BRAINSTOMRMING CASE

A 7-year-old girl, is brought to the pediatrician's office by her parents

with complaints of severe pain in her left leg. Her parents report that
she has been limping for the past few days and has been reluctant to
bear weight on her leg. They also note that she has been feeling
generally unwell and has had a low-grade fever. Upon examination, the
pediatrician observes localized tenderness, warmth, and swelling over
her left shin. She winces in pain when her leg is palpated, and she is
unable to fully extend or flex her knee. There are no visible wounds or
injuries on the skin surface. Her temperature is slightly elevated, and
she appears fatigued.
• What could be the most likely diagnosis?
OSTEOMYELITIS
Learning outcomes
• Describe osteomyelitis
• Describe epidemiology of osteomyelitis
• Explain the risk factors of osteomyelitis
• Identify clinical features of osteomyelitis
• Establish provisional diagnosis and differential diagnoses of
osteomyelitis
• Request appropriate investigations
• Provide pre referral treatment
• Conduct follow up services
• Outline the complication of osteomyelitis
Describe osteomyelitis
• Definition of osteomyelitis
• Types of osteomyelitis
• Route of spread of osteomyelitis
• Relevant anatomy in osteomyelitis
 Osteomyelitis
• Osteomyelitis is defined as a suppurative process of the bone
caused by pyogenic organisms or simply a pyogenic infection
of the cancellous portion of the bone.
Types of osteomyelitis
• There are three types based on duration of symptoms, route
of spread of infection and host response:
 Acute osteomyelitis
Less than two weeks, spread by hematogenous and it is
pyogenic.
 Sub-acute osteomyelitis
2-3 weeks, non pyogenic
 Chronic osteomyelitis
More than 3 weeks, spread by direct.
Route of spread
• Haematogenous spread.
• Contagious focus; spread from neighbouring infective
sites(infection spreads to adjacent bone through the soft
tissue) .
• Direct bone infection; microbes gain entry to the bone
through open fractures, penetrating wounds, or contamination
in a surgical procedure.
Relevant anatomy
 Relevant anatomy
• Metaphysis of the long bones is the common site for
osteomyelitis. Why? Hair-pin arrangement of blood vessel
causes stasis of blood which is favorable for bacteria to settle.
Acute osteomyelitis
• Can be primary (haematogenous) or secondary (following an open
fracture or bone operation).
• Haematogeous osteomyelitis is the commonest and is often seen in
children.
Epidemiology of acute osteomyelitis
Incidence
The annual incidence of pediatric osteomyelitis is approximately 13 per
100,000 individuals.
The annual incidence in adult osteomyelitis is approximately 90 per 100,000
individuals.
Age
Osteomyelitis occurs in all patient age groups.
Hematogenous osteomyelitis occurs predominantly in children and elderly
patients.
The most common form of the disease in adults is osteomyelitis due to
contiguous infection, resulting from trauma or surgery.
Vertebral osteomyelitis typically occurs in patients older than 50 years of age.
Epidemiology of acute osteomyelitis
Gender
Osteomyelitis occurs more commonly in males for unknown reasons.
Race
Osteomyelitis occurs equally among all races.
Developed vs Developing Countries
Osteomyelitis is more common in developing countries
Aetiology of acute osteomyelitis
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.
• Lower femoral metaphysis is the commonest site.
• The other common sites are the upper tibial, upper femoral and
upper humeral metaphyses.
Risk factors of acute osteomyelitis
• Long term skin infections.
• Inadequately controlled diabetes.
• Poor blood circulation (arteriosclerosis).
• Risk factors for poor blood circulation, which include high blood
pressure, cigarette smoking, high blood cholesterol and diabetes.
• Immune system deficiency.
• Prosthetic joints.
• The use of intravenous drugs.
• Sickle cell anaemia.
• Cancer.
 The pathophysiology of acute osteomyelitis

• The host bone initiates an inflammatory reaction in response to the

bacteria.
• This leads to bone destruction and production of an inflammatory
exudate and cells (pus).
• Once sufficient pus forms in the medullary cavity, it trickles along
the medullary cavity and causes thrombosis of the venous and arterial
medullary vessels.
• Blood supply to a segment of the bone is thus cut off.
• Pus travels along Volkmann’s canals and comes to lie sub-
periosteally.
 The pathophysiology of acute osteomyelitis
• 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.
• The abscess, if unattended, bursts out of the skin, forming a
discharging sinus.
 Clinical features of acute osteomyelitis

