OSTEOMYELITIS

By:
Prof.dr.Hafas Hanafiah, SpB, SpOT(K) Paed

Definition
Osteomyelitis is an infection at cortex and
medulla of bone caused by pyogenic or
non-pyogenic infection.1
Osteomyelitis is an acute or chronic bone
infection that are usually caused by
bacteria.2
Osteomyelitis is an infectious usually
painful inflammatory disease of bone that
is often of bacterial origin and may result
in death of bone tissue3

Etiology
Staphylococcus aureus, Hemophylus
influenza, Mycobacterium
tuberculosa, Peptostreptococcus sp.,
Actinomyces sp., Propionibacterium
acnes

Epidemiology
About 1 in every 675 US hospital admissions each year
(50,000 cases annually) is due to osteomyelitis.
Staphylococcus aureus strains cause serious
nosocomial infections all over the world. Overall,
approximately 20% of S. aureus isolates in Europe are
reported as methicillin-resistant, whereas in the US, the
prevalence ranges from 33% to 55%.
Post-traumatic osteomyelitis accounts for as many as
47% of cases of osteomyelitis in some series..
Haematogenous osteomyelitis is primarily a disease of
children, with 85% of cases occurring in patients
younger than 17 years of age, and accounts for about
20% of cases overall

Classification of
Osteomyelitis
Hematogenous
Hematogenous

Waldvogels Classification

Contigous

Contigous w/
w/ vascular
vascular
Contigous
insufficiency
insufficiency

Classification of
Osteomyelitis

Cierny & Mader Classification

Classification by Duration
Acute:
Recent onset of symptom
No previous treatment
Chronic:
Symptoms for 4-6 weeks
Previous attempts at therapy
Infection following open fracture or
surgical prosedures
Complications: sequestrum, sinus tract
with pus drainage

A small septic microabcess is forming at

capillary loops. Expansion of septic focus
stimulates resorption of adjacent bony
trabecular. Woven bone surround this focus
The abcess expands into the cartilage and
stimulates reactive bone formation by the
periosteum
The abcess which expandthrough the cortex into
subperioseal tissue, shears off the perforating arteries
that suply the cortex with blood, leading to necrosis of
cortex

The extension of this process into the joint space, the

epiphysis, and the skin produce a draining sinus

The necrotic bone is called a sequestrum. The viable bone

surrounding sequestrum is termed the involucrum

Clinical
Manifestation

Hematogenous long-bone osteomyelitis

Abrupt onset of high fever (fever is present in only 50% of
neonates with osteomyelitis)
Fatigue
Irritability
Malaise
Restriction of movement (pseudoparalysis of limb in
neonates)
Local edema, erythema, and tenderness

Hematogenous vertebral osteomyelitis

Insidious onset
History of an acute bacteremic episode
May be associated with contiguous vascular insufficiency
Local edema, erythema, and tenderness
Failure of a young child to sit up normally

Chronic osteomyelitis

Nonhealing ulcer
Sinus tract drainage
Chronic fatigue
Malaise

Diagnosis

CBC count
Culture
Radiography
MRI
Radionuclide bone scanning
CT scanning
Ultrasonography

Treatment of
Osteomyelitis
Stage 1 osteomyelitis:
Usually treated with antibiotic and
operative intervention.
Antimicrobial therapy is given for 4
weeks
Therapy fails & compromised by
recurreant infection bone or soft
tissue debridement followed by
another 4 weeks antibiotics

Stage 2 osteomyelitis:
Shorter course of antibiotics usually
needed.
2 week course antibiotics following
debridement of cortex an tissue
coverage an arrest rate 100% in A
host and 79% in B host.

Stage 3 and 4:
Antimicrobial therapy is received 4 to 6
weeks dated from the last major
debridemant surgery.
Even if necrotic tissue has been
debrided, the remaining tissue bed
must be considered contaminated.
An arrest rate of 98% in A host and 80%
(stage 4) to 92% (stage 3) in B host.

Acute Hematogenous Osteomyelitis

Pain relief by bed rest
Give IV antibiotics according to local
guidelines (after blood cultures and
swab sample) eg. Flucloxacillin IV
then orally for 4 to 6 weeks dose
adjusted according to age,
Clindamycin penicillin alergic
Vancomycin MRSA
Ampicillin - Haemophilus

 Surgical drainage of mature

subperiosteal abscess with
debridement of all necrotic tissue,
obliteration of dead spaces,
adequate soft tissue coverage, and
restoration of an effective blood
suply.

Chronic Osteomyelitis
Secondary to ac. Osteomyelitis
Conservative surgery for case where
abscess form
Chronic abcess require drainage,
debridment dead tissue, obliteration of
dead space.
Closed suction drainage/irrigation
system
Antibiotic impregnated beads
Unresolviing cases may requre
amputation

 Secondary to trauma
Prevention of compound fracture with
debridement and lavage of
contaminated tissue

Excise all dead tissue widely

Copious lavage
Skeletal stabilization
IV antibiotics

PROGNOSIS
The prognosis of osteomyelitis
depends on 4 factors:
1. Interval of infection to the intitution
of treatment
2. Sensitivity of antibacterial drugs
3. Adequate dose of antibacterial
drugs
4. Duration of antibacterial therapy

COMPLICATION
1. Acute Hematogenous
Osteomyelitis
a. Early Complication
septicemia
abscess formation
septic arthritis
b. Late Complication
chronic osteomyelitis
pathological fracture
joint contracture
local growth
disturbances

2. ChronicOsteomyelitis
joint contracture
pathologycal fracture
amyloid disease
epidermoid carcinoma
3. Acute Septic Arthritis
a. Early Complication
. septicemia
. destruction of joint
cartilage
. avascular necrosis of the
epiphysis
b. Late Complication
. degenerative disease
. permanent dislocation

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