ORTHO Osteomyelitis

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Osteomyelitis
Department of Orthopaedics
Learning objectives
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• Definition
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• Aetiology
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• Pathogenesis
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• Clinical picture
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• Investigations
• Differential diagnosis
• Treatment
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Definition
• Inflammation of bone
• Osteo= bone ,myelitis = inflammation of marrow
• Rapid destructive pyogenic infection
• Most frequently in infants and children
Aetiology
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• Bacterial infection but at times can be fungal infection

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• Causes can be –
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1. Diabetes
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2. Intravenous drug use

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3. Trauma to the part

4. Immunocompromised status of the host.
5. Poor nutrition ,unhygienic surroundings
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Aetiology
• Sex: Male /female -4:1

• Location :metaphysis of long bone
due to rich blood supply to that
area
• Hairpin bent of the metaphyseal
vessels
• Metaphyseal hemorrhage
• Defective phagocytosis
• Vasospasm of the end arteries
preventing the antibiotics to reach
there.
Micro-organism
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• In Infants : Staphylococcus aureus ,S. agalactiae and E.coli

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• In children >1 yr. : Staphylococcal Aureus , Streptococcus pyogenes ,H.

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influenzae
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• In adults : S.aureus and streptococcus species

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• In patients of sickle cell anemia – salmonella species
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CLASSIFICATION
• According to duration of symptoms
▪ Acute (<2 weeks)
▪ Subacute (2-3 weeks)
▪ Chronic (>3 weeks)
Pathophysiology
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Mechanism of spread :
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• Hematogenous – MC aetiology in children

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• Contiguous spread –associated with previous surgery ,trauma,

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cellulitis
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• Direct inoculation –in penetrating injuries ,open injuries, orthopaedic

surgeries like joint replacement and fixation of fractures.
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• Preexisting focus / Exogenous Infection

• Infective embolus enters nutrient artery
• Trapped in a vessel of small Caliber(metaphysis)
• Blocks the vessel
• Active hyperemia + PMN cells exudate
• In order to engulf the bacteria they release
enzymes and lyse the bone around.
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• Hyperemia and immobilization causes decalcification.

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• Proteolytic enzymes destroy bacteria and medullary

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elements.
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• The debris increase and intramedullary pressure

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increases.
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Cont.
• Enter subperiosteal space.
• Strips periosteum.
• Perforation of periosteum / reach joint by piercing capsule.
• Enters soft tissue and may drain out
Clinical presentation
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• Severe pain ,malaise ,fever

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• Recent history of infection

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• Child looks ill and feverish

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• temperature raised
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• Limb held still and acute tenderness present over the involved limb
• Manipulation of limb painful :pseudo paralysis
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• Infants:
➢Failure to thrive and drowsy
➢h/o birth difficulties ,umblical
artery catherization or site of
infection
Laboratory investigations
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• Elevations in the peripheral white blood cell count (WBC),

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• Erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)

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• Blood culture is positive in half of cases.

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Radiological findings
• Negative for 1st week or 10 days
• Localised area of bone destruction
• Periosteal shadow is elevated
• multiple lamination of bone deposition
• Periosteal new bone formation is seen after 2
weeks.
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• Ultrasonography – juxtacortical soft tissue swelling with periosteal

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thickening
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• Radionuclide scanning – sensitive but not specific

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increased uptake
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• Magnetic resonance imaging – hypointense on T1 weighted image

hyperintense on T2
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Differential diagnosis
• Rheumatic fever : Onset -more gradual,
pain and tenderness less intense.
polyarticular.
Response to salicylates
• Acute suppurative arthritis : Pain and tenderness limited to the joint,
joint movements -restricted
aspiration reveals purulent synovial fluid.
• Ewing’s sarcoma : biopsy demonstrates tumor cells
Treatment
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• General management-
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➢ Rest in bed
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➢ Elevation of the part

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➢ Systematic treatment- IV fluids, correct shock
➢ Treatment with antibiotics
➢ Surgery
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Principles of antibiotic therapy

• Appropriate drug
• Appropriate route
• Appropriate dose
• Appropriate time to stop
• Appropriate adjunctive measures.
Treatment
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• Local management
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Well timed surgery

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Nade’s indication for surgery-

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• Abscess formation
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• Severely ill and moribund child.

