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  1. 1. Osteomyelitis Dr. Usman Shams
  2. 2. Osteomyelitis • Inflammation of bone (osteo) and marrow (myelo), virtually always secondary to infection. • Frequently manifests as a solitary focus of disease. • All types of organisms can produce osteomyelitis, but the most common are • Pyogenic bacterial osteomyelitis • Tuberculous osteomyelitis
  3. 3. Pyogenic osteomyelitis • Always caused by bacteria • Routes of infection • Hematogenous spread • Extension from a contiguous site • Direct implantation
  4. 4. Causes • In children • Hematogenous in origin • Develops in the long bones • Bacteremia stem from trivial mucosal injuries, such as may occur during defecation or vigorous chewing of hard foods. • In adults • Often occurs as a complication of open fractures, surgical procedures, and diabetic infections of the feet.
  5. 5. Infection • Most common … Staphylococcus aureus in 80% to 90% of cases • In patients with genitourinary tract infections and IV drug abusers … E.coli, Pseudomonas, and Klebsiella • In neonates … Hemophilus influenza and group B streptococci • In patients with sickle cell disease … Salmonella infection • During surgery and in open fractures … Mixed infection
  6. 6. Location • In neonates • Metaphysis, epiphysis or both • In children • Metaphysis • In adults • Epiphysis and subchondral
  7. 7. Morphology • Depends upon on the stage and location of lesion • Acute • Subacute • Chronic
  8. 8. Acute stage • Bacteria proliferate and induce a neutrophilic inflammatory reaction and cause cell death. • Bone undergoes necrosis within first 48 hours • The inflammation spread and may percolate throughout the Haversian systems and reach the periosteum • Subperiosteal abscess • Lifting of periosteum … segmental bone necrosis … sequestrum (dead piece of bone) • Rupture of periosteum leads to a soft tissue abscess in the surrounding soft tissue and the formation of draining sinus.
  9. 9. • In infants • epiphyseal infection spreads through the articular surface or along capsular and tendoligamentous insertions into a joint, producing septic or suppurative arthritis • In children • periosteum is loosely attached to the cortex … subperiosteal abscesses may dissect for long distances along the bone surface.
  10. 10. Chronic stage • After first week, chronic inflammatory cells become more numerous. • Cytokines from leukocytes stimulates • osteoclastic bone resorption • ingrowth of fibrous tissue • deposition of reactive bone in the periphery • Reactive woven or lamellar bone which forms sleeve of living tissue surrounding dead bone is called involucrum (living piece of bone).
  11. 11. MorphologicVariants • Brodie abscess: It is a small intraosseous abscess that frequently involves the cortex and is walled off by reactive bone • Sclerosing osteomyelitis of Garre: It typically develops in jaw and is associated with extensive new bone formation that obscures much of the underlying osseous structure.
  12. 12. Sequestrum (necrotic bone)
  13. 13. Involucrum (new bone)
  14. 14.
  15. 15. CLINICAL MANIFESTATIONCLINICAL MANIFESTATION HEMATOGENOUS OSTEOMYELITIS / ACUTE Classic presentation: Sudden onset High fever, Night sweats, Fatigue, Anorexia, Weight loss Restriction of movement Local edema, Erythema, & Tenderness
  16. 16. Clenched fist osteomyelitis
  17. 17. CHRONIC •5% to 25% of acute osteomyelitis fails to resolve •Develop when there is delay in diagnosis, extensive bone necrosis, inadequate antibiotic therapy or surgical debridement, or weakened host defenses. •Course … acute flare-ups
  18. 18. Complications of chronic osteomyelitis  Deformities of bones:  Pathological fractures.  Systemic effects such as chronic fever & fatigue.  Amyloidosis of the AA type (secondary amyloidosis). This can get further deposited in the kidney, liver & blood vessels.  Squamous cell carcinoma of the skin: The skin at the edges of the draining sinus tracts may undergo malignant transformation over time.  Sepsis  Rarely sarcoma in the infected bone
  19. 19. LAB DIAGNOSISLAB DIAGNOSIS • WBC  May be elevated, Usually normal • C-Reactive Protein (CRP) • Erythrocyte Sedimentation Rate • Elevated at presentation • Falls with successful therapy • Blood culture • ( Acute osteomyelitis + ve > 50% ) • Biopsy • Bone cultures {{
  20. 20. RADIOLOGY Normal Soft tissue swelling Periosteal elevation Lytic bone lesion surrounded by a rim of sclerosis
  21. 21. TB osteomyelitis • Dissemination of tuberculosis outside the lungs can lead to the appearance of skeletalTB: • SkeletalTuberculosis: Tuberculous osteomyelitis involves mainly the thoracic and lumbar vertebrae (known as Pott disease) followed by knee and hip. There is extensive necrosis and bony destruction with compressed fractures (with kyphosis) and extension to soft tissues, including psoas "cold" abscess.
  22. 22. • Tuberculous osteomyelitis of the bone is secondary hematogenous spread from a primary source in the lung or GI tract. • Once established, the bacilli provoke a chronic inflammatory reaction. • Small patches of caseous necrosis occur, and these coalesce to form larger abscesses. • The infection may spread across the epiphysis into the joints or track along soft tissue to appear as a cold abscess at a distant site (e.g. psoas abscess in case of spinal tuberculosis).
  23. 23. Syphilitic osteomyelitis • The transplacental spread of spirochetes from mother to the fetus results in congenital syphilis. • Long bones, such as the tibia, are mainly affected. • Congenital syphilis has 2 forms: • Periosteitis and osteochonditis.
  24. 24. • Regarding acquired syphilis, bone lesions are manifestations of tertiary syphilis. • Gummatous lesions appear as discrete punched-out radiolucent lesions in medulla or destructive lesions within the cortex. • The surrounding bone is sclerotic, and no discharge is present. • Bones frequently affected are those of nose, palate, skull and extremities, especially the long tubular bones such as tibia. • Histology : edematous granulation tissue containing numerous plasma cells and necrotic bone.
  25. 25. “Saber” shin •