Definition:

Inflammation of the bone caused by

infecting organism
Localized or spread trough the bone,
involving marrow, cortex, periosteum and
surrounding soft tissue

Definition
Infection of bone and bone marrow
direct inoculation of an open traumatic
wound or by blood-borne organisms
(hematogenous)
Classifications
The duration and type of symptoms:
1. Acute
2. Subacute
3. Chronic
The mechanism of infection:
1. Exogenous
2. Hematogenous



Classifications
Weiland et al,1984 the nature of the
bony involvement ;
Type I - Open, exposed bone w/ soft
tissue infection
Type II- Circumferential cortical n
endosteal infection
Type III - Associated with a segmental
defect
Classifications
Cierny and Mader (adult osteomyelitis)
Type I - medullary osteomyelitis (ex.of which
include hematogenous osteomyelitis and
infections of intramedullary rods)
Type II - superficial osteomyelitis confined to
the bone surface
Type III - localized osteomyelitis involving the
full thickness of the cortex
Type IV - diffuse osteomyelitis involving the
circumference of the cortex
Classifications
The general condition of the patient response
to infection and treatment
Class A; normal systemic defenses,metabolic
capabilities, and vascular supply to the limb
Class B; local or systemic deficiency in wound
healing (immunosuppressed,
corticosteroids,peripheral vascular disease)
Class C; the patients are those in whom the
treatment morbidity is worse than the
presenting condition poor prognosis
Acute Hematogenous
Osteomyelitis
The most common type
Disease of children
Bone n bone marrow infection blood borne
organism
Adult debility, disease or drugs (vertebrae >
long bone)
Children < 2 y.o. , 8 -12 y.o.
Boys > girls
Metaphysis or diaphysis long bone
Proximal tibia or distal,proximal ends of femur
Acute Hematogenous
Osteomyelitis
Causal organism ;
- S. aureus (>>)
- S. pyogenes/ S. pneumoniae
< 4 y.o : H. Influenzae (5-50%)

Pathological picture:
1. Inflammation
2. Suppuration
3. Necrosis
4. Reactive new bone formation
5. Resolution and healing

Clinical:
Fever and unexplained pain.
Refused to move the affected limb.
Tenderness over the involved bone.
Decreased ROM in adjacent joint.
Swelling, erythema, warmth.
History of infection
Laboratory:
WBC not reliable indicator.
ESR elevated in over 90%.
C-reactive protein (CRP) over 19mg/l.
Blood cultures are positive 50%.
Aspiration of the affected site.
Radiological:
Plain radiographs.
Bone scan.
CT-Scan.
Magnetic resonance imaging (MRI).
Ultrasound.
Radiological:
Plain radiographs may show soft tissue
swelling within 3 days, but bone changes
do not appear for 7 to 14 days.
By the end of the 2
nd
week, there may be
a faint extra-cortical outline due to
periosteal new bone formation
Treatment should not be delayed
Bone-scan
May be used to:
- located the area of
involvement in
difficult site.
- Multiple site
involvement.

Computed tomography (CT):
- To evaluate bone abscesses.
- To differentiating from other
lucent lesions.
- To identifying extraosseous of
pus.
MRI:
Very sensitive, but
not specific.

It can be used to
differentiated
between the soft
tissue infection and
osteomyelitis

Ultrasound:
Is useful in localizing a subperi-osteal
abscess.
It can show early changes in soft tissue.
These change were detectable within 24
hours.

Differential Diagnosis

Cellulitis
Streptococcal necrotizing myositis
Acute supurative arthritis
Acute rheumatism
Sickle cell crisis
Gaucher disease
Factors determine the effectiveness of
antibacterial treatment :
The time interval between the onset of infection
and the institution of treatment.
The effectiveness of the antibacterial drug
against the specific causative bacteria.
The dosage of the antibacterial drug.
The duration of antibacterial therapy.

