Acute Osteomyelitis Pathology l starts at metaphysis l ?trauma l vascular stasis l acute inflammation l suppuration l necrosis l new bone formation l resolution
Acute Osteomyelitis Pathology: zPrimary focus and stage of inflammation zSpread of infection with pus formation zFormation of subperiosteal abscess zPus tracks toward skin to form a sinus zBone infarction (Sequestrum) zNew bone formation (involucrum)
Age variation Neonates: zExtensive bone necrosis zIncreased ability to absorb large sequestrum zIncreased ability to remodel zEpiphysio-metaphyseal vascular connection leading to secondary septic arthritis
Acute Osteomyelitis Clinical Features l severe pain l reluctant to move l fever l malaise l toxemia
Acute Osteomyelitis Clinical Pictures Symptoms: zPain, restless zMalaise and fever zThe limb is held still (pseudo paralysis) zSometimes mild or absent (neonates)
Acute Osteomyelitis Clinical Pictures Signs: General and Local Laboratory Tests: yCBC yESR+CRP yBlood culture (+ve in 50-70%) yAspiration (Gram stain + culture and sensitivity)
Acute Osteomyelitis Infant l failure to thrive l drowsy l irritable l metaphyseal tenderness l decrease ROM l commonest around the knee
Acute Pyogenic Osteomyelitis Age variation Adults: zNo subperiosteal abscess due to adherent periosteum zSoft tissue abscess zVascular connection with the joint leading to secondary septic arthritis
Acute Osteomyelitis Adult l commonly thoracolumbar spine l fever l backache l history of UTI or urological procedure l old,diabetic,immunocompromised
Acute Osteomyelitis Diagnosis l History and clinical examination l FBC, ESR, B.C. l X-ray (normal in the first (10-14) days l Ultrasound l Bone Scan Tc 99, Gallium 67 l MRI l Aspiration
Acute Osteomyelitis Radiography zPlain X-ray zUltrasound zBone & gallium scan (Sensitive but not specific) zCT scan zMRI
Acute Osteomyelitis Treatment l supportive treatment for pain and dehydration l splintage l antibiotics l surgery
Acute Osteomyelitis Treatment zAntibiotics: Start blindly after taking blood culture. zOlder child & previously fit adults.(staph inf): I/V flucloxacillin and fusidic acid. 2-3 wks. Then orally 3-6 wks. zChild under 4 (haemophilus inf.): Cefuroxime or cefotaxime or co-amoxiclav. zImmunocompromised pts: Third generation cephalosporins.
Acute Osteomyelitis Treatment zNeonates and infants up to 6 months of age :penicillin-resistant Staphylococcus aureus, Group B streptococcus and Gram-negative organisms. flucloxacillin plus a third-generation cephalosporin like cefotaxime. z Children 6 months to 6 years of age :Haemophilus influenzae. combination of intravenous flucloxacillin and cefotaxime or cefuroxime.
Acute Osteomyelitis Treatment zElderly and previously unfit patients, Gram-negative infections, combination of flucloxacillin and a second- or third-generation cephalosporin. zHeroin addicts and immunocompromised patients Unusual infections (e.g. with Pseudomonas aeruginosa, Proteus mirabilis or anaerobic Bacteroides species) third-generation cephalosporins or a fluoroquinolone preparation, depending on the results of sensitivity tests.
Acute Osteomyelitis Treatment zDrainage: 1.CF do not improve within 36 Hrs. 2.Signs of deep pus.( swelling, oedema, fluctuation). 3.If pus is aspirated.
Acute Osteomyelitis Complications l septicemia l metastatic infection l septic arthritis l altered bone growth l chronic osteomyelitis
Acute Osteomyelitis Prognosis Factors affecting prognosis: zOrganisms zInfected Bone zAge of the Patient zTreatment
Subacute Osteomyelitis Clinical features l long history (weeks, months) l pain, limp l swelling occasionally l local tenderness
Subacute Osteomyelitis Pathology Brodies abscess a well defined cavity in cancellous bone
Subacute Osteomyelitis Investigation l X ray l Bone scan l Biopsy(50%) grow organism
Subacute Osteomyelitis Treatment l antibiotics for 6 months l surgery