Bone Infections

ISTAN. I. IRSAN

Outline

Acute Osteomyelitis

Subacute Osteomyelitis

Post-Operative Infections

Defining Osteomyelitis
Whats in a Name?
Osteomyelitis (Osteo- bone, MyeloMarrow, and itis -Inflammation)

Defining Osteomyelitis
What is it?
It is an infection of the of the bone or bone
marrow which leads to a subsequent
Inflammatory process.

Defining Osteomyelitis
Where does it come from?
Micro-Organisms may reach bones via the
Bloodstream or by Direct Invasion.

Defining Osteomyelitis
What affects its
development?

Organism involved

Host Factors (i.e. Age, Immunity, Diseases)

Site of Involvement (i.e. local factors)

Defining Osteomyelitis
What affects its
development?

Organism involved

Host Factors (i.e. Age, Immunity, Diseases)

Site of Involvement (i.e. local factors)

Acute Osteomyelitis

Types of Acute
Osteomyelitis
I.

Hematogenous Osteomyelitis

II.

Direct Inoculation Osteomyelitis

Acute Osteomyelitis
Hematogenous Osteomyelitis:

Bacterial seeding from the blood.

Seen primarily in Children.

The most common site is the Metaphysis

at the growing end of Long Bones in
Children, and The Vertebrae and pelvic in
Adults.

Acute Osteomyelitis
Direct Inoculation
Osteomyelitis

Direct contact of the tissue and

bacteria as a result of an Open
Fracture or Trauma.

Tend to involve multiple organisms.

Acute Osteomyelitis
Causative Organisms:

Staphylococcus aureus (Mainly)

Streptoccous pyogens or pneumoniae.

(Less)

H.Influenzae (Young Children)

Salmonella (Sickle-Cell)

Acute Osteomyelitis
Pathology:

Inflammation.
Earliest Change
Increase interaosseous pressure leads to Pain.
Suppuration.
Pus @ Medulla =Volkmann canals=>Surface =>
Subperiosteal Abscess=> spread along the shaft=>
re-enter the bone or burst into the soft tissue
May extend to Epiphysis and Metaphysis in
Neonates and Children. May extend to
Interverteberal Discs in Adults.

Acute Osteomyelitis
Pathology:

Necrosis.
Begin to see signs with in one week.
New-bone formation.
Bone thickens to form an involucrum enclosing the
infected tissue.
Perforation may occur converted acute into chronic
osteomyelitis.
Resolution.

Acute Osteomyelitis
Clinical Features:

Pain
Fever and Malaise
Tenderness
Restricted Joint Movement
Redness, Edema, Warmth (Signify Pus)
History preceding Skin Lesion or Sore
Throat.

Acute Osteomyelitis
Imaging:

First 10 days X-Rays Show No Abnormality.

By the end of the 2nd Week signs of
rarefaction of Metaphysis and New Bone
Formation.
With Healing there is Sclerosis and
thickening of Cortex.
MRI may help to distinguish between Bone
and Soft-Tissue Infection.

Acute Osteomyelitis
Investigations:
CBC

Leucocytosis
C-reactive protein level usually is elevated

ESR usually is elevated

Investigations
1.

Lab studies

2.

Radiological studies

Lab studies

CBC: leucocytosis
The C-reactive protein level usually is elevated (nonspecific

but more useful than ESR).

ESR usually is elevated (90%) nonspecific.

Aspiration of the pus from the subperiosteal abscess

and culture, and test sensitivity for antibiotics

Blood culture results are positive in only 50% of

patients with hematogenous osteomyelitis.

Radiological studies
X-Ray:

First sign is soft-tissue edema at 3-5 days after

infection.
Bony changes are not evident for 14-21 days:
1. early radiographic signs of rarefraction (thining of bony tissue

sufficient to cause decreased density of bone) of the metaphysis

and periosteal new bone formation
2. increasing ragged if treatment is delayed
3. sclerosis and thickening of the bone at healing

Approximately 40-50% focal bone loss is

necessary to cause detectable lucency on plain
films.

Plain-film radiograph showing

osteomyelitis of the second
metacarpal (arrow). Periosteal
elevation, cortical disruption and
medullary involvement are
present.

The above X-ray of the left

ankle of a 10-year-old boy
shows lucency in the tibial
metaphysis secondary to
acute hematogenous
osteomyelitis (AHO).

