OSTEOMYELITIS

236-TOM BASTIAN
237-TOM BETSON BOSE
238-T VARNA
 INTRODUCTION
 Osteon (bone) ; myelo(marrow) ; itis (inflammation)
 Inflammation of the bone by infection by a microorganism.
 ANATOMY

 Thus, the vessels in this zone are arranged in the form of a

loop (hair-pin arrangement).
 The blood stasis resulting from such an arrangement is
probably responsible for the metaphysis favourite site for
bacteria to settle, and thus a common site for osteomyelitis.
 In most joints, the capsule is attached at the junction of the epiphysis with the metaphysis i.e.,
the metaphysis is extra-articular.
 In some joints, part of the metaphysis is intra-articular, so that the infection from the
metaphysis can spread to the joint, resulting in pyogenic arthritis.
CLASSIFICATION
 ACUTE OSTEOMYTELITIS
 This can be primary (hematogenous) or secondary (following an open fracture or bone
operation).
 AETIOLOGY
 Staphylococcus aureus is the commonest causative organism.
 Others are Streptococcus and Pneumococcus.
 These organisms reach the bone via the blood circulation. Primary focus of infection is generally not detectable.
 The bacteria, as they pass through the bone, get lodged in the metaphysis.
 commonest site :Lower femoral metaphysis
 Other sites: upper tibial, upper femoral and upper humeral metaphyses.
 PATHOLOGY
The host bone initiates an inflammatory reaction in response to the bacteria

Bone destruction and production of an inflammatory exudate and cells (pus)

Once sufficient pus forms in the medullary cavity, it spreads in the following
directions
a)Along the medullary cavity:
Pus trickles along the medullary cavity

thrombosis of the venous and arterial medullary vessels

Blood supply to a segment of the bone is thus cut off.

  b) Out of the cortex:

Pus travels along Volkmann’s canals and comes to lie sub-periosteally

The periosteum is thus lifted off the underlying bone, resulting in damage to the periosteal
blood supply to that part of the bone

A segment of bone is thus rendered avascular (sequestrum).

Pus under the periosteum generates sub-periosteal new bone (periosteal reaction).

Eventually the periosteum is perforated, letting the pus out into the muscle or subcutaneous
plane, where it can be felt as an abscess. If left unattented it forms discharging sinus.
  In other directions:
The epiphyseal plate is resistant to the spread of pus. At times it
may be affected by the inflammatory process.

The capsular attachment at the epiphysis metaphysis junction

prevents the pus from entering the nearby joint

 In joints with an intra-articular metaphysis, pus can

spread to the joint, and cause acute pyogenic arthritis
e.g., in the hip, in the shoulder etc.
 DIAGNOSIS
 The diagnosis of acute osteomyelitis is basically clinical.
 It is a disease of childhood, more common in boys, probably because they are more prone to injury.
 PRESENTING SYMPTOMS: child presents with an
# acute onset of pain
#swelling at the end of a bone
# associated with systemic features of infection like fever etc.
Often the parents attribute the symptoms to an episode of injury, but the injury is coincidental.
One may find a primary focus of infection elsewhere in the body (tonsils, skin, etc.).
 EXAMINATION
 The child is febrile and dehydrated with classic signs of inflammation – redness, heat, etc. localized to the
metaphyseal area of the bone.
 In later stages, one may find an abscess in the muscle or subcutaneous plane. There may be swelling of the
adjacent joint, because of either sympathetic effusion or concomitant arthritis.
 Any history of trauma, particularly in children must be thoroughly questioned
 INVESTIGATIONS
 Blood: There may be polymorphonuclear leukocytosis
and an elevated ESR.
A blood culture at the peak of the fever may yield the
causative organism.
 X-ray : The earliest sign to appear on the X-ray is a
periosteal new bone deposition (periosteal reaction) at
the metaphysis. It takes about 7-10 days to appear.
 Bone scan: A bone scan using Technetium-99 may show
increased uptake by the bone in the metaphysis.
~This is positive before changes appear on X-ray. This may be
indicated in a very early case where diagnosis is in doubt.
~Indium-111 labelled leucocyte scan is most specific for
diagnosis of bone infection.
 DIFFERENTIAL DIAGNOSIS

