Acute Hematogeneous

Osteomyelitis
• Osteo -> Bone
• Myelum-> Bone marrow

• Inflammation of bone and surrounding tissue

caused by an infecting organism
• Mainly in Children
 incidence
• Boy : girl = 3:1 • In adults only 20% of
• Age 2-6 years old osteomyelitis are
• Predilection : hematogenous ->
– Femur vertebra
– Tibia
– Humerus
– Radius
– Ulna
– Fibula
 Etiology
• 90 % is Staphylococcus Aureus
• Spread by bacteraemia, port the entry :
– Secondary infected skin ( abrasions, scratches,
pimples)
– Mucous membrane of upper respiratory tract (nose
or throat infection)
• Streptococcus pyogens in chronic skin
infection
• S.pneumonia in new born babies
Other risk factors :
• Localized trauma
• Chronic illness
• Malnutrition
• Inadequate immune system
 Pathology
• Inflammation intra osseous -> early edema,
pus forms -> increase pressure (severe pain) ->
compromise local circulation -> necrosis of
bone -> sequestra
•
• The pus breakthrough cortex -> Subperiosteal
abcess -> spread subperiosteally to entire
bone or break to soft tissue -> cloacae -> sinus
(pus to the skin)
• Unhealed infected bone -> locked inside bone
-> discharged intermittently
 Clinical features
General : Localized :
• Severe pain (refuse to • Redness
touch) • Swelling
• Malaise • Warmth
• Fever • oedema
• Rest limb
• History of infection
• Pulse > 100x/min
 Imaging
Plain X-Ray
• 1st week onset : normal
xray
• 2nd week : extra cortical
outline
• Late : local osteolysis,
dense margin
Bone scan :
• Sensitive, but not specific
• Early phase
• Can differetiate soft tissue or bone

MRI :
• Especially for axial bone
 Laboratory
• The most sensitive test is pus or fluid aspiration
from localized bone/soft tissue
• Test for culture and antimicroba
• this test is + in 60% cases
• Blood culture is + in <50% cases
• C-reactive protein is elevated in 12-24 hours after
onset
• Erithrocyte Sedimentation Rate is elevated in 24-
48 hours after onset
 Differential diagnoses
• Cellulitis
• Acute suppurative arthritis
• Necrotizing myositis
• Acute rheumatism
• Sickle cell crisis
• Gaucher’s disease
 Treatment
Priciples of treatment :
1. Analgesia & general supprotive
2. Rest
3. Identify specific organism & adminis sensitive antibiotic
4. Release or eradicate the pus
5. Stabilize the bone
6. Eradicate the necrotic tissue
7. Restore any gap in bone
8. Maintain soft tissue and bone cover
Patient suspected for osteomyelitis should be
taken blood and fluid sample, and then treat
without waiting for the result
Empiric antibiotic :
• Neonates to 6mo old :
- S.aureus -> flucoxacillin + 3rd gen sephalosporin
- Group B strep -> benzylpenicillin
- Gram (-) -> gentamicin
• 6mo – 6yo :
- Haemophilus influenza -> fluxocacillin +
cefotaxime/cefuroxime
• Older child & adults :
- fluxocacillin + cefotaxime/cefuroxime
• Patients with MRSA -> Vacnomycin
 Surgery
• Antibiotic given <48hours after onset ->
usually no need
Indications :
• Doesn’t improve > 36 hours treatment
• Deep pus (oedem, fluctuation, swelling)
-> open the cortex through medulla
Chronic Osteomyelitis
• Sequele of acute osteomyelitis
Acute :
• Failure early diagnosis
• Failure treat antibiotic
• Failure treat operative
=> Chronic osteomyelitis
 pathology
• Infected dead bone (sequestre) ->
• Bacteria living in the haversian canal -> pus
surrounding protecting the bacteria from
leucocyte & antimicroba
 Clinical
• Usally no longer general
illness
• Localized pain, redness,
swelling, loss of
function
• One or more draining
sinuses
 Imaging
• Sequstre
• Local rarfaction, new
periosteal form,
sclerosis
• Mimic osteosarcoma,
Ewing sarcoma

• Lab : persistent anemia

and elevated ESR
Classification ( Cierny & Mader)
 Treatment
• Correct general condition
• Radical debridement & sequestrectomy
• Antibiotic ( 4-6 weeks, IV or oral)