Acute Osteomyelitis & its Management
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Transcript Acute Osteomyelitis & its Management
Acute Osteomyelitis
Infection in bone
Osteomyelitis
acute (subacute)
chronic
specific (eg TB)
non specific(most common)
Acute haematogenous OM
mostly children
boys> girls
history of trauma
Acute Osteomyelitis
Organism
Gram +ve
staphylococus aureus
strep pyogen
strep pneumonie
Gram -ve
haemophilus influnzae (50% < 4 y)
e .coli
pseudomonas auroginosa,
proteus mirabilis
Acute Osteomyelitis
Source Of Infection
infected umbilical cord in infants
boils, tonsilitis, skin abrasions
in adults UTI, in dwelling arterial line
Acute Osteomyelitis
Source of Infection:
Hematogenous
Direct spread
Exogenous
Acute Osteomyelitis
Pathology
starts at metaphysis
?trauma
vascular stasis
acute inflammation
suppuration
necrosis
new bone formation
resolution
Acute Osteomyelitis
Pathology:
Primary focus and stage of inflammation
Spread of infection with pus formation
Formation of subperiosteal abscess
Pus tracks toward skin to form a sinus
Bone infarction (Sequestrum)
New bone formation (involucrum)
Acute Osteomyelitis
Acute Osteomyelitis
Acute Osteomyelitis
Age variation
Neonates:
Extensive bone necrosis
Increased ability to absorb large sequestrum
Increased ability to remodel
Epiphysio-metaphyseal vascular connection
leading to secondary septic arthritis
Acute Osteomyelitis
Clinical Features
severe pain
reluctant to move
fever
malaise
toxemia
Acute Osteomyelitis
Clinical Pictures
History:
Skin lesion
Sore throat
Trauma
Acute Osteomyelitis
Clinical Pictures
Symptoms:
Pain, restless
Malaise and fever
The limb is held still
(pseudo paralysis)
Sometimes mild or
absent (neonates)
Acute Osteomyelitis
Clinical Pictures
Signs:
General and Local
Laboratory Tests:
CBC
ESR+CRP
Blood culture (+ve in 50-70%)
Aspiration (Gram stain + culture and sensitivity)
Acute Osteomyelitis
Infant
failure to thrive
drowsy
irritable
metaphyseal tenderness
decrease ROM
commonest around the knee
Acute Pyogenic
Osteomyelitis
Age variation
Adults:
No subperiosteal abscess due to adherent
periosteum
Soft tissue abscess
Vascular connection with the joint leading to
secondary septic arthritis
Acute Osteomyelitis
Adult
commonly thoracolumbar spine
fever
backache
history of UTI or urological procedure
old ,diabetic ,immunocompromised
Acute Osteomyelitis
Diagnosis
History and clinical examination
FBC, ESR, B.C.
X-ray (normal in the first (10-14) days
Ultrasound
Bone Scan Tc 99, Gallium 67
MRI
Aspiration
Acute Osteomyelitis
Radiography
Plain X-ray
Ultrasound
Bone & gallium scan (Sensitive but not
specific)
CT scan
MRI
Acute Osteomyelitis
Acute Osteomyelitis
Differential Diagnosis
Acute Septic Arthritis
Acute monoarticular
rheumatoid arthritis
Sickle cell crisis
Cellulitis
Ewing’s Sarcoma
Acute Osteomyelitis
Treatment
Antibiotics:
Type?
Route?
When to start?
When to stop
Monitoring?
Acute Osteomyelitis
Treatment
Surgical Drainage:
Indications?
Procedure?
Drilling?
Acute Osteomyelitis
Treatment
General:
Hospitalization
Hydration
Electrolyte replacement
Analgesia
Immobilization
Acute Osteomyelitis
Treatment
supportive treatment for pain and
dehydration
splintage
antibiotics
surgery
Acute Osteomyelitis
Treatment
Antibiotics: Start blindly after taking blood
culture.
Older child & previously fit adults.(staph inf): I/V
flucloxacillin and fusidic acid. 2-3 wks. Then
orally 3-6 wks.
Child under 4 (haemophilus inf.): Cefuroxime or
cefotaxime or co-amoxiclav.
Immunocompromised pts: Third generation
cephalosporins.
Acute Osteomyelitis
Treatment
Neonates 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.
Children 6 months to 6 years of age
:Haemophilus influenzae. combination of
intravenous flucloxacillin and cefotaxime or
cefuroxime.
Acute Osteomyelitis
Treatment
Elderly and previously unfit patients, Gram-negative infections,
combination of flucloxacillin and a second- or third-generation
cephalosporin.
Heroin 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
Drainage:
1. CF do not improve within 36 Hrs.
2. Signs of deep pus.( swelling, oedema,
fluctuation).
3. If pus is aspirated.
Acute Osteomyelitis
Complications
septicemia
metastatic infection
septic arthritis
altered bone growth
chronic osteomyelitis
Acute Osteomyelitis
Prognosis
Factors affecting prognosis:
Organisms
Infected Bone
Age of the Patient
Treatment
Subacute Osteomyelitis
Clinical features
long history (weeks, months)
pain, limp
swelling occasionally
local tenderness
Subacute Osteomyelitis
Pathology
Brodies abscess
a well defined cavity
in cancellous bone
Subacute Osteomyelitis
Investigation
X ray
Bone scan
Biopsy(50%) grow organism
Subacute Osteomyelitis
Treatment
antibiotics for 6 months
surgery