
<3years, whereas the knee joint is more
common in older children.
Acute Septic Arthritis
Clinical Pictures
 General manifestations:
constitutional symptoms and signs of acute
infection
 Local manifestation:
Swelling, hotness and redness
Deformity with muscle spasm
Restriction of all movements of the joint
The joint is fixed in the position of ease
Acute Septic Arthritis Acute Septic Arthritis
Investigations Differential Diagnosis
 Lab tests/ cultures
 Acute osteomyelitis
 Plain X-ray
 Bone scan & Gallium scan  Transient synovitis of the hip (<10)
 Ultrasound  Acute rheumatic fever
 Aspiration: if WBC >50,000with >90% PMNLs
 Haemoarthrosis
suspect septic arthritis even if culture is
negative.  Haemophilic arthritis

Acute Septic Arthritis

Treatment
 Aspiration

 Antibiotics

 Splintage

 Surgical drainage

 Treatment of complications
THANK YOU!