Acute Osteomyelitis
Infection in bone
Osteomyelitis
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acute (subacute)
chronic
specific (eg TB)
non specific(most common)
Acute haematogenous OM
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mostly children
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boys> girls
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history of trauma
Acute Osteomyelitis
Organism
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Gram +ve
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staphylococus aureus
strep pyogen
strep pneumonie
Gram -ve
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haemophilus influnzae (50% < 4 y)
e .coli
pseudomonas auroginosa,
proteus mirabilis
Acute Osteomyelitis
Source Of Infection
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infected umbilical cord in infants
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boils, tonsilitis, skin abrasions
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in adults UTI, in dwelling arterial line
Acute Osteomyelitis
Source of Infection:
Hematogenous
Direct spread
Exogenous
Acute Osteomyelitis
Pathology
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starts at metaphysis
?trauma
vascular stasis
acute inflammation
suppuration
necrosis
new bone formation
resolution
Acute Osteomyelitis
Pathology:
Primary focus and stage of inflammation
Spread of infection with pus formation
Formation of subperiosteal abscess
Pus tracks toward skin to form a sinus
Bone infarction (Sequestrum)
New bone formation (involucrum)
Acute Osteomyelitis
Acute Osteomyelitis
Acute Osteomyelitis
Age variation
Neonates:
Extensive bone necrosis
Increased ability to absorb large sequestrum
Increased ability to remodel
Epiphysio-metaphyseal vascular connection
leading to secondary septic arthritis
Acute Osteomyelitis
Clinical Features
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severe pain
reluctant to move
fever
malaise
toxemia
Acute Osteomyelitis
Clinical Pictures
History:
Skin lesion
Sore throat
Trauma
Acute Osteomyelitis
Clinical Pictures
Symptoms:
Pain, restless
Malaise and fever
The limb is held still
(pseudo paralysis)
Sometimes mild or
absent (neonates)
Acute Osteomyelitis
Clinical Pictures
Signs:
General and Local
Laboratory Tests:
CBC
ESR+CRP
Blood culture (+ve in 50-70%)
Aspiration (Gram stain + culture and sensitivity)
Acute Osteomyelitis
Infant
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failure to thrive
drowsy
irritable
metaphyseal tenderness
decrease ROM
commonest around the knee
Acute Pyogenic
Osteomyelitis
Age variation
Adults:
No subperiosteal abscess due to adherent
periosteum
Soft tissue abscess
Vascular connection with the joint leading to
secondary septic arthritis
Acute Osteomyelitis
Adult
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commonly thoracolumbar spine
fever
backache
history of UTI or urological procedure
old ,diabetic ,immunocompromised
Acute Osteomyelitis
Diagnosis
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History and clinical examination
FBC, ESR, B.C.
X-ray (normal in the first (10-14) days
Ultrasound
Bone Scan Tc 99, Gallium 67
MRI
Aspiration
Acute Osteomyelitis
Radiography
Plain X-ray
Ultrasound
Bone & gallium scan (Sensitive but not
specific)
CT scan
MRI
Acute Osteomyelitis
Acute Osteomyelitis
Differential Diagnosis
Acute Septic Arthritis
Acute monoarticular
rheumatoid arthritis
Sickle cell crisis
Cellulitis
Ewing’s Sarcoma
Acute Osteomyelitis
Treatment
Antibiotics:
Type?
Route?
When to start?
When to stop
Monitoring?
Acute Osteomyelitis
Treatment
Surgical Drainage:
Indications?
Procedure?
Drilling?
Acute Osteomyelitis
Treatment
General:
Hospitalization
Hydration
Electrolyte replacement
Analgesia
Immobilization
Acute Osteomyelitis
Treatment
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supportive treatment for pain and
dehydration
splintage
antibiotics
surgery
Acute Osteomyelitis
Treatment
 Antibiotics: Start blindly after taking blood
culture.
 Older child & previously fit adults.(staph inf): I/V
flucloxacillin and fusidic acid. 2-3 wks. Then
orally 3-6 wks.
 Child under 4 (haemophilus inf.): Cefuroxime or
cefotaxime or co-amoxiclav.
 Immunocompromised pts: Third generation
cephalosporins.
Acute Osteomyelitis
Treatment
Neonates and infants up to 6 months of age
:penicillin-resistant Staphylococcus aureus,
Group B streptococcus and Gram-negative
organisms.
flucloxacillin plus a third-generation
cephalosporin like cefotaxime.
 Children 6 months to 6 years of age
:Haemophilus influenzae. combination of
intravenous flucloxacillin and cefotaxime or
cefuroxime.
Acute Osteomyelitis
Treatment
 Elderly and previously unfit patients, Gram-negative infections,
combination of flucloxacillin and a second- or third-generation
cephalosporin.
 Heroin addicts and immunocompromised patients
Unusual infections (e.g. with Pseudomonas aeruginosa,
Proteus mirabilis or anaerobic Bacteroides species)
third-generation cephalosporins or a fluoroquinolone
preparation, depending on the results of sensitivity tests.
Acute Osteomyelitis
Treatment
 Drainage:
1. CF do not improve within 36 Hrs.
2. Signs of deep pus.( swelling, oedema,
fluctuation).
3. If pus is aspirated.
Acute Osteomyelitis
Complications
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septicemia
metastatic infection
septic arthritis
altered bone growth
chronic osteomyelitis
Acute Osteomyelitis
Prognosis
Factors affecting prognosis:
Organisms
Infected Bone
Age of the Patient
Treatment
Subacute Osteomyelitis
Clinical features
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long history (weeks, months)
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pain, limp
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swelling occasionally
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local tenderness
Subacute Osteomyelitis
Pathology
Brodies abscess
a well defined cavity
in cancellous bone
Subacute Osteomyelitis
Investigation
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X ray
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Bone scan
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Biopsy(50%) grow organism
Subacute Osteomyelitis
Treatment
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antibiotics for 6 months
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surgery