 Any acute inflammatory disease at the end of a bone, in a child, should be taken as acute osteomyelitis unless
proved otherwise.
 Acute septic arthritis:
This can be differentiated from acute osteomyelitis by the following features in arthritis:
• Tenderness and swelling localized to the joint rather than the metaphysis.
• Movement at the joint is painful and restricted.
 Acute rheumatic arthritis:
The features are similar to acute septic arthritis.
• The fleeting character of joint pains
•elevated ASLO titer and CRP values may help in diagnosis.
 Scurvy: There is formation of sub-periosteal hematomas in scurvy.
Radiologically similar to acute osteomyelitis. But there is relative absence of pain, tenderness and fever
points to the diagnosis of scurvy.
There may be other features of malnutrition.
 Acute poliomyelitis:
In the acute phase of poliomyelitis,
there is fever and the muscles are tender, but there is no tenderness on the bones.
 TREATMENT
 The child is admitted and investigated.
 Treatment depends upon the duration of illness after which the child is brought.
 Cases can be arbitrarily divided into two groups:
a) If the child is brought within 48 hours of the onset of symptoms:
 If a child is brought early, it is supposed that pus has not yet formed and the inflammatory process can be halted by
systemic antibiotics.
 Treatment consists of rest, antibiotics and general building-up of the patient.
~The limbIn
is children
put to rest in than
less a splint or by traction.
4 months of age
Ceftriaxone + Vancomycin in older children
(in appropriate dose is preferred. ) Ceftriaxone + Cloxacillin is given

Antibiotics are started after taking blood for culture and sensitivity.
 The child is adequately rehydrated with intravenous fluids.
 As the child improves, the limb can be mobilized. Weight bearing is restricted for 6-8 weeks
 After 2 weeks, antibiotics can be administered by oral route for 6 weeks.
b) If the child is brought after 48 hours of the onset of symptoms:
• If the child is brought late or if he does not respond to conservative treatment, it is taken for granted that there is
already a collection of pus within or outside the bone.
• Detection of pus is often difficult by clinical examination because it may lie deep to the periosteum. ~ultrasound
examination( early detection of deep collection of pus)
• Surgical exploration and drainage is the mainstay of treatment at this stage.
• A drill hole is made in the bone in the region of the metaphysis. If pus wells up from the drill hole, the hole is enlarged
until free drainage is obtained.
• A swab is taken for culture and sensitivity.
• The wound is closed over a sterile suction drain.
• Rest, antibiotics and hydration are continued post-operatively.
• Gradually, the inflammation is controlled and the limb is put to use.
• Antibiotics are continued for 6 weeks.
 COMPLICATIONS
 GENERAL COMPLICATION:
Septicemia and pyemia. (Either complication, if left uncontrolled, may prove
fatal)
 LOCAL COMPLICATIONS:
1.Chronic osteomyelitis:
commonest complication of acute osteomyelitis.
There are hardly any radiological features in the early stage. A delay in diagnosis
leads to sequestrum formation and pent-up pus in the cavities inside the bone.
Poor host resistance is another reason for the chronicity of the disease.
2. Acute pyogenic arthritis:
This occurs in joints where the metaphysis is intra-articular e.g., the hip
(upper femoral metaphysis), the shoulder (upper humeral metaphysis), etc.
3. Pathological fracture:
This occurs through a bone which has been weakened by the disease or by the window made during
surgery.
It can be avoided by adequately splinting the limb.
4. Growth plate disturbances:
It may be damaged leading to complete or partial cessation of growth.
This may give rise to shortening, lengthening or deformity of the limb
 SECONDARY OSTEOMYELITIS
 Arises due to wound infection in open fractures or after operations on the bone.
 The constitutional symptoms are less severe than those in hematogenous osteomyelitis as the wound
provides some drainage.
 The condition can be largely prevented by adequate initial treatment of open fractures, and adherence to
sterile operating conditions for routine orthopaedic operations.
 CHRONIC OSTEOMYELITIS
 There are three types of chronic osteomyelitis:
 a) Chronic osteomyelitis secondary to acute
osteomyelitis.
 b) Garre’s osteomyelitis.
 c) Brodie’s abscess.
 The other causes of chronic osteomyelitis are
tuberculosis, fungal infections etc.
 CHRONIC OSTEOMYELITIS SECONDARY TO ACUTE