• Failure to respond to intravenous antibiotics for more than 48 hours.
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Surgical methods
• Aspiration
• Incision and drainage
• Multiple drill holes
• Small bone window

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• Bone abscess
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• Septic Arthritis
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• Septicemia
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• Fracture
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• Growth arrest
• Overlying soft-tissue cellulitis
• Chronic infection
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Subacute osteomyelitis
• insidious onset, mild symptoms, lack of systemic reaction
• Its relative mildness is due to:
Organism being less virulent OR
Patient more resistant OR
(Both)
• Most common site: Distal femur, Proximal & Distal Tibia
Causative organism
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• Staphyloccocus aureus (30-60%)

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• Others (Streptococcus, Pseudomonas, Haemophilus influenzae)

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• Pseudomonas aeruginosa (IV drug user)

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• Salmonella (patient with sickle cell anemia)

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Radiographic findings
Brodie’s abscess
- circumscribed, round/oval cavity containing pus and pieces of dead
bone (sequestra) surrounded by sclerosis.
• MC in tibial / femoral metaphysis.
• May occur in epiphysis / cuboidal bone (eg: calcaneum).
• Metaphyseal lesion cause no / little periosteal reaction.
• Diaphyseal lesion may be associated with periosteal new bone
formation and marked cortical thickening.
Clinical features
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• Pain (several weeks / months)

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• Limping
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• Swelling & Local tenderness

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• Muscle wasting
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• Body temperature usually normal (no fever)
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A circumscribed, oval cavity This is a lateral view X-ray of left

surrounded by a zone of tibia and fibula. There is a marked
sclerosis at the proximal periosteal reaction at the
tibia (Brodie’s abscess) diaphysis.
Investigations
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• X-ray (may resemble osteoid osteoma / malignant bone tumor)

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• Biopsy
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• Fluid aspiration & culture

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• ESR raised
• WBC count may be normal
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Treatment
Conservative :
a) Immobilization
b) Antibiotics for 6weeks
Surgical (if the diagnosis is in doubt / failed conservative treatment) :

a) Open biopsy
b) Perform curettage on the lesion
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BRODIE’S ABSCESS
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• Subacute osteomyelitis persist for many years before progressing to

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chronic osteomyelitis.
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• Classically it is abscess formation surrounded by fibrous tissue or host

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tissue.
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• Causative organism is staphylococcal aureus in most of the cases.
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Presentation
• Localized pain
• Often nocturnal
• Alleviated by aspirin.
location
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• Metaphysis of long bones

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▪ Upper end of tibia

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▪ Lower end of tibia

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▪ Lower end of femur

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▪ Lower end of fibula
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Radiographic findings
Brodie’s abscess
- circumscribed, round/oval cavity containing pus and pieces of dead
bone (sequestra) surrounded by sclerosis.
• MC in tibial / femoral metaphysis.
• May occur in epiphysis / cuboidal bone (eg: calcaneum).
• Metaphyseal lesion cause no / little periosteal reaction.
• Diaphyseal lesion may be associated with periosteal new bone
formation and marked cortical thickening.
Radiologically
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• Oval, elliptical, or serpentine radiolucency usually greater than 1 cm

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surrounded by a heavily reactive sclerosis.

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Radiologically
• lytic lesion in the distal
metaphysis with a narrow zone
of transition more caudally
• with a faint sclerotic rim and a
wide zone of transition more
cephalad.
Radiologically
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• hyper intense edema in the calf

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musculature, marrow edema,

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and sub-periosteal pus.

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Radiologically
• The thin hypointense rim
surrounding the intramedullary
collection represents the
reactive interface between the
abscess and the body's attempt
to wall it off.
Radiologically
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• post gadolinium image showing

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the extent of the multiloculated

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intramedullary abscess.
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Treatment
• In the majority of cases surgery has to be performed.
• If the cavity is small then surgical evacuation and curettage is
performed under antibiotic cover.
• If the cavity is large then the abscess space may need packing
with cancellous bone chips after evacuation.
SALMONELLA OSTEOMYELITIS
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• Seen in patient with sickle cell anemia and thalassemia.

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• Clinical features –
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▪ Several bones involved

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▪ Symmetrical involvement of bones

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▪ Severe osteomyelitis
▪ Spine may be involved
▪ Sickle cell anemia present.
▪ Stool may be positive.
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Treatment
• The most commonly used antimicrobials are
▪ chloramphenicol,
▪ third generation cephalosporin's
▪ Fluoroquinolones (ciprofloxacin)
▪ In unresponsive cases surgical resection along with prolonged antibiotic therapy needs to be
performed.
Question 1
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Chronic Osteomyelitis
• Definition:
“ A severe, persistent and incapacitating infection of bone and bone
marrow ”
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Etiological Agents
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Usual organisms (with time there is always a mixed infection)

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• Staph.aureus(commonest)
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• Strep.pyogenes
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• E.coli
• Pseudomonas
• Staph.epidermidis (commonest in surgical implant)
Clinical Features
a) Pain
b) Low grade fever
c) Mild Redness
d) Mild Tenderness
e) Discharging sinus
(seropurulent discharge)
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Pathogenesis
Inadequate treatment of acute OM /Foreign implant /
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Open fracture
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Inflammatory process continues with time

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together with persistent infection by infecting organism

