Osteomyelitis

For UGM Students

BLH

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 Definition
• It is an inflammation of bone caused by
infective organisms.
• The organisms could be :
-Non specific pyogenic (Staph. Strept)
-Specific (m.TB, Syphilis, Typhoid…)
-Fungal (Myetoma)
-Parasitic (H.Cyst) 3
Clinical forms of Pyogenic OM.

• 1. Acute OM
• 2. Sub-acute OM
• 3. Chronic OM
• 4. Acute on chronic OM
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 Definition
• Acute osteomyelitis (AO) is an infection
of bone involving the periosteum,
cortical bone and the medullary cavity.
• does not specify the causative
organism (bacteria, Mycobacteria,
fungi) or the disease process
(pyogenesis or granuloma formation).

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 Epidemiology
• more common in children
• boy’s>girls

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 Aetiology
• dependent upon the age and
immunocompetence of the patient.
• Overall, around 80% of AO is
caused by S. aureus.

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 Aetiology
Patient Likely pathogens Treatment

Streptococci Gp B and A
3rd generation
Newborn Staphylococcus aureus Escherichia
cephalosporin
coli

1st or 3rd
S. aureus, E. coli, Serratia generation 3rd
Children marcescens, Pseudomonas generation
aeruginosa cephalosporin
+ticarcillin

Sickle-cell
Salmonella spp. S. aureus Cefotaxime
Anaemia

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 Pathogenesis
• AO results in one of three ways:
• 1. Haematogenous spread - bacteria reach
bone tissue via the blood stream from a 1o nidus of
infection (e.g. a boil, or breach in the skin)
• 2. Direct extension of infection into bone from
adjacent soft tissue (e.g. a cellulitis)
• 3. Direct bone infection from a penetrating
wound or open fracture. By far the haematogenous
route is the most common.

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 Pathology
• The infective process usually begins in the
metaphysis.
• In children the growth plate is rarely affected
• Pus formed during the necrotic process pushes
against the periosteum eventually bursting through it.
• tracks towards the skin via muscle and soft tissue -
form a sinus
• The infarcted bone is called sequestrum.
• New periosteal bone surrounding dead bone is
called the involucrum,
• and the pores within the involucrum through which
pus tracks are called cloacas.
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 Clinical Features
• Pain is the first and most important symptom.
• swelling, erythema and /or an abscess
• A history of trauma
• The lower limb is more often the site than the upper
limb.
• Distal femur and proximal tibia are sites of
predilection in children.
• The crucial physical signs are
– bony tenderness
– loss of limb function and
– fever.
• Important - differentiation between Osteomyelitis and
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septic arthritis.
 Investigations
• ESR and CBC
• serum Caz+, P043- and alkaline phosphatase level
• Radiology –
• CT , MRI scans , Isotope bone scan
• Blood cultures (positive in 50-70% of cases)
• Biopsy - for identification of pathogen (NB. adequate
specimens for Mycobacterial and fungal identification
have to be taken);
• Antibiotic sensitivities (positive culture -in 80% of
cases)
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 Differential
Diagnosis
• Important diagnoses to consider are:

• Septic arthritis
• Acute rheumatic arthritis
• Haemarthrosis
• Ewing's sarcoma
• Osteosarcoma
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 Management
• Acute management involves admission into hospital,
splinting of the limb, and
• resuscitation the patient - fluid and electrolyte
imbalances.
• Antibiotic treatment is entirely dependent upon
identification of the causal organism and its
sensitivities
• intravenous antibiotics are prescribed for 3 weeks,
followed by 3 weeks of oral antibiotics. (A minimum
of 4-6 weeks of antimicrobial therapy)
• successful response is indicated by a fall in WBC
count, ESR, temperature and improvement of local
symptoms/signs.
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 Management

• Surgical management may be required

if improvement is not seen within 36
hours of treatment, as this indicates the
presence of pus in the metaphysis and
immediate drainage is necessary.

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 General complications
• septicaemia and metastatic
abscesses
• secondary involvement of the
adjacent joint
• chronic osteomyelitis
• Recurrence of AO
– higher for lower limb lesions than for
upper limb and spine. In particular
infection of the metatarsals (50%
recurrence) and femur/tibia (25%).
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 Subacute Osteomyelitis
• This is a variant of AO
– with a more prolonged history
– usually a less virulent pathogen
– It often presents incidentally on radiology or
the patient may present with a painful limp;
– there are no systemic signs of infection and
– often no local signs either

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 Subacute
Osteomyelitis
• It most frequently affects the femur and
tibia radiologically, a localised
translucency is found in the metaphysis
of long bone (Brodie's abscess)
• Investigations include baseline ESR,
CBC and blood/urine cultures ·
• Treatment is surgical curettage

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 Chronic
Osteomyelitis
• This is variant of bone
infection where certain
aetiological and
management factors lead
the disease process
towards a more prolonged
and debilitating path.
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 Factors influencing the development of
chronicity include:

• General nutritional status of the involved tissues

• Degree of bone necrosis
• Virulence of the pathogen
• Treatment appropriateness and compliance
• Host factors such as -vascular disease, diabetes
mellitus, immunocompromised states · risk factors
such as penetrating trauma, infection of a prosthesis,
animal bite,intravenous drug use, etc.
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 Aetiology
Likely pathogen (s) Treatment
Aetiology/Risk factor

Post-traumatic S. aureus 3rd generation

infection Streptococci cephalosporin
Gram -ve bacilli
Post-operative S. aureus as above
infection G -ve bacilli
S. epidermidis S. aureus Vancomycin +
Prosthesis infection
gentamicin
Puncture wound P. aeruginosa S. aureus ciprofloxacin

Dog/cat bite Pasteurella multocida ampicillin; amoxicillin+

Capnocytophaga S. aureus clavulanate
Traumatic exposure Mycobacterium marinum ethambutol/rifampin
to marine life
IVDU S. aureus P. aeruginosa Serratia gentamicin+ ticarcillin
marcescens 23
 Pathology
• There are four types of chronic
osteomyelitis (I-IV).
I. Medullary - only endosteum is involved
II. Superficial - surrounding soft tissue is
unable to heal (cortex and periosteum is
involved)
III. Combined localised - both medulla and
cortex involved (there may be a fistula)]
IV. Combined diffuse - as above but the
bone is unstable as is the
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Clinical Features
• · pain
• · loss of limb function
• · +/_ discharge of pus from a
sinus
• · +/- adjacent joint effusion
• · IVDUs - lumbar vertebrae are
commonly affected.

