ACUTE OSTEOMYELITIS

Classification
According to course:
Acute, Sub acute, Chronic
According to source: Haematogenous, Externous
According to host:
Suppurative, Non suppurative
Etiology:
Staphylococcus aureus
In infants Streptococci
Other: H influenzae, pneumococcus, Salmonella in sickle cell disease, Fungal,
Tuberculous.
Site:
Metaphysis in young children
1.
More blood flow
2.
Hair pin bend
3.
Immature vessels
4.
Rapidly growing cells
Diaphysis in adults
Epiphysis in infants
Pathology:
Haematogenous Osteomyelitis:
Bacteremia Local factors / poor host immunity
Suppuration spread through Haversian and Volkmanns systemsubperiosteal pus- circumferential stripping soft tissue pus
Necrosis Infective thrombosis, tension in bone, stripping of periosteum
Sequestrum
New bone formation Involucrum Cloaca
Externous Osteomyelitis
Surgery, Trauma, Contagious infection
Clinical features
History of sore throat or boil
Fever, Pain, Ill, toxic child
Local signs:
Inspection:
Loss of function, swelling, redness
Palpation:
Local tenderness, warmth, edema
Movement: Little movement possible in the neighboring joint
X-rays
First few days No change
Patchy rarefaction, periostitis
Sequestrum, Involucrum, Cloaca
Treatment:
Antibiotics
Splintage
Drainage
Complications:
Septicemia
Metastatic abscess
Septic arthritis
Limb length discrepency
Chronic Osteomyelitis
Chronic Osteomyelitis
Pathology:
Cavities, sequestra, dense sclerosis, sinuses
Clinical varieties:
1. Sinuses
2. Flares
3. Sinuses with recurrent flares
Treatment:
Debridement
Saucerization

Closing the gap soft tissue, flaps

Bone grafting
Antibiotics
Chronic Osteomyelitis of Insidious Onset
1.
2.
3.
4.

Brodies Abscess
Tuberculous Osteomyelitis
Syphilitic Osteomyelitis
a.
Gumma
b.
Diffuse periostitis
Chronic sclerosing osteomyelitis of Garre

Septic Arthritis
Spread
1.

Haematogenous
2.
Direct inoculation from trauma or surgery
3.
Contiguous spread from an adjacent site of osteomyelitis or cellulitis.
Predisposing factors:
1.
Young children and elderly
2.
Immune Suppression- Neoplasm, Chronic diseases - DM, RA, SLE, chronic
hepatic/ renal failure
3.
Malnutrition, IV drug use, alcoholism.
4.
Previous joint trauma or arthritis.
Micro-organisms:
NeonatesStreptococcus (commonest); Staphylococcus, Candida, and gram-negative
bacilli, Haemophilus influenzae type B
Adults
Staphylococcus aureus, Neisseria gonorrhoeae
Pathology
1.
Raised pressure in the joint due to exudates or pus destruction of epiphysis.
2.
Thrombosis of vessels destruction of epiphysis and associated AVN.
3.
Discharge Pus
4.
Fibrosis intra & peri-articular fibrosis limitation of joint motion
Site:
Usually mono-articular- hips and knees.
Gonococcal Poly articular
Clinical Features:
In neonates local signs may be minimal and general signs predominate difficult
to diagnose.
General
Fever, infection at another site (e.g., the umbilical catheter), irritability,
failure to thrive, asymmetry of limb position, displeasure at being handled.
Local
Symptoms: Pain, Swelling and loss of motion
Signs:
Position of ease, erythema, Swelling, warmth, local
tenderness, No passive motion (Murphys aphorism).
Gonococcal Poly-articular and may be associated with a papular rash.
Diagnosis:
1.
Joint aspiration: RE & C/S Gram staining, culture, cell counts> 50,000/mm3
2.
TLC, ESR, C-reactive protein levels.
Management
1.
Drainage - Open surgical, Arthroscopic, Multiple aspirations; Continuous
irrigation.
2.
Antibiotics- Empirically / according to C/S- 4 to 6 weeks.
3.
Rest: Position of function to prevent deformity - Thomas splint, skin traction,
isometric muscle strengthening, and active range-of-motion exercises, CPM
4.
Exercises: As the infection resolves, therapy to restore normal joint function,
functional splinting, dynamic splints, serial casting.
5.
Sequele: Arthrodesis / Joint replacement once the infection is quiescent for 2
years.

Slides
Bones
1.
2.
3.
4.
5.

Bone
Sources of infection
Metaphysis
Pathogenesis
Treatment

Joints
1.
2.
3.
4.
5.

Joint
Pathogenesis
Treatment Drainage : Repeat aspiration; arthroscopic, open, irrigation
Rest
Arthrodesis / Replacement