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Persistent infection in the bone leads to increase in

intramedullary pressure due to inflammatory exudates
(pus)
stripping the periosteum
Pathogenesis (Contd.)
Vascular thrombosis
Bone necrosis (Sequestrum formation)
New bone formation occur (Involucrum)
Multiple openings appear in this

involucrum, through which exudates
& debris from the sequestrum pass via
the sinuses
(Sinus formation)
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Staging Of Osteomyelitis:
• The Cierny-Mader staging system.
• Determined by the status of the disease process.
• It takes into account the state of the bone,
• the patient's overall condition and factors affecting the development of
osteomyelitis.
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Cierny-Mader Classification
• 1: Medullary Osteomyelitis - Infection

confined to medullary cavity.
• 2: Superficial Osteomyelitis -
Contiguous type of infection. Confined
to surface of bone.
• 3: Localized Osteomyelitis - Full-
thickness cortical sequestration which
can easily be removed surgically.
• 4: Diffuse Osteomyelitis -Loss of
bone stability, even after surgical
debridement.
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Radiographic Findings
1) X-ray examination
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- Usually show bone resorption (patchy loss of density / osteolytic lesion)

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- Thickening & sclerosis around the bone

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- Presence of sequestra
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- Occasionaly it may present as a Brodie’s abscess surrounded by vascular tissue and

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area of sclerosis
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2) Radioisotope scintigraphy
- Sensitive but not specific
- Technetium labelled hydroxymethylene diphosphonate (99mTc-HDP) may
show increased activity in both perfusion phase and bone phase
3) CT scan & MRI

- Show the extent of bone destruction, reactive oedema, hidden abscess and
sequestra
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MRI of Osteomyelitis of metatarsal
Decreased signal in T1
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weighted images
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Appears bright in T2
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weighted images.
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Treatment -
• Antibiotics
• Host immunity
• Surgical – sequestrectomy and debridement
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Complications
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1) Pathological Fracture
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- This occurs in the bone weakened by chronic osteomyelitis

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2) Deformity
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– In children the focus of osteomyelitis destroys part of the epiphysis growth

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plate.
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3) Shortening/ lengthening
- Destruction of growth plate arrest growth.
- Stimulation of growth plate due to hyperemia.

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www.FirstRanker.com www.FirstRanker.

• Bacterial infection but at times can be fungal infection

2. Intravenous drug use

3. Trauma to the part

• Sex: Male /female -4:1

• In Infants : Staphylococcus aureus ,S. agalactiae and E.coli

• In children >1 yr. : Staphylococcal Aureus , Streptococcus pyogenes ,H.

• In adults : S.aureus and streptococcus species

• In patients of sickle cell anemia – salmonella species

• Hematogenous – MC aetiology in children

• Contiguous spread –associated with previous surgery ,trauma,

• Direct inoculation –in penetrating injuries ,open injuries, orthopaedic

• Preexisting focus / Exogenous Infection

• Hyperemia and immobilization causes decalcification.

• Proteolytic enzymes destroy bacteria and medullary

• The debris increase and intramedullary pressure

• Severe pain ,malaise ,fever

• Recent history of infection

• Child looks ill and feverish

• Elevations in the peripheral white blood cell count (WBC),

• Erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)

• Blood culture is positive in half of cases.

• Ultrasonography – juxtacortical soft tissue swelling with periosteal

• Radionuclide scanning – sensitive but not specific

• Magnetic resonance imaging – hypointense on T1 weighted image

➢ Elevation of the part

➢ Systematic treatment- IV fluids, correct shock

➢ Treatment with antibiotics

Principles of antibiotic therapy

Well timed surgery

Nade’s indication for surgery-

• Severely ill and moribund child.

• Incision and drainage

• Multiple drill holes

• Small bone window

• Staphyloccocus aureus (30-60%)

• Others (Streptococcus, Pseudomonas, Haemophilus influenzae)

• Pseudomonas aeruginosa (IV drug user)

• Salmonella (patient with sickle cell anemia)

• Pain (several weeks / months)

• Swelling & Local tenderness

• Body temperature usually normal (no fever)

A circumscribed, oval cavity This is a lateral view X-ray of left

• X-ray (may resemble osteoid osteoma / malignant bone tumor)

• Fluid aspiration & culture

Surgical (if the diagnosis is in doubt / failed conservative treatment) :

• Subacute osteomyelitis persist for many years before progressing to

• Classically it is abscess formation surrounded by fibrous tissue or host

• Causative organism is staphylococcal aureus in most of the cases.

• Metaphysis of long bones

▪ Upper end of tibia

▪ Lower end of tibia

▪ Lower end of femur

▪ Lower end of fibula

• Oval, elliptical, or serpentine radiolucency usually greater than 1 cm

surrounded by a heavily reactive sclerosis.

• hyper intense edema in the calf

musculature, marrow edema,

and sub-periosteal pus.