The above X-ray of the

right ankle of a 10-yearold boy shows lucency in
the tibial metaphysis
secondary to acute
hematogenous
osteomyelitis (AHO).

Here is an X-ray of an
AHO lesion extending
into the growth plate.

Radiological studies

MRI :
Early detection and surgical localization of
osteomyelitis.
Sensitivity ranges from 90-100%.

Radionuclide bone scanning :

A 3-phase bone scan with technetium 99m is
probably the initial imaging modality of choice
Show increase activity but it is a non specific sign of
inflamation.

This MRI sagittal section shows the same

AHO lesions with the right lesion extending
into the growth plate.

Bone scans, both anterior (A) and lateral (B), showing

the accumulation of radioactive tracer at the right
ankle (arrow). This focal accumulation is
characteristic of osteomyelitis.

Radiological studies
CT scan (spinal vertebral lesions, complex
anatomy: pelvis, sternum, and calcaneus)
Ultrasound
In children with acute osteomyelitis.
May demonstrate changes as early as 1-2 days after
onset of symptoms.
Abnormalities include soft tissue abscess or fluid
collection and periosteal elevation.
Ultrasonography allows for ultrasound-guided
aspiration.
It does not allow for evaluation of bone cortex

Diagnosis
Diagnosis requires 2 of the 4 following criteria:

Localized classic physical findings of bony

tenderness, with overlying soft-tissue erythema
or edema.
Purulent material on aspiration of affected bone.
Positive findings of bone tissue or blood culture.
Positive radiological imaging study.

Treatment
Principles of treatment:
1.

Analgesia an general supportive measures.

2.

Rest of the affected part

3.

Antibiotic treatment.

4.

Surgical eradication of pus and necrotic

tissue(debridement).

Treatment
Antibiotic treatment:
Start with IV antibiotics for 1-2 weeks then oral for 3-6 weeks.
Take cultures to detect the organism and its sensitivity pattern.
Start empirical treatment before the results came back, then
modify it according to the results.

Treatment
Antibiotic choices:
Older children and adults (staph infection): fluloxacillin and fusidic acid.
MRSA: Vancomycin
Children younger than 4 year-old or those with gram negative
organisms: 3rd generation cephalosporins.
Heroin addicts and immuno-compromised patients: more specific
antibiotics.

Cont
Sickle cell anemia and osteomyelitis: fluoroquinolone antibiotic

(not in children). A 3rd cephalosporin (eg, ceftriaxone) is an

alternative choice.

Nail puncture occurs through an athletic shoe (S aureus and

Pseudomonas aeruginosa): ceftazidime or cefepime.

Ciprofloxacin is an alternative treatment.

Trauma (S aureus, coliform bacilli, and Pseudomonas

aeruginosa): nafcillin and ciprofloxacin. Alternatives include

vancomycin and a 3rd cephalosporin with antipseudomonal
activity.

Treatment
# Drainage:
Subperiosteal abscess
Pyrexia and local tenderness more than 24 hour

after adequate antibiotic treatment.

# Removal of prosthetic implants:

If they become unstable after a trauma.
Or intractable infection following joint replacement.

# Severe cases may lead to the loss of a

limb.

Prevention

Improve immunity.

Post-traumatic infection (regular wound dressing for

established infection):
1.
2.
3.
4.

Debridement of open fractures.

Stabilization of fractures.
Antibiotics.
Closure of exposed bone surfaces.

Postoperative infection:
1.
2.
3.
4.

Cleanest possible surgical environment.

Careful haemostasis.
Suction drainage.
Prophylactic antibiotics in high risk surgeries.

Subacute Osteomyelitis

Results from a less virulent Microorganism,

or a patient with an elevated resistance.
Occurs Mostly at the Distal Femur or
Proximal Tibia
On X-Ray we See Brodies Abcess:
Small and Oval in shape
It is surrounded by sclerotic bone
May be mistaken for Ostieoid
Osteoma

Subacute Osteomyelitis

An image depicting subacute osteomyelitis

Post Operative Infections

Prophylaxis is KEY in prevention.

Treated According to Infection

Post Operative Infections

Not Uncommon, about a 5% incidence.

Predisposed by:
Debility
Chronic disease
Previous Infection
Tight Dressing
Corticosteroid Treatment
Long Surgery
Hematoma
Foreign Material Implants

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