osteomylitis

OSTEOMYLITIS

BY- DR. ALOK VERMA

Defination

Inflammation of bone tissue or/& bone marrow

due to pyogenic infection.

CLINICAL PRESENTATION

ACUTE

CHRONIC

ACUTE

Can be primary (Hematogenous) or secondary (following an open fracture or operation).

Hematogenous is commonest and often seen in children.

AETIOLOGY Mainly two cause

1 – Low Immunity of individual.

2 – High virulence of causative organism.

CAUSETIVE ORGANISM Age group Most common organisms Newborns (younger than 4 mo) ----- S. aureus, Enterobacter species,

and group A and B Streptococcus species. Children (aged 4 mo to 4 y) ---------- S. aureus, group A Streptococcus

species, Haemophilus influenzae, and Enterobacter species. Children, adolescents (aged 4 y to adult) -------- S. aureus (80%),

group A Streptococcus species, H. influenzae, and Enterobacter species.

Adult --------S. aureus and occasionally Enterobacter or Streptococcus species.

Sickle Cell Anemia Patients ---------------Salmonella species.

COMMON SITE

METAPHYSIS OF LOWER END FEMUR , UPPER END OF TEBIA , UPPER FEMUR , UPPER HEUMERUS.

IN SOME JOINT METAPHYSIS IS INTRACAPSULAR LEADS PYOGENIC ARTHRITIS.

ANATOMY OF BONE

PATHOGENESIS HOST INFLAMMATORY RESPONSE TO BACTERIA LEADS DESTRUCTION OF BONE TISSUE FOLLOWED BY

FORMATION OF EXUDATION AND PUS CELLS ONCE SUFFICIENT AMOUNT OF PUS IS FORM IT SPREAD IN

FOLLOWING DIRECTION

MEDULLARY CAVITY OUT OF CORTEX JOINT CAPSULE

TOWARDS MEDULLARY CAVITY

THROMBOSIS OF VEIN AND ARTERIES

CUT OFF BLOOD SUPPLY OF PERTICULAR THAT SEGMENT

TOWARDS CORTEX

PUS GOES TO SUBPERIOSTEAL SPACE LIFTING OF PERIOSTIUM LEADING TO

DAMAGE THE BLOOD SUPPLY OF THAT PERTICULAR PART

THAT SEGMENT RENDERED AVASCULAR

K/A SEQUESTRUM

TOWARDS CORTEX………….. PERIOSTIUM GENRATES NEW BONE

SUBPERIOSTIALY (INVOLUCRUM)

PERIOSTIUM PERFORATES AND PUS COME INTO SUBCUTANEOUS PLANE ,AS ABSCESS

BURSTING OF ABSCESS ,LEADING

DISCHARGING SINUS.

TOWADRS EPIPHYSEAL PLATE RESISTENT TO PUS

LATER ON MAY CAUSE PYOGENIC ARTHRITIS.

CLINICAL FEATURE IN CASE OF PRIMARY O.M. CHILDREN OR

ADOLESCENTS ARE USUALLY VICTIM HISTORY OF TRAUMA MAY OR MAY NOT BE

FOUND. SIGN OF INFLAMMATION AS PAIN , SWELLING,

REDNESS,WARMNESS WILL BE PRESENTS. AFFECTED REGION IS TENDER. SIGN OF TOXAEMIA AS CHILD BECOMES

FEBRIL ALONG WITH RIGORS ,CHILLS, HEADACHE , BACKACHE.

ON PALPATION IF MAXIMUM TENDERNESS IS OVER THE

METAPHYSIS OF LONG BONE THEN DIAGNOSIS IS O.M.

IF MAXIMUM TENDERNESS IS OVER JOINT LINE THEN DIAGNOSIS IS SUPPURATIVE ARTHRITIS.

THERE MAY BE SOME EFFUSION IN ADJACSENT JOINT.

WHEN ABSCESS IS BURST INTO SUBCUTANEOUS TISSUE FLCTUAT ABSCESS MAY BE PALPATED.

PATIENT MAY NOT PERMIT MOVENENT OF NEARBY JOINT.

ONLY WHEN METAPHYSIS IS INTRACAPSULAR ACUTE OM MAY TURN INTO ACUTE SUPPURATIVE ARTHRITIS.

INVESTIGATION

1- BLOOD EXAMINATION WITH CULTURE

(REVEALS LEUCOCYTOSIS AND RAISED ESR AND CAUSETIVE ORGANISM).

2-ASPIRATION OF PUS WITH THICK NEEDLE TO CONFERM PRESESNCE OF PUS WITHIN BONE.

X-RAY NO ROLE IN FIRST FEW DAYS

PATCHY RAREFRACTION AT SITE ON 10TH DAY DUE TO HYPARAEMIA AND LATER NEW BONE FORMATION BY PERIOSTIUM.

SOMETIME SMALL SEQUESTRUM MAY BE SEEN.

DIFFRENTIAL DIAGNOSIS 1 Acute septic arthritis.

2 Acute rheumatic arthritis.

3 Scurvy

4 Acute poliomyelitis

Acute septic arthritis.

Tenderness and swelling localized to joint rather than metaphysis

Movement of joint is restricted and painful.

In case of doubt joint fluid may e aspirated, but under full antiseptic condition.

Acute rheumatic arthritis.

Most feature are similar to ASA but fleeting character of joint pain, elevated ASLO titre and CRP values , positive RA factor may help in diagnosis.

