FirstRanker Logo

FirstRanker.com - FirstRanker's Choice is a hub of Question Papers & Study Materials for B-Tech, B.E, M-Tech, MCA, M.Sc, MBBS, BDS, MBA, B.Sc, Degree, B.Sc Nursing, B-Pharmacy, D-Pharmacy, MD, Medical, Dental, Engineering students. All services of FirstRanker.com are FREE

📱

Get the MBBS Question Bank Android App

Access previous years' papers, solved question papers, notes, and more on the go!

Install From Play Store

Download MBBS Orthopaedics PPT 13 Osteomyelitis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 13 Osteomyelitis Lecture Notes

This post was last modified on 07 April 2022

--- Content provided by⁠ FirstRanker.com ---

Learning objectives

? Definition
? Aetiology
? Pathogenesis

--- Content provided by⁠ FirstRanker.com ---

? Clinical picture
? Investigations
? Differential diagnosis
? Treatment

--- Content provided by⁠ FirstRanker.com ---


Definition

? Inflammation of bone
? Osteo= bone ,myelitis = inflammation of marrow

--- Content provided by‍ FirstRanker.com ---

? Rapid destructive pyogenic infection
? Most frequently in infants and children

Aetiology

--- Content provided by​ FirstRanker.com ---

? Bacterial infection but at times can be fungal infection

? Causes can be ?
1. Diabetes
2. Intravenous drug use

--- Content provided by‍ FirstRanker.com ---

3. Trauma to the part
4. Immunocompromised status of the host.
5. Poor nutrition ,unhygienic surroundings


--- Content provided by‍ FirstRanker.com ---

Aetiology

? Sex: Male /female -4:1

? Location :metaphysis of long bone

--- Content provided by FirstRanker.com ---


due to rich blood supply to that
area

? Hairpin bent of the metaphyseal

--- Content provided by‌ FirstRanker.com ---


vessels

? Metaphyseal hemorrhage

--- Content provided by FirstRanker.com ---

? Defective phagocytosis

? Vasospasm of the end arteries

preventing the antibiotics to reach

--- Content provided by‍ FirstRanker.com ---

there.

Micro-organism

? In Infants : Staphylococcus aureus ,S. agalactiae and E.coli

--- Content provided by‍ FirstRanker.com ---

? In children >1 yr. : Staphylococcal Aureus , Streptococcus pyogenes ,H.

influenzae

? In adults : S.aureus and streptococcus species

--- Content provided by⁠ FirstRanker.com ---

? In patients of sickle cell anemia ? salmonella species
CLASSIFICATION

? According to duration of symptoms
Acute (<2 weeks)

--- Content provided by​ FirstRanker.com ---

Subacute (2-3 weeks)
Chronic (>3 weeks)

Pathophysiology

--- Content provided by⁠ FirstRanker.com ---

Mechanism of spread :
? Hematogenous ? MC aetiology in children
? Contiguous spread ?associated with previous surgery ,trauma,

cellulitis

--- Content provided by⁠ FirstRanker.com ---


? Direct inoculation ?in penetrating injuries ,open injuries, orthopaedic

surgeries like joint replacement and fixation of fractures.

--- Content provided by FirstRanker.com ---


? Preexisting focus / Exogenous Infection
? Infective embolus enters nutrient artery
? Trapped in a vessel of small Caliber(metaphysis)
? Blocks the vessel

--- Content provided by‍ FirstRanker.com ---

? Active hyperemia + PMN cells exudate
? In order to engulf the bacteria they release
enzymes and lyse the bone around.

? Hyperemia and immobilization causes decalcification.

--- Content provided by⁠ FirstRanker.com ---

? Proteolytic enzymes destroy bacteria and medullary

elements.

? The debris increase and intramedullary pressure

--- Content provided by​ FirstRanker.com ---


increases.


Cont.

--- Content provided by‍ FirstRanker.com ---


? Enter subperiosteal space.
? Strips periosteum.
? Perforation of periosteum / reach joint by piercing capsule.
? Enters soft tissue and may drain out

--- Content provided by‍ FirstRanker.com ---


Clinical presentation

? Severe pain ,malaise ,fever
? Recent history of infection

--- Content provided by FirstRanker.com ---

? Child looks ill and feverish
? temperature raised
? Limb held still and acute tenderness present over the involved limb
? Manipulation of limb painful :pseudo paralysis

--- Content provided by FirstRanker.com ---


? Infants:
Failure to thrive and drowsy
h/o birth difficulties ,umblical

--- Content provided by FirstRanker.com ---

artery catherization or site of
infection

Laboratory investigations

--- Content provided by​ FirstRanker.com ---

? Elevations in the peripheral white blood cell count (WBC),
? Erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)
? Blood culture is positive in half of cases.


