1. Acute Osteomyelitis

2. Infection in bone Osteomyelitis l acute (subacute) l chronic l specific (eg TB) l non specific(most common)

3. Acute haematogenous OM l mostly children l boys> girls l history of trauma

4. Acute Osteomyelitis Organism l Gram +ve l staphylococus aureus l strep pyogen l strep pneumonie l Gram -ve l haemophilus influnzae (50% < 4 y) l e.coli l pseudomonas auroginosa, l proteus mirabilis

5. Acute Osteomyelitis Source Of Infection l infected umbilical cord in infants l boils, tonsilitis, skin abrasions l in adults UTI, in dwelling arterial line

6. Acute Osteomyelitis Source of Infection: zHematogenous zDirect spread zExogenous

8. 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

9. 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)

10. Acute Osteomyelitis

12. 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

13. Acute Osteomyelitis Clinical Features l severe pain l reluctant to move l fever l malaise l toxemia

14. Acute Osteomyelitis Clinical Pictures History: Skin lesion Sore throat Trauma

15. Acute Osteomyelitis Clinical Pictures Symptoms: zPain, restless zMalaise and fever zThe limb is held still (pseudo paralysis) zSometimes mild or absent (neonates)

16. 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)

17. Acute Osteomyelitis Infant l failure to thrive l drowsy l irritable l metaphyseal tenderness l decrease ROM l commonest around the knee

18. 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

19. Acute Osteomyelitis Adult l commonly thoracolumbar spine l fever l backache l history of UTI or urological procedure l old,diabetic,immunocompromised

20. 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

21. Acute Osteomyelitis Radiography zPlain X-ray zUltrasound zBone & gallium scan (Sensitive but not specific) zCT scan zMRI

26. Acute Osteomyelitis

27. Differential Diagnosis zAcute Septic Arthritis zAcute monoarticular rheumatoid arthritis zSickle cell crisis zCellulitis zEwing’s Sarcoma

28. Acute Osteomyelitis Treatment Antibiotics: xType? xRoute? xWhen to start? xWhen to stop xMonitoring?

29. Acute Osteomyelitis Treatment Surgical Drainage: xIndications? xProcedure? xDrilling?

30. Acute Osteomyelitis Treatment General: zHospitalization zHydration zElectrolyte replacement zAnalgesia zImmobilization

31. Acute Osteomyelitis Treatment l supportive treatment for pain and dehydration l splintage l antibiotics l surgery

32. 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.

33. 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.

34. 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.

35. 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.

36. Acute Osteomyelitis Complications l septicemia l metastatic infection l septic arthritis l altered bone growth l chronic osteomyelitis

37. Acute Osteomyelitis Prognosis Factors affecting prognosis: zOrganisms zInfected Bone zAge of the Patient zTreatment

38. Subacute Osteomyelitis Clinical features l long history (weeks, months) l pain, limp l swelling occasionally l local tenderness

39. Subacute Osteomyelitis Pathology Brodies abscess a well defined cavity in cancellous bone

40. Subacute Osteomyelitis Investigation l X ray l Bone scan l Biopsy(50%) grow organism

41. Subacute Osteomyelitis Treatment l antibiotics for 6 months l surgery