Osteomyelitis: Diagnosis

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In-labeled WBC scan
– Can distinguish infected bone from bone that has
increased turnover from fractures, surgery,
prostheses, osteoarthropathy, and tumor.

– Usually reserved for situations of equivocal or

normal bone scans in patients where osteomyelitis
is still a consideration
 Osteomyelitis: Diagnosis

• CT
– Used for infection in bones that are difficult to visualize on
plain radiographs and bone scans: sternum, vertebrae,
pelvic bones, and calcaneus
– Appears as rarefaction, or lucent areas, on the CT scan
images
– Gas may also be visible in bony abscess cavities
– Limitation: disease must be present for > 1 week .
 Osteomyelitis: Diagnosis
• MRI
– Good for early detection
– Limited availability
 History , physical examination,
ESR suggestion of acute osteomyelitis

Plain radiograph +
Blood cultures
Start antibiotics

-
Admit patient
Needle aspirate
or bone resection

Tc99MDP 3phasw scintygraphy

+
Or indeterminate
consider CT or MRI in selected patient

Clinical evedence strong Clinical evidence weak

Blood culture
Out patient workup
Start antibiotics
Admit patient With possible indium
Inject for indium or or gallium scan
gallium scintygraphy
 Acute Pyogenic Osteomyelitis

Differential Diagnosis

• Acute Septic Arthritis

• Acute monoarticular rheumatoid
arthritis
• Sickle cell crisis
• Cellulitis
• Ewing’s Sarcoma
 Acute Pyogenic Osteomyelitis

Prognosis
Factors affecting prognosis:
• Organisms
• Infected Bone
• Age of the Patient
• Treatment
 Acute Pyogenic Osteomyelitis

Complications
• Septicemia & metastatic abscesses
• Septic arthritis
• Growth disturbance (children)
• Pathological fracture
• Chronic osteomyelitis
 Differential diagnosis
Image Findings

Osteosarcoma
Best diagnostic clue: Bone destruction
with associated tumor bone formation
and aggressive periosteal reaction .
Osteosarcoma
Ewing Sarcoma
Diaphysis of long bone
Large soft tissue mass
Osteomyelitis
No bone formation
Sequestrum

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Do Not Delay

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 Treatment

If osteomyelitis is suspected on clinical grounds,

Take blood and fluid samples for laboratory investigation

Start treatment immediately without confirmation

of the diagnosis.

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The principles of treatment

1. To provide analgesia and general supportive measures; to

rest the affected part;
2. To identify the infecting organism and administer effective
antibiotic treatment or chemotherapy;
3. To release pus as soon as it is detected;
4. To stabilize the bone if it has fractured;
5. To eradicate avascular and necrotic tissue;
6. To restore continuity if there is a gap in the bone; and
7. To maintain soft-tissue and skin cover.
8. Acute infections, if treated early with effective antibiotics,
can usually be cured. Once there is pus and bone necrosis,
operative drainage will be needed .
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 Acute Pyogenic Osteomyelitis

Treatment
Antibiotics:
• Type?
• Route?
• When to start?
• When to stop ?
• Monitoring?
 Acute Pyogenic Osteomyelitis

Treatment
Surgical Drainage:
• Indications?
• Procedure?
• Drilling?
 Supportive treatment
 The distressed child needs to be comforted
 Analgesics at repeated interval without waiting for the
patient to ask for
 Septicaemia and fever may cause dehydration –IV fluid
may be necessary.
 Nutritious food
Splintage
– For comfort
– To prevent joint contracture /dislocation
Method
– plaster slab/ surface traction

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 Antibiotics
• Prompt intravenous antibiotic is vital
• Initially as per “best guess”
• Recommendations
Neonates and infants
flucloxacilin & cefotaxime
Children 6 months -6 years
flucloxacilin & cefotaxime /cefurosime
Older children and previously fit adults
flucloxacilin & fusidic acid

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 Disposition:
• Inpatient
• Outpatient IV antibiotic therapy
• Outpatient PO antibiotic therapy (usually as
step-down)
 Empiric Therapy Adults
Osteomyelitis Pathogen Therapy
Hematogenous S. aureus Cloxacillin or Cefazolin +/-
Gentamicin
IVDU S. aureus Cloxacillin or Cefazolin
P. aeruginosa + Gentamicin
Contiguous: vascular Polymicrobial Clinda + Cipro or
insufficiency, diabetic Ancef + Metronidazole
foot Severe: imipenem or pip-
tazo

Nail-puncture of foot P. aeruginosa Prophylaxis: cipro

Treatment:pip-tazo +
tobramycin
Post-op prosthetic joint S. aureus Vancomycin +
S. epidermidis Gentamicin
 Empiric Therapy Kids
Osteomyelitis Pathogen Therapy
Neonates GBS, S. aureus, Cloxacillin +
Enterobacteriaceae Cefotaxime
Children S. aureus, Strep, H. flu Cloxacillin

Sickle cell S. aureus, Salmonella Cloxacillin +

sp. Cefotaxime
Post-op S.aureus, GAS, Cefazolin +/-
Enterobacteriaceae Gentamicin

Post-op spinal rods or S. aureus, CNS, GAS, Vancomycin +

sternotomy Enterobacteriaceae, Gentamicin
Pseudomonas
Nail puncture of foot Pseudomonas Piperacillin+Tobra or
aeruginosa Ceftazidime + Tobra
 IV antibiotics

• Until patient’s condition begins to

improve
• CRP values return to normal
• Usually 2-4 weeks

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 Oral antibiotics

• Orally for another 3–6 weeks, may have to be

longer,
• Ensure minimal inhibitory concentration(MIC) is
maintained or exceeded.
• Check CRP, ESR and WBC values at regular intervals ,
• Treatment can be discontinued when these are seen
to remain normal.

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 surgery
• Indications
Presence of an abscess requiring drainage
Failure to improve despite appropriate antibiotic
treatment.
Failure to improve within 36 hrs of treatment

• Objective
To drain any abscess
To remove all nonviable or necrotic tissue

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 Surgery
• Multiple drill hole
• Small window in cortex
• Wound closed without drain

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 Complications

 Epiphyseal damage and altered bone growth

 Supportive arthritis
 Metastatic infection
 Pathological fracture
 Chronic osteomyelitis
 Septicaemia

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 Sequel of acute osteomyelitis
• Chronic pyogenic infection

Characterized by
Hallmark is infected dead bone within a compromised soft
tissue envelope
Persistence of organism in pockets of necrotic tissue.
Pus discharging through sinuses at the skin
Poorly healed wound.

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