Presenting complaints:
• The child presents with an acute onset of pain and swelling
at the end of a bone.
• A/w systemic features of infection like fever.
• 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)
Clinical features of acute osteomyelitis
Acute onset of pain at the end of a bone.
Fever:
• This is the most common presenting symptom. (high grade fever)
The child usually has very high fever a/w profuse sweating, chills
and rigors.
Swelling:
• This usually follows the fever and may affect the ends of long
bones. The swelling may be acutely painful and the skin may
appear red.
Limitation of Movement:
• The child may not move the joint near the affected bone due to
pain and swelling.(state of pseudoparalysis.)
 Clinical features of acute osteomyelitis
Symptoms
• Bone pain
• Fever
• Swelling
• Limitation of movement
 Clinical features of acute osteomyelitis
Signs:
• The child is febrile and dehydrated with classical signs of
inflammation: redness, heat, swelling, tenderness, localised 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.
• Decreased movements of nearby joints.
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.
Investigation
• Investigations provide few clues in the early phase of the
disease.
• In general, in acute osteomyelitis, laboratory investigations
and bone scan are more useful. Radionucleotide scan.
• Radiology is of much help in chronic osteomyelitis.
Investigations in acute osteomyelitis
• Blood:
FBP: polymorphonuclear leucocytosis and an
ESR: elevated
Culture at the peak of the fever may yield the causative
organism.
• X-rays:
The earliest sign to appear on the X-ray is a periosteal new bone
deposition (periosteal reaction) at the metaphysis.
It takes about seven to ten days to appear.
• Bone scan:
A bone scan using Technetium-99 may show increased uptake
by the bone in the metaphysis.
Differential diagnoses of acute osteoarthritis
• Any acute inflammatory disease at the end of a bone, in a
child, should be taken as acute osteomyelitis unless proved
otherwise.
• Following are some of the differential diagnosis to be
considered:
Acute septic arthritis
Acute rheumatic arthritis
Scurvy
Acute poliomyelitis
Cellulitis
Other differential diagnoses
• Fracture
• Toxic synovitis
• Juvenile rheumatoid arthritis
• Streptococcal necrotizing myositis.
• Sickle-cell crisis
 Pre referral treatment

• Since the patient presents with pain,fever, swelling, limited

range of adjacent joint movement and may be dehydrated, the
following can be done at the lower health facility:
Secure i.v line and give i.v fluid-RL/NS
Splint the affected part to alleviate pain and spasm
Give analgesics
Give antipyretics
Start i.v antibiotics
Refer the patient to hospital.
 Definitive treatment of acute osteomyelitis
• Acute osteomyelitis is an orthopaedic emergency.
• The patient should be admitted.
• Treatment depends upon the duration of illness after which the
patient is brought.
• Cases can be arbitrarily divided into two groups:
Patient brought within 48 hours of the onset of symptoms.
Patient brought after 48 hours of the onset of symptoms.
Patient brought within 48 hours of the onset of symptoms:

• Rest:
The limb is put to rest in a splint or by traction.
• Antibiotics:
I.V for two weeks then continue with oral for 6 weeks.
In children <4 months of age, a combination of ceftriaxone and
vancomycin is preferred.
In older children, give a combination of ceftriaxone and
cloxacillin.
Started after taking blood for culture and sensitivity.
Patient brought within 48 hours of the onset
of symptoms:
• Rehydration:
Adequately rehydrate the patient with intravenous fluids-
RL/NS
• Surgical intervention:
If the patient does not respond within 48 hours of treatment.
Treatment response:
Fever starts declining
Tenderness subsides
Antibiotic Therapy in acute osteomyelitis
According to STG of Tanzania 2021:
• Cloxacillin (IV) 1–2g 6hourly then continue with ampicillin + cloxacillin (FDC) (PO)
500mg 8hourly to complete 3-6weeks course or until CRP and x ray become
negative.
OR
• Ampicillin+sulbactam (FDC) (IV) 3g 6hourly for two weeks THEN
Amoxillin+clavulanate (FDC)(PO) 625mg 12hourly for 4weeks.
Patients with penicillin allergy consider.
Clindamycin (IV) 60mg 6hourly for 2weeks then orally to complete 4-6weeks
AND
Ciprofloxacin (IV) 400mg 12hourly for 2weeks then orally to complete 4-6weeks
For sickle cell patient if salmonella spp is suspected consider
Ciprofloxacin (IV) 400mg 12hourly for 4weeks, you may change to oral after 2weeks
 Patient brought after 48 hours of the onset of symptoms:

• If the patient 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.
• Treatment will be as follows:
 Surgical intervention and drainage:
Multiple drill holes are made in the bone in the region of the
metaphysis for free drainage of pus.
Note: Swab is taken for culture and sensitivity.
 Patient brought after 48 hours of the
onset of symptoms
 Wound closure:
Done over a sterile suction drain.
 Rest the limb in a splint or traction
 Antibiotics:
I.V for 2 weeks then oral for 6 weeks.
 Hydration continued post operation
Sterile suction drain
Complications of acute osteomyelitis
• General complications
Septicaemia
Pyaemia
• Local complications
Chronic osteomyelitis
Acute pyogenic arthritis
Pathological fracture
Growth plate disturbances
Chronic osteomyelitis
By definition:
• Any osteomyelitis lasting for more than three weeks
• Chronic pyogenic osteomyelitis.
• An important problem in developing countries.
Epidemiology of chronic osteomyelitis
• Chronic osteomyelitis is more common in males and in the
age group from 41–50 years of age.
• Common infection sites are the femur, tibiofibular, and hip
joint.
• S. aureus the most commonly observed pathogenic organism.
• Treatment of chronic osteomyelitis with two-stage
debridement, plus antibiotic- loaded polymethylmethacrylate
(PMMA) beads provided good clinical results
Aetiology of chronic osteomyelitis
• Sequelae of acute osteomyelitis (5-10%)
• Following compound fractures
• Following surgery on bones and joints
• Chronic from the beginning (e.g. tuberculosis, syphilis,
Brodie’s abscess)
• Anaerobic organisms (sclerosing osteomyelitis of Garre)
• Fungal osteomyelitis.
Risk factors of chronic osteomyelitis

• Sickle cell disease (SCD)

• Open reduction and internal fixation utilizing an implant.
• Peripheral vascular diseases (PVD)
• Diabetes mellitus
• Septicaemia: clinical and laboratory confirmed.
• Buluri ulcers; caused by Mycobacterium ulcerans, at 60%,
bone beneath are likely to suffer.
Clinical features of chronic osteomyelitis
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 sero- purulent to thick pus.
• There may be a history of extrusion of small bone fragments
from the sinus.
• Pain is minimal, fever; these are present only in acute
exacerbations.
Clinical features of chronic osteomyelitis
• Chronic discharging sinus:
Characteristic feature.
Fixed to the bone
There may be sprouting granulation tissue at its opening.
• Thickened, irregular bone:
Can be appreciated on comparing the girth of the affected
bone with that of the bone on the normal side
• Tenderness on deep palpation: mild in some cases.
• Adjacent joint may be stiff: due to excessive scarring in the
soft tissues around the joint, or because of associated arthritis
of the joint.
Clinical features: in summary
Features in chronic osteomyelitis:
• Multiple scars and sinuses
• Sequestrum
• Cavity
• Sinus tract
• Irregular thickening of bone
• Sprouting granulation tissue
• Discharge of bony spicules and pus
Diagnosis of chronic osteomyelitis
• 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.
Investigation
• X-ray of the affected limb.
• Sinogram of the affected limb: helps localise better where is
the pus coming from.
• CT scan and MRI of the affected limb: used in better defining
the cavities and sequestra.
• Pus for culture and sensitivity
Taken deep in the sinus.
Identify the causative organism
May also help in selecting the pre-operative antibiotics as
and when operation is performed.
 Differential diagnosis of chronic
osteomyelitis
• 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 DDx are:
Tubercular osteomyelitis
Soft tissue infection
Ewing’s sarcoma
Treatment of chronic osteomyelitis

Principles of treatment:
• Treatment of chronic osteo- myelitis is primarily surgical.
• Antibiotics are useful only during acute
exacerbations( trauma & lowered resistance) and during post-
operative period.
• Aim of surgical intervention:
Removal of dead bone
Elimination of dead space and cavities
Removal of infected granulation tissue and sinuses.
Treatment: Operative procedures
• Following are some of the operative procedures commonly
performed:
Sequestrectomy
Saucerisation
Curettage
• Sequestrectomy:
This means removal of the sequestrum.
If it lies within the medullary cavity, a window is made in the overlying
involucrum and the sequestrum removed.
One must wait for adequate involucrum formation before performing
sequestrectomy.
• Saucerisation:
Conversion of bone cavity into a ‘saucer’ by removing its wall.
 This allows free drainage of the infected material.
• Curettage:
The infected granulation tissue lining the wall of the cavity is curetted until
the underlying normal-looking bone is seen.
The cavity is sometimes obliterated by filling it with gentamycin
impregnated cement beads or local muscle flap.
Complications of chronic osteomyelitis
• Joint stiffness
• Shortening of the limb
• Muscle contracture
• Pathological fracture
• Sinus tract malignancy
• Amyloidosis
Case scenario
A 20-year-old male, a local footballer from Gamboshi
sustained open fracture of distal right tibia during a match. He
was traditionally treated and showed healing. 3 months post-
accident started noticing bone pain at the former injured site
associated with a sinus discharging tiny bony pieces. On
examination: the right lower limb is irregularly thickened,
lengthened and stiff right ankle joint.
What is the likely diagnosis?
References
• Essential Orthopaedics 5th Edition, J. Maheshwari
• Textbook of Orthopedics 4th Edition, John Ebenezar.
• STG Tanzania 2021.
• Scientific report on Chronic osteomyelitis, Northern China,
5th Oct 2018.
• Research by Kubwimana Olivier, University of Rwanda.