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Investigations
Treatment
• Generally choice of course depends on
the agent and its sensitivity..
• Surgical debridement -may need to be
carried out repeatedly.
• Even so bony defects may persist and
require grafting or amputation.

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 Complications
• can be fatal. They include:
• destruction of adjacent soft
tissue and skin
• epidermoid carcinoma of the
fistula
• neoplasms - fibrosarcoma,
rhabdomyosarcoma, SCC
(Marjolin's ulcer) · amyloidosis

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Septic Arthritis

• bacterial infection of a
joint.
• Viral arthritides are
usually self limiting and
treatment is supportive.

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 Epidemiology
• Half the cases of septic arthritis occur in
children aged below 3 years.
• The hip joint is most commonly
involved in infants, whereas
• the knee joint is more common in older
children.
• 10% of childhood cases have
polyarticular involvement.
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 Pathogenesis
• Direct infection of the joint -
penetration through trauma or a
diagnostic/therapeutic procedure OR
• local extension of a neighbouring
focus of infection (eg. epiphyseal or
metaphyseal osteomyelitis) OR
• Haematogenous spread of organisms
(usually Streptococci, Staphylococci)

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Aetiology
risk factor Likely pathogen(s) involved

Arthritis (esp. RA) S. aureus

trauma S. aureus, Streptococci &

neighbouring OM same as that causing the bone

sickle--cell anaemia Salmonella spp. and Strep. pneumoniae

sexual activity N. gonorrhoeae

IVDU Pseudomonas, Serratia spp. and S.aureus

dog/cat bite Pasteurella multocida

human bite Eikenella corrodens

tick exposure Borrelia burgdorfori

exposure to marine life Mycobacterium marinum

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 Clinical
Features
• Patient complains of fever,
chilli/rigors, joint pain, swelling and
immobility.
• The joint is fixed in the position of
ease. (Knee flexed; hip flexed,
externally rotated and abducted).
• Signs include heat, tenderness and
possibly a joint effusion.

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Investigations
• CBC, ESR
• Blood cultures before instituting antibiotic
treatment
• X-ray
• CT, MRI, isotope scans
• Diagnostic aspiration and analysis of
synovial fluid
- send for cytology, biochemistry and
microbiology
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Synovial Fluid
=> If WBC count >50,000/uL (with >90% PMNLs)
suspect septic arthritis
(Even if culture is negative)
=> Usually glucose is down and protein is up
Important: examine fluid for crystals (urate or CaPP)
Gram stain and culture / sensitivities

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 Differential Diagnosis
• In children
– transient synovitis of the hip (commonest cause of
irritable hip in kids <l0yrs)
– Perthes' disease - excluded by history and MRI
– Acute rheumatic fever
– Henoch-Schonlein purpura
• In children and adults
– Acute osteomyelitis · RA, OA
– Crystal arthropathies
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Management

• Treatment of pain and fever.

• The joint must be immobilised
-in the position of maximum
function.
• Antibiotic therapy -empiric
therapy can be started after
blood samples are taken

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 Empiric therapy is as
follows:

Patient Covered pathogens Empiric treatment

Children 3rd generation

S. aureus, Streptococci cephalosporin
H. influenzae

Adults ceftriaxone
S. aureus & N.
gonorrhoeae

vancomycin/gentamicin
Prosthetic S. epidermidis & S.
joint aureus

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• Treatment is initially parenteral, followed
by an oral regime, in total 4-6 weeks.
• Aspiration is both diagnostic and
therapeutic.
• Open surgical debridement and drainage
is controversial but widely used.
arthrotomy is essential.
• Local administration of antibiotics

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 Prognosis
• It is curable and recurrences are not
common.
• However, complications of chronic
infection include
– loss of articular cartilage,
– pathological joint dislocation,
– epiphyseal necrosis.
• In the long term
– joint stiffness and bony ankylosis
– Degenerative osteoarthritis is almost
guaranteed.
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 Causative organism
Likely pathogen (s) Treatment
Aetiology/Risk factor

Post-traumatic S. aureus 3rd generation

infection Streptococci cephalosporin
Gram -ve bacilli
Post-operative S. aureus as above
infection G -ve bacilli
S. epidermidis S. aureus Vancomycin +
Prosthesis infection
gentamicin
Puncture wound P. aeruginosa S. aureus ciprofloxacin

Dog/cat bite Pasteurella multocida ampicillin; amoxicillin+

Capnocytophaga S. aureus clavulanate
Traumatic exposure Mycobacterium marinum ethambutol/rifampin
to marine life
IVDU S. aureus P. aeruginosa Serratia gentamicin+ ticarcillin
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marcescens
 Cenry-Mader’s Classification
I. Medulary - endosteal diseases

I. Superficial – Cortical surface infected

because of coverage defect

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 Cont’d…
III. Localized – Cortical sequestrum that can
be excised with outcompromising
stability .
IV. Diffuse – Features of I, II and III plus
mechanical instability.

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 THE END!

Thank you

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