a) Delayed and inadequate treatment:

non-collapsing’ bone cavities and sequestra are
responsible for persistent infection.
b) Type and virulence of organism :
body’s defense mechanism may not be able to
control the damaging influence of a highly
virulent organism, and the infection persists.
c) Reduced host resistance:
Malnutrition compromises the body’s defense
mechanisms, thus letting the infection persist
 SEQUESTRUM AND INVOLUCRUM
 Sequestrum: is a piece of dead bone,
surrounded by infected granulation tissue
trying to ‘eat’ the sequestrum away. It
appears pale and has a smooth inner and
rough outer surface because the latter is
being constantly eroded by the surrounding
granulation tissue.

Involucrum is the dense sclerotic bone
overlying a sequestrum. There may be some
holes in the involucrum for pus to drain out.
These holes are called cloacae. The bony
cavities are lined by infected granulation
tissue.
TYPES OF SEQUESTRUM
 DIAGNOSIS
 DIAGNOSIS :Diagnosis is suspected clinically but can be confirmed radiologically by its
characteristic features. The disease begins in childhood but may present later. The lower-end of the
femur is the commonest site.
• Presenting complaints:
• -A chronic discharging sinus is the commonest presenting symptom. Often sinuses heal for short
periods, only to reappear with each acute exacerbation. Quality of discharge varies from
seropurulent to thick pus. There may be a history of extrusion of small bone fragments from the
sinus.
• - Pain is usually minimal but may become aggravated during acute exacerbations
• -Generalized symptoms of infection such as fever etc., are present only during acute exacerbations.
 PRESENTING COMPLAINTS
• Chronic bone pain
• Erythema around the affected bone
• Swelling and bone tenderness
• Impaired wound healing
• Increased drainage or persistent sinus tracts
• Chills
• Low grade fever
• General malaise
• Long-standing discharging sinuses
• Muscle wasting and joint contractures
 EXAMINATION
 Chronic discharging sinus: This is a
characteristic feature of chronic infection. A
sinus fixed to the underlying bone indicates
that infection is coming from the bone.
There may be sprouting granulation tissue
at its opening, indicating a sequestrum
within the bone. The sequestrum may be
visible at the mouth of the sinus itself. The
sinus may be surrounded by healed
puckered scars, indicating previous healed
sinuses.
 EXAMINATION
 • Thickened, irregular bone: This can be appreciated on comparing the girth of the affected bone
with that of the bone on the normal side
 • Tenderness on deep palpation, usually mild, is present in some cases
 • Adjacent joint may be stiff, either due to excessive scarring in the soft tissues around the joint, or
because of associated arthritis of thejoint
INVESTIGATIONS
 RADIOLOGY
• Thickening and irregularity of the cortices
• Patchy sclerosis
• Bone cavity: This is seen as an area of rarefaction
surrounded by sclerosis
• Sequestrum: This appears denser than the
surrounding normal bone because the
decalcification which occurs in normal bone, does
not occur in dead bone. Granulation tissue
surrounding the sequestrum gives rise to a
radiolucent zone around it. A sequestrum may be
visible in soft tissues
• Involucrum and cloacae may be visible.
 SINOGRAM
 Sinogram:
 In this test, a sterile thin catheter is
introduced into the sinus as far as it can
go.Then, a radio-opaque dye is injected, and
X-rays taken. The radio-opaque dye travels
to the root of the infection, and thus helps
localise it better. It is indicated in situations
where one cannot tell on X-rays where the
pus may be coming from.
 RADIOLOGY
 CT scan and MRI: are sometimes indicated
in patients where diagnosis is in doubt. CT
scan is of particular use in better defining
the cavities and sequestra, which sometimes
cannot be seen on routine X-rays. Exact
localisation of a cavity or sequestrum has
bearing on surgical treatment
 OTHER INVESTIGATIONS
 Blood: A blood examination is usually of no help. ESR may be normal or mildly elevated. Total blood
counts may be normal, may be increased during acute exacerbation only.
 Pus: Pus culture may grow the causative organism.This should be taken from depth of the sinus after
proper cleaning of the skin.
 DIFFERENTIAL DIAGNOSIS
 A discharging sinus on a limb indicates deeper infection which could be from tissues, skin
downward. A history of bone piece discharge from a sinus is diagnostic of chronic osteomyelitis.
Other differential diagnosis to be considered in the absence of such a history are as follows:
1. Tubercular osteomyelitis
2. Soft tissue infection
3. Ewing’s sarcoma
 TREATMENT
 Antibiotics are useful only during acute
exacerbations and during postoperative period
• Operative procedures
• GOALS:
(i) removal of dead bone;
(ii) elimination of dead space and cavities;
(iii) removal of infected granulation tissue
and sinuses.
• Sequestrectomy: This means removal of the
sequestrum. One must wait for adequate
involucrum formation before performing
sequestrectomy.
• Saucerization: A bone cavity is a ‘non-collapsing
cavity’, so that there is always some pent-up pus
inside it. This is responsible for the persistence of
an infection. In saucerization, the cavity is
converted into a saucer’ by removing its wall (Fig-
22.8). This allows free drainage of the infected
material.
 TREATMENT
• Curettage: The wall of the cavity, lined by infected
granulation tissue, is curetted until the underlying normal-
looking bone is seen.
• Excision of an infected bone: In a case where the affected bone can
be excised en bloc without compromising the functions of the limb
• Amputation: especially if the sinus undergoes a malignant
change.
• After surgery the wound is closed over a continuous suction
irrigation system has an inlet tube going to the medullary cavity,
and an outlet tube bringing the irrigation fluid out. A slow
suction is applied to the outlet tube. The irrigation fluid consists
of suitable antibiotics and a detergent. The medullary canal is
irrigated in this way for 4 to 7 days.
 COMPLICATIONS
1. An acute exacerbation
2. Growth abnormalities: shortening , lengthening or deformity
3. Pathological fracture
4. Joint stiffness
5. Sinus tract malignancy - SCC
6. Amyloidosis
 GARRE’S OSTEOMYELITIS
•sclerosing, non-suppurative chronic
osteomyelitis begin with acute local pain, pyrexia
and local swelling
•Shafts of the femur or tibia are the most commonly
affected.
•Pyrexia and pain subside but the fusiform osseous
enlargement persists.
 The importance of Garre's osteomyelitis lies in differentiating it from bone
tumours, which commonly present with similar features e.g.,
Ewings tumour or osteosarcoma
 TREATMENT
• Acute symptoms subside with rest and broad-spectrum antibiotics.

