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Osteomyelitis

Hendy Buana Vijaya


Introduction
• Acute haematogenous osteomyelitis show a characteristic progression
marked by imflamation, suppuration, bone necrosis, reactive new bone
formation, resolution and healing.
• Acute haematogenous osteomyelitis, if left untreated and provided the
patient does not succumb to septicaemia – will subside into a chronic bone
infection
Aetiology
• The causal organism in both adults and children is usually Staphylococcus
aureus (found in over 70% of cases), and less often one of the other Gram-
positive cocci, such as the Group A beta-haemolytic streptococcus
(Streptococcus pyogenes) which is found in chronic skin infections, as well
as Group B streptococcus (especially in new-born babies)
Predisposing to bone infection
Pathogenesis

Increasingly
compromise
Intraosseous the blood
pressure rise supply

Acute
imflammatory
reaction
Pathogenesis

a. Infection in the
metaphysis may speard
toward surface
b. Encased in periosteal
newborn as a
sequestrum
c. Encasing involucrum is
sometimes perforated
by sinus.
Differential diagnosis
• Cellulitis. There is widespread superficial redness and lymphangitis
• Acute suppurative arthritis. Tenderness is diffuse, and movement at the joint is
completely abolished by muscle spasm
• Streptococcal necrotizing myositis. Occasionally invade muscles and cause an acute
myositis which, in its early stages, may be mistaken for cellulitis or
osteomyelitis
Classification
Clinical features
• Severe pain
• Malaise and fever
• Fails to thrive
• Drowsy
Diagnosis (Plain X-ray)

The first x-ray, 2 days after


symptoms began, is normal – it
always is; metaphyseal
mottling and periosteal changes were
not obvious until the
second film, taken 14 days later;
eventually much of the
shaft was involved
(a,b) The classic Brodie’s abscess
looks like a small walled-off cavity in
the bone with little or no periosteal
reaction;
(c) sometimes rarefaction is more
diffuse and there may be cortical
erosion and periosteal reaction.
Chronic osteomyelitis
may follow acute. The
young boy
(a) presented with
draining sinuses at the
site of a previous acute
infection. The x-ray
shows densely sclerotic
bone. (b) In adults,
chronic osteomyelitis is
usually a sequel to
open trauma or
operation.
Diagnosis
• Ultrasonography may detect a subperiosteal collection of fluid in the early
stages of osteomyelitis, but it cannot distinguish between a haematoma and
pus.
• Magnetic resonance imaging can be helpful in cases of doubtful
diagnosis, and particularly in suspected infection of the axial skeleton. It is
also the best method of demonstrating bone marrow inflammation. It is
extremely sensitive, even in the early phase of bone infection, and can
therefore assist in differentiating between soft-tissue infection and
osteomyelitis.
• Laboratory investigation Tissue aspiration will give a positive result in
over 60% of cases; blood cultures are positive in less than half the cases of
proven infection. The C-reactive protein (CRP) values are usually elevated
within 12–24 hours and the erythrocyte sedimentation rate (ESR) within
24–48 hours after the onset The white blood cell (WBC) count rises and
the haemoglobin concentration may be diminished
Treatment
There are four important aspects to the management of the patient:
• Supportive treatment for pain and dehydration.
• Splintage of the affected part.
• Appropriate antimicrobial therapy.
• Surgical drainage.
Antibiotic
• Neonates and infants up to 6 months of age Initial antibiotic treatment should be effective against penicillin-resistant Staphylococcus
aureus, Group B streptococcus and Gram-negative organisms. Drugs of choice are flucloxacillin plus a third-generation
cephalosporin like cefotaxime.
• Children 6 months to 6 years of age Empirical treatment in this age group should include cover against Haemophilus influenzae, unless it
is known for certain that the child has had an anti-haemophilus vaccination. This is best provided by a combination of
intravenous flucloxacillin and cefotaxime or cefuroxime
• Older children and previously fit adults The vast majority in this group will have a staphylococcal infection and can be started on
intravenous flucloxacillin and fusidic acid. Patients who are allergic to penicillin should be treated with a second- or
thirdgeneration cephalosporin.
• Elderly and previously unfit patients In this group there is a greater than usual risk of Gram-negative infections, due to respiratory,
gastro-intestinal, or urinary disorders and the likelihood of the patient needing invasive procedures. The antibiotic of choice
would be a combination of flucloxacillin and a second- or third-generation cephalosporin
Operation
• Debridement At operation all infected soft tissue and dead or devitalized bone, as well as any infected
implant, must be excised. After three or four days the wound is inspected and if there are renewed
signs of tissue death the debridement may have to be repeated several times if necessary
• Dealing with the ‘dead space’ There are several ways of dealing with the resulting ‘dead space’. Porous
antibiotic-impregnated beads can be laid in the cavity and left for 2 or 3 weeks and then replaced with
cancellous bone grafts.
• Soft-tissue cover Last but not least, the bone must be adequately covered with skin. For small defects
splitthickness skin grafts may suffice; for larger wounds local musculocutaneous flaps, or free
vascularized flaps, are needed
Complication
• Epiphyseal damage and altered bone growth
• Suppurative arthritis
• Metastastic infection
• Pathological fracture
• Chronic osteomyelitis

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