--- Content provided by‍ FirstRanker.com ---

Radiological findings

? Negative for 1st week or 10 days
? Localised area of bone destruction
? Periosteal shadow is elevated

--- Content provided by‌ FirstRanker.com ---

? multiple lamination of bone deposition
? Periosteal new bone formation is seen after 2
weeks.

? Ultrasonography ? juxtacortical soft tissue swelling with periosteal

--- Content provided by FirstRanker.com ---


thickening

? Radionuclide scanning ? sensitive but not specific

--- Content provided by⁠ FirstRanker.com ---

increased uptake

? Magnetic resonance imaging ? hypointense on T1 weighted image

hyperintense on T2

--- Content provided by‌ FirstRanker.com ---

Differential diagnosis

? Rheumatic fever : Onset -more gradual,

pain and tenderness less intense.

--- Content provided by‌ FirstRanker.com ---


polyarticular.

Response to salicylates

--- Content provided by‍ FirstRanker.com ---

? Acute suppurative arthritis : Pain and tenderness limited to the joint,

joint movements -restricted

aspiration reveals purulent synovial fluid.

--- Content provided by⁠ FirstRanker.com ---


? Ewing's sarcoma : biopsy demonstrates tumor cells

Treatment

--- Content provided by FirstRanker.com ---

? General management-

Rest in bed

Elevation of the part

--- Content provided by FirstRanker.com ---


Systematic treatment- IV fluids, correct shock

Treatment with antibiotics

--- Content provided by FirstRanker.com ---

Surgery
Principles of antibiotic therapy

? Appropriate drug
? Appropriate route

--- Content provided by​ FirstRanker.com ---

? Appropriate dose
? Appropriate time to stop
? Appropriate adjunctive measures.

Treatment

--- Content provided by‌ FirstRanker.com ---


? Local management
Well timed surgery
Nade's indication for surgery-
? Abscess formation

--- Content provided by‌ FirstRanker.com ---

? Severely ill and moribund child.
? Failure to respond to intravenous antibiotics for more than 48 hours.


Surgical methods

--- Content provided by⁠ FirstRanker.com ---


? Aspiration

? Incision and drainage

--- Content provided by‍ FirstRanker.com ---

? Multiple drill holes

? Small bone window

? Bone abscess

--- Content provided by‌ FirstRanker.com ---

? Septic Arthritis
? Septicemia
? Fracture
? Growth arrest
? Overlying soft-tissue cellulitis

--- Content provided by‌ FirstRanker.com ---

? Chronic infection


Subacute osteomyelitis

--- Content provided by‍ FirstRanker.com ---

? insidious onset, mild symptoms, lack of systemic reaction
? Its relative mildness is due to:

Organism being less virulent OR

--- Content provided by‍ FirstRanker.com ---

Patient more resistant OR

(Both)

? Most common site: Distal femur, Proximal & Distal Tibia

--- Content provided by⁠ FirstRanker.com ---


Causative organism

? Staphyloccocus aureus (30-60%)
? Others (Streptococcus, Pseudomonas, Haemophilus influenzae)

--- Content provided by‍ FirstRanker.com ---

? Pseudomonas aeruginosa (IV drug user)
? Salmonella (patient with sickle cell anemia)
Radiographic findings

Brodie's abscess

--- Content provided by⁠ FirstRanker.com ---

- circumscribed, round/oval cavity containing pus and pieces of dead

bone (sequestra) surrounded by sclerosis.

? MC in tibial / femoral metaphysis.

--- Content provided by FirstRanker.com ---

? May occur in epiphysis / cuboidal bone (eg: calcaneum).
? Metaphyseal lesion cause no / little periosteal reaction.
? Diaphyseal lesion may be associated with periosteal new bone

formation and marked cortical thickening.

--- Content provided by‌ FirstRanker.com ---


Clinical features

? Pain (several weeks / months)
? Limping

--- Content provided by​ FirstRanker.com ---

? Swelling & Local tenderness
? Muscle wasting
? Body temperature usually normal (no fever)


--- Content provided by FirstRanker.com ---

A circumscribed, oval cavity

This is a lateral view X-ray of left

surrounded by a zone of

--- Content provided by FirstRanker.com ---


tibia and fibula. There is a marked

sclerosis at the proximal

--- Content provided by FirstRanker.com ---

periosteal reaction at the

tibia (Brodie's abscess)

diaphysis.