Scurvy

There is formation of subperiosteal heamatoma in scurvy also.

Absence of fever , tenderness and pain along with other feature of malnutrition may help in diagnosis.

Acute poliomyelitis

Fever may be present.

Tenderness is present in muscles not in bone.

TREATMENT EARLY, ADEQUATE TREATMENT IS THE

KEY OF SUCCESS IN ACUTE OM

CASES CAN BE DEVIDED IN TWO GROUPS

1. CHILD BROUGHT WITHIN 48 HRS.

2. CHILD BROUGHT AFTER 48 HRS.

CHILD BROUGHT WITHIN 48 HRS.

REST IMPROOVE GC OF PATIENT AQEQUATE ANTIBIOTICS PROPER REHYDRATION OF PATIENT BY IV FLUIDS IF CHILD RESPOND TO TREATMENT AND AREA OF

TENDERNESS IS REDUCED LIMB MAY BE PUT TO USE.

IF CHILD DOSEN’T RESPOND TO TREATMENT WITHIN 48 HRS , SURGICAL INTERVENTION MAY BE RUQUIRED.

CHILD BROUGHT AFTER 48 HRS.

SURGICAL EXPLORATION AND DRAINAGE IS THE MAINSTAY OF TEATMENT.

A DRILL HOLE IS MADE IN THE REGION OF METAPHYSIS AREA.

A SWAB OF PUS IS TAKEN FOR CULTURE AND SENSTIVITY.

WOUND IS CLOSED OVER STERLISE SUCTION DRAIN.

REST ANTIBIOTICS AND HYDRATION IS CONTINUED POSTOPRATIVLY.

COMPLICATION GENERAL

LOCAL

GENERAL COMPLICATION

SEPTICAEMIA

PYAEMIA

EITHER COMPLICATION IF LEFT UNCONTROLLED MAY BECOME FATAL.

LOCAL COMPLICATION 1 CHRONIC OSTEOMYELITIS

2 ACUTE PYOGENIC ARHRITIS

3 PATHOLOGICAL FRACTURE

4 GROWTH PLATE DISTURBENCES

CHRONIC OSTEOMYELITIS1- Chronic osteomyelitis secondary to

acute osteomyelitis( most common)

2- Garre’s osteomyelitis.

3- Brodie’s abscess

PATHOLOGY Acute changes into chronic due to one or

more following reason- 1 Delayed and inadequate treatment.

2 Type and virulence of organism.

3 Reduced host resistence.

Conti…. In response to persistence infection bone genrating

more and more sub-periosteal new bone.

This deposition is in very irregular fashion so that osteomyelitic bone has very irregular surface.

Continuous discharging sinus get fibrosed and become fixed to bone.

This all leading big sequestrum , involucrum and big size cloacae

DIAGNOSIS Diagnosis suspected clinically but can be

confirmed radiologically Clinical examination is most important— 1 Chronic discharging sinus 2 Thickened irregular bone 3 Tenderness on deep palpation 4 Adjacent joint may be stiff

INVESTIGATION A-X-RAY Reavels 1- Thickening and irregularity of bone cortices. 2- Patchy sclerosis gives honey comb

appearences. 3- Bone cavity shows area of rarefaction

sarrounded by sclerosis 4- Sequestrum ( appears denser than

sarrounding bone) 5 –Involucrum and cloaca may be visible.

BLOOD EXAMINATONESR may be raised other no significant

changes seen usualyPUS CULTURE May grow causative organism.

DIFFRENTIAL DIAGNOSIS 1- TUBERCULAR OSTEOMYELITIS

2- SOFT TISSUE INFECTION

3- EVEING SARCOMA

TREATMENT Primarily surgical ,antbiotics may be

used in acute excerbation and in postoprative period.

Aim of surgery is-

1- Removal of dead bone 2- Elimination of dead space 3- Removal of infected granulaton tissue

and sinus.

SURGICAL PROCEDURE A-SEQUESTRECTOMY B- SAUCERIZATION C- CURETTAGE D- EXCISION OF INFECTED BONE E- AMPUTATION

Most of cases combination of procedure may be required.

COMPLICATIONS An acute excerbation Growth abnormality Pathological fracture Joint stiffness Sinus tract malignancy Amyloidosis

GARRE’S OM Sclerosing , Nonsuppurative chronic

osteomylitis May begins with Acute local

pain ,pyrexia, and swelling . There is tenderness on deep palpation.

There is no discharging sinus. Shaft of femur and tebia are commonly

involved Importance lies in diffrentiating it from

bone tumor. Treatment is Rest, Antibootic and

sometime making hole in bone shaft.

BRODIE’S ABSCESS

This is a special type of O.M. in which body’s defence mechanism has been able to contain the infection so as to create a chronic bone abscess containing pus or jelly like granulation tissue , sarrounded by zone of sclerosis.

CLINICAL FEATURE Patient are usually b/w 11- 20 yr. of age. Commonest site are usually upper end of

tibia and lower end of femur , located of metaphysis.

The deep boring pain is predominant symptom that become worse at night.

On examination tenderness and thickening of bone along with transient effusion in adjacent joint may be present.

DIAGNOSIS Radiological

feature is diagnostic.

X-ray shows circular or oval lucent area sarrounded by zone of sclerosis. Rest of bone is normal.

TREATMENTSurgical evacuation and curattage is

performed under good antibiotic cover.

If cavity is very large cancellous bone chips may be packed.