.)
Cloacae :
.)
According to the duration of the
disease
acute
chronic
On the basis of the pathogenesis
hematogenous
secondary to a contiguous focus of
infection
associated with peripheral vascular disease
Acute Osteo Sub-Acute Osteo Chronic Osteo
Begins with marrow Occurs in abnormal bone Occurs after inadequate tx or in
edema, cellular infiltration or after inadequate pts with altered immunity
and vascular engorgement antibiotics
Distinguishing feature is
May progress to necrosis Localized pyogenic necrotic bone surrounded by
and abscess formation process granulation tissue
10
PATHOPHYSIOLOGY
Hematogenous Osteomyelitis
Contiguous-Focus Osteomyelitis
Release enzymes
Lyse bone
PATHOPHYSIOLOGY
Bacteria escape host defenses by:
Persisting in osteoblasts
Children:
Long bone, Femur, Tibia, Humerus
Involucrum
Sequestration
Less common
Special consideration
Sickle cell disease
Injection drug users (IDUs)
Hemodialysis
HIV/AIDS
Immunosuppression
Prosthetic orthopedic device
HEMATOGENOUS OSTEOMYELITIS
Microbiologic features
Staphylococci Aureus, Epidermidis
Streptococci Group A & B
Haemophilus influenzae
Gram-negative enteric bacilli
Anaerobes
Polymicrobial
Mycobacterial
Fungi
HEMATOGENOUS OSTEOMYELITIS
Clinical manifestation
Classic presentation: Sudden onset
Usually presentation: Slow, insidious
Differentials
Cellulitis
Gas gangrene
Neoplasm
Aseptic bone infection
Clenched fist
osteomyelitis
HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Lab study:
WBC May be elevated, Usually normal
Blood culture
( Acute osteomyelitis + ve > 50% )
HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
Radiology:
Normal
Soft tissue swelling
Periosteal elevation
Lytic change
Sclerotic changew
HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
MRI:
Early detection
Superior to plan X ray & CT Scan &
radionuclide bone scan in slected
anatomic location.
Sensitivity 90 100%
HEMATOGENOUS OSTEOMYELITIS
Diagnosis & work-up
Imaging
Radionuclide bone scan:
A 3-phase bone scan ( Technetium 99m )
For: Smear
Culture
Pathology
TREATMENT
Initial treatment shoud be aggressive.
3.Radiography
Diagnostic
Hip joint involvement
Neurologic complication
Poor or no response to IV therapy
Sequestration
SURGICAL MANAGEMENT
Patient age
Fracture
Loosing of the prosthetic implant
Osteomyelitis Scar
Osteomyelitis Deformity of the Forearm
Plain radiograph of the
tibia and fibula in a 14
y/o patient
demonstrating a
pathologic fracture of
the proximal fibula with
periosteal reaction and
erosion of the cortical
bone secondary to
subacute osteomyelitis
CONTIGUOUS-FOCUS
OSTEOMYELITIS
Contiguous-focus Osteomyelitis
Clinical setting:
Postoperative infection
Contamination of bone
Puncture wounds
Contiguous-focus Osteomyelitis
Microbiologic features
Staphylococci Aureus, Epidermidis
Gram-negative bacteria
Anaerobic infection
Antibiotics Specific
Duration
ASSOCIATED WITH
PERIPHERAL VASCULAR DISEASE
Clinical Features
erythema and drainage
either no pain (if there is advanced neuropathy) or excruciating pain
(if the destruction of bone has been acute).
patients are afebrile,
present with an ulcer without evidence of surrounding inflammation.
The ulcer size (> 2 cm2) and depth (> 3 mm) are predictive of the
likelihood of bone involvement. If bone can be felt with a sterile blunt
probe, the likelihood of osteomyelitis is high.
a high ESR, especially if it is over 70 mm/hour, is helpful in making
the diagnosis of osteomyelitis
Found almost exclusively in the feet in
patients with a long history of diabetes
mellitus and peripheral neuropathy.
Bone involvement usually occurs after an
extension of soft tissue infection involving a
plantar ulcer.
ETIOLOGY
Most infections are polymicrobial
S. aureus remains the most common
pathogen
others include Enterococcus faecalis,
group B streptococci,
Enterobacteriaceae, anaerobic
bacteria (especially peptococci,
peptostreptococci, and Bacteroides
species), and P. aeruginosa
Vertebral
Osteomyelitis
Risk factors:
Male
Age > 50
IVDU
Etiology
Virtually always hematogenous
Lumbar more common then
cervical
59
Localized pain and tenderness
Diagnosis often missed or
delayed
60
Plain films
MRI best
CT-guided needle
biopsy
61
Staph Aureus in about 50%
Other organisms:
Gram negative aerobes
Streptococcus sp.
Tuberculosis
Pseudomonas and candida
in IVDU 62
6 to 12 weeks IV antibiotics if
medical treatment alone
Surgical treatment indicated if
abscess
cord compression
failure of medical treatment
Can follow CRP for reoccurrence or
failure of treatment response
63
Risk factors:
Male
Age > 50
IVDU
Etiology
Virtually always hematogenous
Lumbar more common then
cervical 64
Modality of choice for initial evaluation
Advantages
Inexpensive
Exclude other conditions
May help guide further work-up
Disadvantages
Often normal for the first 10 to 21
days of infection
Sensitivity: 43-75%
Specificity: 75-83%
Earliest finding deep soft
tissue swelling
Active infection for 1-2 weeks
bone destruction and
periosteal reaction
Localized osteoporosis
Pathologic fracture
Infectious
Arthritis
Infectious arthritis can generally be divided
into two categories:
Pyogenic or septic arthritis
Most commonly caused by Staphylococcus
aureus, Neisseria gonorrhea, Klebsiella
pneumoniae, Candida albicans, and
Serratia marcescens
Non-pyogenic arthritis
Most commonly caused by tuberculosis or
fungal infections including actinomycosis,
cryptococcosis,
coccidioidomycosis,histoplasmosis, and
sporotrichosis
Infectious agents can enter the joint space in
several ways