--- Content provided by​ FirstRanker.com ---


Investigations

? X-ray (may resemble osteoid osteoma / malignant bone tumor)
? Biopsy

--- Content provided by‍ FirstRanker.com ---

? Fluid aspiration & culture
? ESR raised
? WBC count may be normal

28

--- Content provided by FirstRanker.com ---

Treatment

Conservative :

a)

--- Content provided by FirstRanker.com ---


Immobilization

b) Antibiotics for 6weeks

--- Content provided by FirstRanker.com ---

Surgical (if the diagnosis is in doubt / failed conservative treatment) :

a)

Open biopsy

--- Content provided by‍ FirstRanker.com ---


b) Perform curettage on the lesion

29

--- Content provided by⁠ FirstRanker.com ---

BRODIE'S ABSCESS

? Subacute osteomyelitis persist for many years before progressing to

chronic osteomyelitis.

--- Content provided by​ FirstRanker.com ---


? Classically it is abscess formation surrounded by fibrous tissue or host

tissue.

--- Content provided by⁠ FirstRanker.com ---

? Causative organism is staphylococcal aureus in most of the cases.
Presentation

? Localized pain
? Often nocturnal

--- Content provided by‍ FirstRanker.com ---

? Alleviated by aspirin.

location

? Metaphysis of long bones

--- Content provided by​ FirstRanker.com ---

Upper end of tibia
Lower end of tibia
Lower end of femur
Lower end of fibula
Radiographic findings

--- Content provided by​ FirstRanker.com ---


Brodie's abscess
- circumscribed, round/oval cavity containing pus and pieces of dead

bone (sequestra) surrounded by sclerosis.

--- Content provided by⁠ FirstRanker.com ---


? MC in tibial / femoral metaphysis.
? May occur in epiphysis / cuboidal bone (eg: calcaneum).
? Metaphyseal lesion cause no / little periosteal reaction.
? Diaphyseal lesion may be associated with periosteal new bone

--- Content provided by‌ FirstRanker.com ---


formation and marked cortical thickening.

Radiologically

--- Content provided by‌ FirstRanker.com ---

? Oval, elliptical, or serpentine radiolucency usually greater than 1 cm

surrounded by a heavily reactive sclerosis.


--- Content provided by FirstRanker.com ---

Radiologically

? lytic lesion in the distal

metaphysis with a narrow zone

--- Content provided by‌ FirstRanker.com ---

of transition more caudally

? with a faint sclerotic rim and a

wide zone of transition more

--- Content provided by‍ FirstRanker.com ---

cephalad.

Radiologically

? hyper intense edema in the calf

--- Content provided by‌ FirstRanker.com ---


musculature, marrow edema,
and sub-periosteal pus.


--- Content provided by‌ FirstRanker.com ---

Radiologically

? The thin hypointense rim

surrounding the intramedullary

--- Content provided by FirstRanker.com ---

collection represents the
reactive interface between the
abscess and the body's attempt
to wall it off.

--- Content provided by⁠ FirstRanker.com ---

Radiologically

? post gadolinium image showing

the extent of the multiloculated

--- Content provided by⁠ FirstRanker.com ---

intramedullary abscess.
Treatment

? In the majority of cases surgery has to be performed.
? If the cavity is small then surgical evacuation and curettage is

--- Content provided by FirstRanker.com ---


performed under antibiotic cover.

? If the cavity is large then the abscess space may need packing

--- Content provided by FirstRanker.com ---

with cancellous bone chips after evacuation.

SALMONELLA OSTEOMYELITIS

? Seen in patient with sickle cell anemia and thalassemia.

--- Content provided by‌ FirstRanker.com ---

? Clinical features ?
Several bones involved
Symmetrical involvement of bones
Severe osteomyelitis
Spine may be involved

--- Content provided by⁠ FirstRanker.com ---

Sickle cell anemia present.
Stool may be positive.
Treatment

? The most commonly used antimicrobials are

--- Content provided by⁠ FirstRanker.com ---

chloramphenicol,
third generation cephalosporin's
Fluoroquinolones (ciprofloxacin)

In unresponsive cases surgical resection along with prolonged antibiotic therapy needs to be

--- Content provided by⁠ FirstRanker.com ---


performed.