• Sometimes making a gutter or holes in the bone bring relief in pain

 BRODIES ABSCESS
 It is a special type of osteomyelitis in which
the body's defense mechanisms have been
able to contain the infection so as to create a
chronic bone abscess containing pus or
jelly-like granulation tissue surrounded by a
zone of sclerosis
 CLINICAL FEATURES
•It
is usually located at the metaphysis. A deep
boring pain is the predominant symptom.

•In
some instances, it becomes worse on
walking and is relieved by rest

•usually between 11 to 20 years

•Upper end of the tibia and lower-end of the

femur.
 INVESTIGATIONS
 RADIOLOGY
• It shows a circular or oval lucent area
surrounded by a zone of sclerosis.

• rest of the bone is normal

 TREATMENT
• Treatment is by operation.

• Surgical
evacuation and curettage is performed
under antibiotic cover.

• If
the cavity is large, it is packed with
cancellous bone chips
 SALMONELLA OSTEOMYELITIS
• occurs during the convalescent phase after an attack of typhoid fever.
• subacute type of osteomyelitis, usually occurring in the ulna, tibia or vertebrae
• Often, multiple bones are affected, sometimes bilaterally symmetrical.
• predominant radiological feature is a diaphyseal sclerosis
• Common in children with sickle cell anemia
 REFERENCES
•
Essential orthopaedics J Maheswari 5th edition

• (1)PEDIATRICDENTISTRY/Copyright 1981 by The American Academyof Pedodontics/Vol. 3, No. 3

• (2)Cossio, A., Graci, J., Lombardo, A.S. et al. Bilateral tibial Brodie’s abscess in a young patient
treated with BAG-S53P4: case report. Ital J Pediatr 45, 91 (2019).

• (3) https://radiopaedia.org/cases/brodie-abscess?lang=us
THANK YOU