Osteomyelitis

Aetiology and organism

Aetiology

Causative organism

Post-Trauma

Staphylococcus aureus

Hematogenous spread

Group A beta hemolytic streptococcus

Vascular insufficiency

Group B beta hemolytic streptococcus

H. influenza
Other gram negative

Pathogenesis
Inflammation
Suppuration intraosseus pressure increased, vascular stasis,
small-vessel thrombosis, periostereal stripping
Necrosis - sequestra due to compromised blood vessel

New-bone formation involucrum encasement

Resolution

Clinical Feature
Infant:
Mild and drowsy
History of birth difficulties
Metaphyseal tenderness
Resistance to joint movement
Multiple infection

Adult
Fever and backache
History of urological procedure
Local tenderness not marked

Children:
Fever and severe pain
History of infection
Acute tenderness near one of
the larger joints
Pseudoparalysis and local
inflammation

Investigation
Biochemical:

Imaging:

Tissue aspiration - +ve

Plain X ray periosteal reaction

Blood culture - +ve

Ultrasound subperiosteal collection of

fluid

ESR and CRP elevated

Radionuclide increased in perfusion and

bone phase

WBC - elevated

Periosteal reaction

Treatment
Hematogenous

Post traumatic

1. General supportive treatment for

pain and dehydration

1. Cleansing and debridement of open

fracture

2. Splintage

2. Leave the wound open for drainage

3. Empirical antibiotics 3-6 weeks:

3. Immobilization of the fracture

4. Surgical Drainage

4. Prophylactic antibiotics 6 hourly for

48 hours for 4-5 days:

5. Treat Complication -septic arthritis

-metastatic infection
-pathological fracture

Subacute Hematogenous
OM
Pathology Organism less virulent or host more resistant

Distal femur and the proximal and distal tibia

are common site

Clinical
feature

Child or adolescent
Several weeks - months
Limp, slight swelling, muscle wasting and local
tenderness
Normal temperature, WBC, blood culture

Imaging

Xray
Bone scan

Treatmen
t

Conservative
Immobilization
Antibiotics IV for 4 or 5 days then oral for another 6
weeks
Open biopsy and curettage

Garre Sclerosing
Ostemyelitis
Clinical
feature

Type of chronic OM
Marked sclerosis and cortical thickening

Imaging X-ray Increased bone density and cortical thickening

Differential
Diagnosis

Resemble osteoid osteoma, or Ewing sarcoma

Treatment

Operation and bone grafts

Brodie Abscess

Garre Sclerosing
Ostemyelitis

Tuberculosis
Pathology

Primary, secondary and tertiary

Clinical
features

Previous TB infection,
Muscle spasm during waking and relax with sleep
Lymphadenopathy, limited movement, muscle wasting
Gibbus deformity

Investigati
on

Xray finding
ESR elevated and Mantoux test +ve
Synovial fluid cloudy and high protein
elevated white cell and +ve acid fast bacilli culture

Treatment

1. Rest
2. Chemotherapy
3. Operation

Complications: Vertebral collapse -> Kyphosis

CHRONIC OSTEOMYELITIS

Aetiology
A sequel from Acute Osteomyelitis.
Fx: Host defense compromised by scar, dead and
dying tissue. Poor perfusion and patent cavities.
Bacteria covered in protein-polysaccharide slime.
Systemic disease that affect immune system.

Causative Organisms

Staph Aureus
E. Coli
Strep. Pyogenes
Proteus Mirabilis
Pseudomonas Aeruginosa
Staph Epidermidis (Foreign Implant)

Clinical Features

Pain, pyrexia, redness & tenderness (signs of

inflammation)
Key Word: Recurred
Usually present with discharging sinus

Investigation:

Management

WBC
ESR & CRP
Culture & Sensitivity
Other investigation that can influence the prognosis
such as diabetes and leukemia

Imaging: Can be X-ray, Radioisotope Scintigraphy, MRI

or CT.
X-ray
Patchy loss of density/frank excavation around implant with
sclerosis of the surrounding bone.

Radioisotope
Ga-Citrate / In-labelled leukocyte (hidden foci of infection)

CT/MRI
Operative treatment & reactive oedema

Staging (Cierny Staging):

i)
Lesion
Stage
Stage
Stage
Stage

ii)

1:
2:
3:
4:

Medullary
Superficial
Localised
Diffuse

Host Category
Type A: Normal
Type B: Compromise by local or systemic conditions
Type C: Severely compromise

Treatment:
Antibiotics:
Aim for suppression and control of acute flares (Fucidic Acid,
Clindamycin and Cephalosporin) 4-6 weeks

Local Treatment:
I&D, Dressings & Colostomy

Surgical:
Failure of controlling the symptoms

SEPTIC ARTHRITIS
2.

Aetiology
1.
Direct Invasion
Direct spread from adjacent
3.
Blood spread

The infection settled in synovial fluid -> Acute inflammation

w serous formation-> Increase synovial fluid -> Articular
cartilage eroded by bacterial + proteolytic enzymes
Worsen in children
Causative Organisms
Staph Aureus
Children (1-4 y.o.): Haemophilus Influenza (less likely if
vaccinated)

Management
Investigations:
WBC (50 000 per mL sepsis, 10 000/mL non-infective
inflammatory dis., N less than 300/mL)
ESR & CRP
Culture & Sensitivity (examine the discharge too)
Other investigation that can influence the prognosis such
as diabetes and leukemia

Imaging
Ultrasound (space between capsule & bones should not
more than 3mm)
X-ray (usually limited to soft tissues visualisation)
MRI & Radionuclide for obscure sites

Treatment

Complications
Subluxation or dislocation
Damage to physis or epiphysis
Articular cartilage erosion ->
ankylosing of the joints