Treatment

Supportive treatment for pain &
dehydration
Splintage of the affected part
Antibiotic therapy
Surgical drainage
Treatment
Identify the organism
Select appropriate AB
Deliver AB to the infected site
Halt tissue destruction
Treatment
AB empiric th/ ;
Newborn (up to 4 months of age) ;
>>s.aureus, gram ( - ) bacilli, group B
streptococcus
Primary ; nafcillin or oxacillin plus a third-
generation cephalosporin
Alternative ; vancomycin plus a third-
generation cephalosporin
Treatment
Children 4 years of age or older ; >>
s.aureus, group A strep,coliform
nafcillin or oxacillin
alternative ; vancomycin or
clindamycin,gram ( - ) third
cephalosporin


Treatment
Adult 21 y.o or older ; >> s.aureus
Initial ; nafcillin or oxacillin or cefazolin
Alternative ; vancomycin
Sikle cell anemia ; salmonela
Primary ; fluoroquinolon
Alternative ; third cephalosporin

Treatment
Hemodialysis patients n IV Drug Abusers ;
s.aureus,s.epidermidis,pseudomonas
aeruginosa
th/ of choice ; penicillinase resistant
synthetic penicillins plus ciprofloxacin
alternative ; vancomycin with ciprofloxacin
Treatment
Indications for operative
Drainage of an abscess
Debridement of infected tissues to
prevent further destruction
Refractory cases that show no
improvement following nonoperative
treatment
Acute Osteomyelitis ( after
open # or ORIF )
Open # contaminated
Post operative open # + implant
Post operative mixture of pathogenic
bacteria ( S.aureus,Proteus, E.coli,
Pseudomonas, S.epidermidis )
Local factors ; soft tissue damage,
haematoma formation, bone death

Acute Osteomyelitis ( after
open # or ORIF )
Foreign implant
The race for the surface (Gristina,1988)
Classification of postoperative infection
A.Early infection
1.Superficial
2.Deep
3.Superficial n deep
Acute Osteomyelitis ( after
open # or ORIF )
B.Late infection
1.Following early infection
2.Covert infection appearing later
3.Following a long period of normality
Acute Osteomyelitis ( after
open # or ORIF )
Clinical finding
Early posoperative infection (within 1
month)
Intermediate postoperative infection (
between 1 month 1 year )
Late postoperative infection
Treatment
Prophylaxis ; cleansing & debridement, drainage &
leaving the wound open, immobilization & AB
Prevention ;
1.Avoiding immune-depressed patients
2.Eliminating focus infection
3.Optimal operative sterility
4.Prophylactic AB
4.Handling tissues gently
6.High quality implant materials
7.Ensuring close fit n secure fixation of the implant
8.Preventing or counteracting later intercurrent infection
Treatment
Radical irrigation and debridement
Removal orthopaedic hardware
Rotational or free flap
Empiric th/ ; nafcillin with ciprofloxacin
Alternative th/ ; vancomycin with a third-
generation cephalosporin
Subacute Hematogenous
Osteomyelitis
Discovered radiologically
Painful limp n no systemic signs or
symptoms
Pain near one of the larger joints for
several weeks or event month
Secondary acute osteomyelitis
Develops in # haematoma
WBC count n blood culture N, ESR raised
X-ray : Brodies abscess
Subacute Hematogenous
Osteomyelitis
Treatment ;
Surgical curettage n drainage
Conservative not doubt ; immobilization
and AB
AB ; 48 hours IV oral 6 weeks
(flucloxacillin and fusidic acid)
Chronic Osteomyelitis
Difficult to eradicate completely
Inappropriately treated acute osteomyelitis, soft
tissue spread, immunosuppressed, diabetic, IV
drug abusers
Etiologi : S.aureus, E.coli, S.pyogenes, Proteus &
Pseudomonas
Bone destroyed, devitalized at the focus
infection or diffusely along the surface of a
foreign implant.
Cavities pus & sequestra, surrounding by
vascular tissue& areas of sclerosis

Clinical pictures
Pain, Pyrexia, Redness, Tenderness
Discharging sinus, seropurulent discharge
Excoriated surrounding skin
Deformed or non united bone
Classification ; Cierny and Mader
Diagnostics
X-ray
Bone scan
CT and MRI
Laboratory ; ESR, WBC, antistaphylococcal
antibody

X - Ray
Bone resorption
Thickening & sclerosis of the surounding
bone
Localized loss of trabeculation
Periosteal thickening
Sequestra
CT & MRI
Invaluable in planning operative treatment
Show the extent of bone destruction and
reactive oedema, hidden abcesses and
sequestra
Treatment
Antibiotics alone seldom
Wound care
Surgery ; debridement, sequestrectomy &
resection, soft tissue transfer