OSTEOMYELITIS
By MARIAMAWIT B.(MD)
DBU, COLLEGE OF MEDICINE
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Osteomyelitis :
is the suppurative process of the bone caused by pyogenic
organisms OR
a pyogenic infection of cancellous portion of the bone.
Classification
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Based on the duration is classified in to three:1. Acute osteomyelitis ( <3 weeks)
2. sub acute osteomyelitis--longer than 3 weeks
but who have not developed extensive necrotic
bone
3. Chronic osteomyelitis( >3 weeks)
4. Acute on chronic osteomyelitis.
Based on the mechanism of infection
-hematogenous or secondary to a
-contiguous focus of infection
-Direct inoculation
-Hematogenous osteomyelitis occurs more
commonly in children than adults; in children, long
bones are most often affected, while in adults the
vertebrae are the most common site
Based on the affected portion of the bone
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-stage I Medullary OM(e.g Hematogenous
osteomyelitis and infected intramedullary rod)
-stage II Superficial OM limited to the surface of
exposed bone(contiguous focus infection of bone)
-stage III Localised OM involves some part of
bone. (full thickness, cortical sequestration)
-stage IV Diffuse OM involves entire bone.
Acute Osteomyelitis
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Causes:S- series organisms: ( severe osteomyelitis)
> s. aureus, strept haemolyticus,
salmonella,
P- series via punctured wounds
> pseudomonas, pneumococcus
C series compound fractures
> clostridium, coliforms ( E- coli)
Cont...
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Others:- H influenza, brucella bacillus, Tpallidum, M .tuberculosis, anaerobes
Fungal causes :
actinomycosis
blastomycosis
cryptococcosis
coccidomycosis
candidiasis
Risk factors
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Extremes of age
Immunosuppression
Trauma
Infection ( local or systemic)
Surgical procedures of the bone
DM, Malnutrition
Animal bite
Past hx
pathogenesis
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The infective process usually begins in the metaphysis.
In children the growth plate is rarely affected
Pus formed during the necrotic process pushes against the
periosteum eventually bursting through it.
tracks towards the skin via muscle and soft tissue -form a
sinus
The infarcted bone is called sequestrum.
New periosteal bone surrounding dead bone is called the
involucrum,
and the pores within the involucrum through which pus
tracks are called cloacas.
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Clinical manifestation
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Fever, chills, rigors, profuse sweating
Swelling
Limitation of movement
Tenderness, local warmth,
Point bony tenderness.
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Classic inflammatory signs
Calor - warmth
Rubor redness
Tumor - swelling
Dolor pain
Functio laesa impaired function
Complications
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Septicaemia and pyaemia
Septic arthritis
Chronic osteomyelitis ( 5-10%)
Pathological fracture
Growth disturbance
Brodies abscess.
Recurrence
-Poor prognostic signs:-
> OM of children
> staph aureus infection
> OM around the trunk.
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Diagnosis
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-clinical findings
-history and
-physical examination Look:
redness and oedema may be seen over the affected metaphysis
the limb is held still. (pseudoparalysis).
Feel:
warmth at the affected site
focal bony tenderness-an important sign
fluctuant swelling overlying the bone
Move:
pain on movement.
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radiography
laboratory findings (raised WBC, ESR, CRP)
Blood culture
Management
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Immobilisation and elevation
Antibiotics broad spectrum ( IV for 2wks followed
by PO for 4 weeks)
Analgesics
Surgery:- if no response to antibiotics
- abscess formation
- severely ill
Types of surgery
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Aspiration
Incision and drainage
Multiple drill holes
Small bone window
Sub acute osteomyelitis
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Caused by staph aureus
Pain without constitutional symptoms
Is due to > increased host resistance
> lowered bacterial resistance
> early Rx before Sx appear
> Blood culture is +ve in 60% of cases
> Wbc and ESR raised in 50% of cases.
Chronic Osteomyelitis
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OM lasting > 3weeks
Causes are similar to acute OM
=> may follow acute OM
=> may be chronic from the begining
Clinical manifestations
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Fever, pain, swelling acute exacerbation
of
COM.
Irregular thickening of bone
Sinuses multiple
Indicate:
- unabsorbed sequestra,
- unobliterated cavity or
- presence of anaerobic organism
Scars and muscle contractures.
Cont...
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Shortening or lengthening of the bones
Deformities and decreased movement
Pathological fractures.
Investigation
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ESR,
Blood culture-negative except during a flare-up.
Gram stain from aspirates.
X rays-----cortical erosion, periosteal reaction, mixed
lucency, and sclerosis .
-----Other findings may include sequestra
(radiodense appearance) and soft tissue swelling
(particularly when osteomyelitis is accompanied by cellulitis
or abscess).
Bone scan
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A, Soft tissue loss is seen overlying the 5th
metatarsal head
B, Three weeks later, a corresponding
radiograph reveals cortical destruction of the
5th metatarsal head
Treatment
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Antibiotics -3 months or more
Surgery:
> sequestrectomy
> abscess drainage
> curettage.
> amputation
Complications
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Pathological fracture
Growth disturbance
Deformities
Squamous cell carcinoma around the sinus tract
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THE
END
Septic Arthritis
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Is bacterial infection of the joint.
Causes: s, aureus, streptococcus, gonococci, E. coli,
H. influenza etc
RFs:- DM, trauma, malignancy, steroid Rx, OM etc
Frequently involves major joints: knee > hip > elbow
> shoulder etc
90% - is monoarticular
Pathology
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Exudation in to joint serous, sero-fibrinous or
purulent
2. Destruction of articular cartilage
3. Destruction of capsule and ligaments by pus.
1.
C/M : - constitutional Sx like pain, fever, swelling etc
- local warmth, tenderness etc
- limitation of movement
Ix
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CBC, ESR, CRP
Joint aspirate and synovial fluid analysis ( wbc
>50,000, PMN > 90%)
X Ray : Early stage- ST swelling and peri-articular
osteoporosis
Late stage- narrowing of joint space, necrosis
of bone, cartilage destruction, ankylosis of bone etc
Mx
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Broad spectrum antibiotics
Analgesics
Arthrotomy or joint drainage
Immobilisation - by splint/traction
Complications
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Joint destruction
Pathological dislocation
Osteoarthritis
Acute osteomyelitis
Septicaemia
Etc.
THE END
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