2. Osteomyelitis Inflammation of bone or
bone marrow, usually due to an infection.
Acute: develops over days and weeks.
Chronic: develops over months and years,
involves relapses.
3.
4.
5. Mechanism
Infection starts at metaphysis
It then travels through the cortex, via Haversian Canals
In the first 24-48 hours inflammatory exudate forms deep to the periosteum, elevating
the membrane
The periosteum is innervated and inelastic, so this stretching causes pain
Inflammatory process progresses along the medulla causing cortical infarction
This necrotic cortical bone in K/A the “Sequestrum”.
This is followed by formation of new bone surrounding the sequestrum; this
ensheathing mass of new bone is called “involucrum”
Involucrum can develop multiple openings known as “cloacae” allowing discharge of
pus and sequestrum to allow resolution
6. Symptoms
1) Local pain---) gradual increase in intensity.
2) Fever, pulse rate will increase.
Signs:
1) Site: Bones commonly infected are tibia, femur, humerus, radius and
ulna.
2) Color: Skin over area is red or reddish-brown.
3) Temperature: Raised.
4) Tenderness: Infected area is tender and the whole bone is painful.
5) Swelling: Maybe soft and indistinct initially and later becomes
noticeable if there is pus at the surface, in which it fluctuates.
6) Adjacent joints: May contain an effusion.
7. Acute Osteomyelitis
Diagnosis
History and clinical examination
FBC, ESR, CRP.
X-ray (normal in the first week)
Ultrasound (Biopsy and aspiration)
Bone scan Tc-99m methylene diphosphonate
CT scan can define extent of bone
sequestration and cavitation
MRI is the investigation of choice, MRI of bone
shows edema and periosteal elevation. (Highly
sensitive and specific)
8. X-rays can be normal during first 3 to 5
days
In the second week radiological signs
include:
Periosteal new bone formation
Patchy rarefaction of metaphysis
Metaphyseal bone destruction
9. X-rays can be normal during
first 3 to 5 days
In the second week
radiological signs include:
1)Periosteal new bone
formation
2)Patchy rarefaction of
metaphysis
3)Metaphyseal bone
destruction
10. X-ray of right foot
Blue arrow: Area of bone destruction on
the great toe. Mottled appearance and
irregularities at the edge of the bone.
Red arrow: Notice the normal bone of
the first metatarsal
13. 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.
However, a bone scan will be positive despite the absence of bone or
joint abnormality for ex: gout, degenerative joint disease or a healing
fracture
14. Acute Osteomyelitis
Treatment
supportive treatment for pain and
dehydration
antibiotics (2 weeks IV, then oral)
Splinting
Surgical debridement
Prognosis: Depends on early diagnosis and
treatment. May develop into chronic
osteomyelitis
17. Chronic Osteomyelitis
Organism
usually mixed infection.
mostly staph. Aureus E. Coli . Strep
Pyogen, Proteus.
Disease may take 2 forms:
1) Discharging sinus
2) Brodie’s abscess
18. CF:May remain inactive for
months or years.
X-ray: It reveals sequestrum
which has separated from
surface of bone or which lies
in a cavity.
19. Infection is closely contained so as to
create a chronic abscess within the bone
composed of pus or jelly like granulation
tissue.
CF: 1) Local pain 2) Tenderness and
thickening of the bone 3) Transitory
effusions in adjacent joint during an
exacerbation.
22. Management (Cierny and Mader classification)
Stage 1
Necrosis limited to
medullary contents,
cancellous bone is
involved
Etiology:
Hematogenous
Treatment
Excision of bone,
with antibiotic-
loaded cement
beads.
Stage 2
Necrosis related to
exposed surface,
cortical bone
Treatment
Early: Antibiotics
Late: Superficial
debridement,
Bone grafting
maybe required.
Stage 3
Limited area of dead
bone with medullary
infection
Etiology:
Trauma, involving
stage 2 &3,iatrogenic
Treatment
Antibiotics,
Debridement, Dead
space management,
Temporary
stabilization,bone graft
Stage 4
Entire circumference
Treatment:
Antibiotics.
Stabilization,
External fixation
Debridement,
Possible ablation.
23. Acute Septic Arthritis- Route of Infection
Definition: Inflammation of a joint due to infection. It is a
medical emergency.
RF: Increasing age, DM, IS, pre-existing joint disease, IV drug misuse
Skin is the most common portal of entry.
25. Acute Septic Arthritis-
Pathology
Acute synovitis with purulent joint effusion
Articular cartilage attacked by bacterial toxin and
cellular enzyme
Complete destruction of the articular cartilage.