Question 1

--- Content provided by FirstRanker.com ---


Chronic Osteomyelitis

? Definition:

--- Content provided by⁠ FirstRanker.com ---

" A severe, persistent and incapacitating infection of bone and bone

marrow "

47

--- Content provided by FirstRanker.com ---


Etiological Agents

Usual organisms (with time there is always a mixed infection)
? Staph.aureus(commonest)

--- Content provided by FirstRanker.com ---

? Strep.pyogenes
? E.coli
? Pseudomonas
? Staph.epidermidis (commonest in surgical implant)

--- Content provided by​ FirstRanker.com ---

48


Clinical Features

--- Content provided by‌ FirstRanker.com ---

a)

Pain

b) Low grade fever

--- Content provided by‌ FirstRanker.com ---


c)

Mild Redness

--- Content provided by‌ FirstRanker.com ---

d) Mild Tenderness

e)

Discharging sinus

--- Content provided by‌ FirstRanker.com ---


(seropurulent discharge)

49

--- Content provided by FirstRanker.com ---

Pathogenesis

Inadequate treatment of acute OM /Foreign implant /

Open fracture

--- Content provided by⁠ FirstRanker.com ---


Inflammatory process continues with time

together with persistent infection by infecting organism

--- Content provided by‍ FirstRanker.com ---

Persistent infection in the bone leads to increase in

intramedullary pressure due to inflammatory exudates

(pus)

--- Content provided by⁠ FirstRanker.com ---


stripping the periosteum

50

--- Content provided by‍ FirstRanker.com ---


Pathogenesis (Contd.)

Vascular thrombosis

--- Content provided by⁠ FirstRanker.com ---

Bone necrosis (Sequestrum formation)

New bone formation occur (Involucrum)

Multiple openings appear in this

--- Content provided by‌ FirstRanker.com ---


involucrum, through which exudates

& debris from the sequestrum pass via

--- Content provided by‌ FirstRanker.com ---

the sinuses

(Sinus formation)

51

--- Content provided by⁠ FirstRanker.com ---



Staging Of Osteomyelitis:

? The Cierny-Mader staging system.

--- Content provided by FirstRanker.com ---

? Determined by the status of the disease process.
? It takes into account the state of the bone,
? the patient's overall condition and factors affecting the development of

osteomyelitis.

--- Content provided by‌ FirstRanker.com ---


53

54

--- Content provided by‌ FirstRanker.com ---


Cierny-Mader Classification

? 1: Medullary Osteomyelitis - Infection

--- Content provided by FirstRanker.com ---

confined to medullary cavity.

? 2: Superficial Osteomyelitis -

Contiguous type of infection. Confined

--- Content provided by‌ FirstRanker.com ---


to surface of bone.

? 3: Localized Osteomyelitis - Full-

--- Content provided by‍ FirstRanker.com ---

thickness cortical sequestration which

can easily be removed surgically.

? 4: Diffuse Osteomyelitis -Loss of

--- Content provided by​ FirstRanker.com ---


bone stability, even after surgical

debridement.

--- Content provided by FirstRanker.com ---

55

Radiographic Findings

1) X-ray examination

--- Content provided by‌ FirstRanker.com ---


-

Usually show bone resorption (patchy loss of density / osteolytic lesion)

--- Content provided by FirstRanker.com ---

-

Thickening & sclerosis around the bone

-

--- Content provided by⁠ FirstRanker.com ---


Presence of sequestra

-

--- Content provided by‌ FirstRanker.com ---

Occasionaly it may present as a Brodie's abscess surrounded by vascular tissue and
area of sclerosis

56

--- Content provided by​ FirstRanker.com ---


2) Radioisotope scintigraphy

-

--- Content provided by‍ FirstRanker.com ---

Sensitive but not specific

-

Technetium labelled hydroxymethylene diphosphonate (99mTc-HDP) may

--- Content provided by​ FirstRanker.com ---

show increased activity in both perfusion phase and bone phase

3) CT scan & MRI

-

--- Content provided by​ FirstRanker.com ---


Show the extent of bone destruction, reactive oedema, hidden abscess and
sequestra

57

--- Content provided by FirstRanker.com ---


MRI of Osteomyelitis of metatarsal

Decreased signal in T1
weighted images

--- Content provided by⁠ FirstRanker.com ---


Appears bright in T2

weighted images.

--- Content provided by‍ FirstRanker.com ---

58
Treatment -

? Antibiotics
? Host immunity

--- Content provided by​ FirstRanker.com ---

? Surgical ? sequestrectomy and debridement

59

Complications

--- Content provided by‍ FirstRanker.com ---


1) Pathological Fracture

-

--- Content provided by FirstRanker.com ---

This occurs in the bone weakened by chronic osteomyelitis

2) Deformity

?

--- Content provided by‌ FirstRanker.com ---


In children the focus of osteomyelitis destroys part of the epiphysis growth
plate.

3) Shortening/ lengthening

--- Content provided by‌ FirstRanker.com ---


-

Destruction of growth plate arrest growth.

--- Content provided by FirstRanker.com ---

-

Stimulation of growth plate due to hyperemia.

60

--- Content provided by FirstRanker.com ---