Acute Septic Arthritis Sequelae
Complete recovery
Partial loss of the articular cartilage
Fibrous or bony ankylosis
27. Acute Septic Arthritis-Neonate
Picture of Septicemia (Hip joint is commonly
affected)
Irritability
Resistant to movement
Acute Septic Arthritis-Child
Acute pain in single large joint
Reluctant to move the joint
Increase temp. and pulse
It is a hot, swollen, tender joint
28. Acute Septic Arthritis-Adult
Often involve superficial joint (knee, ankle, wrist)
Joint is swollen, hot, red and held in the “loose pack”
position, with an effusion
Fever may be low grade
Any movement causes pain
Investigation
CBC, WBC, ESR, CRP ,blood culture
X-ray
Ultrasound
Aspiration or biopsy
30. Acute Septic Arthritis-Treatment
Emergency management:
Perform urgent investigations
1) Aspirate joint 2) Blood test
Commence intravenous antibiotic
1) Floxacillin 2g 6-hourly for 2 weeks 2) Clindamycin
Relieve pain
1) Oral or IV analgesics 2)Local ice packs
Keep joint decompressed
1) Serial needle aspiration to dryness (1-3 times/day as required)
2)Difficult aspiration consider lavage or arthroscopy
Physiotherapy from first day
1) Early regular passive movement
31. Tuberculosis
Bone And Joint
Organism Mycobacterium tuberculosis
1) Human type (Droplet) 2) Bovine type (Milk)
Route of infection
Thru bloodstream
Primary focus
1) Lungs 2) GIT
Site: 1)Any synovial joint, esp. hip and knee
2)Tendon synovial sheath esp. those of finger flexors
3)Bursae
4)Vertebrae (Potts disease)
32. Tuberculosis
Pathology
Primary complex ( in the lung or the gut)
Secondary spread
Tuberculous granuloma
The characteristic
microscopic lesion is the
tuberculous granuloma – a
collection of epithelioid and
multinucleated giant cells
surrounding an area of
necrosis, with round cells
(mainly lymphocytes )
around the periphery.
33. Pathology In Synovial membrane
Typical tubercles develop in synovial membrane
They become bulky and inflamed, a infected effusion collects in the synovial cavity
Progressively the articular cartilage is destroyed and adjacent bone is involved
Healing occurs that results in fibrous ankylosis
In tuberculosis of spine
Bodies of 2 vertebrae are involved, they are replaced by fibrous tissue
If treatment is delayed abscess formation occurs and vertebra collapse
Vertebral collapse produces forward angulation of spine ( Kyphosis)
Abscess & spinal angulation compress & damage the spinal cord
Paraplegia ma develop
34. Clinical features
There may be a history of previous infection or recent contact with
tuberculosis.
The patient is usually a child or young adult.
Pain and (in a superficial joint) swelling.
In advanced cases there may be attacks of fever or lassitude and
loss of weight.
Relatives tell of “ night cries “ .
Muscle wasting is characteristic.
Synovial thickening is often striking.
Movements are limited in all directions.
As articular erosion progresses the joint becomes stiff and
deformed.
35. TB spine
In tuberculosis of the spine, pain may be deceptively slight.
Consequently the patient may not present until there is a visible abscess
(usually in the groin or the lumber region to one side of the midline ) or until
collapse causes a localized kyphosis. Occasionally the presenting feature is
weakness or loss of sensibility in the lower limbs.
36.
37. Investigations
The ESR: is increased.
CBC: relative lymphocytosis.
The mantoux or Heaf test: will be positive, these are sensitive
but not specific tests.
If synovial fluid is aspirated, it may be cloudy, the protein
concentration is increased and the white cell count is elevated.
Acid-fast bacilli are identified in synovial fluid in 10-20 of cases,
and cultures are positive in over half.
A synovial biopsy is more reliable; sections will show the
characteristic histological features, and acid fast bacilli may be
identified; cultures are positive in over 80 of cases.
38. X – ray
Soft - tissue swelling and periarticular osteoporosis are
characteristic.
The bone ends take on a “ washed-out “ appearance
and the articular space is narrowed.
Later on there is erosion of the subarticular bone,
characteristically seen on both sides of the joint.
Cystic lesions may appear in the adjacent bone ends but
there is little or no periosteal reaction.
In the spine: bone erosion and collapse around an
intervertebral disc space; the soft tissue shadows may
define a paravertebral abscess.
39. TB hip
Uniform narrowing
of left hip joint due
to synovial disease
(white arrowhead)
Osteporosis of left
hip
No osteophytes and
no sclerosis
Normal right hip
joint
