Osteomyelitis

Presentation on osteomyelitis for physiotherapy students
It includes the explanation along with the treatment for osteomyelitis which may be benefitial for the physiotherapy students
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1. OSTEOMYELITIS PRESENTED BY - Dr. Gurjant Singh (PT), MPT, ( Ph.D ) Assistant Professor, MMIPR

2. DEFINITION OF OSTEOMYELITIS Osteo =bone Myelo =marrow Itis =inflammation So we can conclude that ostemyelitis is a disease in which infection of bone marrow occurs. Osteomyelitis is an infection of bone & bone marrow that may be caused by direct inoculation of an open traumatic wound or by blood-borne organisms ( hematogenous )

3. CLASSIFICATION OfOSTEOMYELITIS ACC TO DURATION- ACUTE OSTEOMYELITIS(Less than 2 weeks) SUB-ACUTE OSTEOMYELITIS(Between 2-6 weeks) CHRONIC OSTEOMYELITIS(more than 6 week) ACC TO ROUTE OF INFECTION(Acc toWaldogel’s ) HEMATOGENOUS(Most common) DIRECT CONTIGUITY ACC TO HOST RESPONSE PYOGENIC NON PYOGENIC

4. Anatomic Classification ( Cierny-Mader ) 1985 1.Medullary Endosteal 2.Superficial Localized to surface of bone, usually 2 ° to soft tissue defect.

5. 3.Localized Localized sequestra , usually associated sinus tract Bone structurally stable 4. Diffuse Permeative process, combination of I/II/III, Commonly unstable

6. Infecting microorganisms can invade by … Indirect entry Direct entry

7. INDIRECT ENTRY Frequently affects growing bone in boys <12 years old Associated with increased incidence of blunt trauma Most common sites of indirect entry …… Distal femur Proximal tibia Humerus Radius

8. Adults with increased risk Vascular disorders Genitourinary and respiratory infections Spread infection from blood to bone Vascular-rich bone sites Pelvis Tibia Vertebrae

9. Direct Entry Can occur at any age Open wound where microorganisms can gain entry to body May also occur in presence of foreign body Implant Orthopedic prosthetic device

10. Direct Entry After entry, microorganisms lodge in an area of bone where circulation slows. Usually the metaphysis Microorganisms grow causing increased pressure because most bone is nonexpanding Increased pressure leads to ischemia and vascular compromise of periosteum

11. Direct Entry Eventually, infection passes through bone cortex and marrow cavity Results in cortical devascularization and necrosis

12. Direct Entry Once ischemia occurs, bone dies Sequestrum forms Devitalized bone separates from living bone . Part of periosteum that continues to have a blood supply forms new bone called involucrum

13. Etiology and Pathophysiology Caused by a variety of microorganisms Most common infecting microorganism is Staphylococcus aureus . ORGANISM POSSIBLE PROBLEM Staphylococcus aureus Pressure ulcer, penetrating wound, open fracture, orthopedic surgery Staphylococc Epidermis Indwelling prosthetic device Streptococcus viridans Abscessed tooth, gingvial disease

14. Escherichia coli Urinary tract infection Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhoeae Gonorrhea Pseudomonas sp Puncture wounds, intravenous drugs Salmonella sp. Sickle cell disease Fungi, mycobacterium Immunocompromised host Escherichia coli Urinary tract infection Mycobacterium tuberculosis Tuberculosis Neisseria gonorrhoeae Gonorrhea Pseudomonas sp Puncture wounds, intravenous drugs Salmonella sp. Sickle cell disease Fungi, mycobacterium Immunocompromised host

15. PATHOPHYSIOLOGY Microorganisms enter bone (Phagocytosis). Lyse bone Phagocyte contains the infection Release enzymes

16. PATHOPHYSIOLOGY Pus spreads into vascular channels Raising intraosseous pressure Impairing blood flow Chronic ischemic necrosis Separation of large devascularized fragment New bone formation ( involucrum ) (Sequestra)

17. Pathophysiology of Osteomyelitis

18. Acute Osteomyelitis Types of Acute Osteomyelitis Hematogenous Osteomyelitis Direct Inoculation Osteomyelitis

19. 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.

20. 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.

21. Acute Haematogenous Osteomyelitis It is an endogenous form of the disease most often affecting neonates. Source of infection may be umblicus Organisms – Staphlococci , Steptococci , E.Coli , Klebsiella , Pasteurella , Proteus, etc :  Hematogenous -common in children . It is highest in the first two decades of life. < 5 years of age. In adult- Haematogenous is less common but they suffered due to debility disease(diabetes mellitus)drugs( immunosuppresion Clinical signs – Fever, malaise, non weight bearing lameness, soft tissue swelling over the involved bone .

22.   Pathophysiology Septicaemia initiated from focus of infection ( umblicus ) Infective emboli enters the nutrient arteries of long bones The emboli gets entrapped in the end arteries and capillaries of the metaphyseal area ( epiphyseal plate) Bacterial emboli causes inflammation, microthrombi formation, ischaemia , bacterial proliferation & necrosis :  Hyperaemia , migration of leucocytes & pus formation Purulent material travels under pressure in plane of least resistance Reaches the outer cortex and elevates the periosteum This compromise cortical blood supply Leads to sequestrum formation

23. SYMPTOMS Temperature >102ºF long-lasting pain, Decreased range of motion in the case of joint involvement. local warmth, tenderness, swelling . CLINICAL FINDINGS Within three to seven days- : I nterposed translucent fat planes within muscle are obliterated by edema fluid. Periosteal elevation or thickening may represent new bone formation, pus, or reactive edema from adjacent soft tissue infection .

24. DIAGNOSIS Aspiration of pus and send for culture W.B.C. CRP and ESR Blood for culture Plain films, bone scintigram , ultrasound, CT Scan and MRI Even a biopsy all show positive results   Elevations in the peripheral white blood cell count (WBC ), Erythrocyte sedimentation rate (ESR), and C-reactive protein ( CRP) in children with hematogenous osteomyelitis are variable and nonspecific Blood culture is positive in half of cases. Laboratory findings: Lytic and sclerosis, indicating chronic infection. Periosteal new bone formation, with compatible

25. CLINICAL FINDINGS Within three to seven days- : I nterposed translucent fat planes within muscle are obliterated by edema fluid . Periosteal elevation or thickening may represent new bone formation, pus, or reactive edema from adjacent soft tissue infection .

26. In acute osteomyelitis - principle of treatment are- General supportive treatment Analgesic for relieve pain I/V fluid(fever with shock, septicaemia ) Spintage of the affected part Antibiotics(oral/intravenous )-It should be started immediately not waiting for culture of blood and pus management. Drainage-if necesssary

27. Management and Treatment Of Acute Osteomyelitis : Acute osteomyelitis is an orthopaedic emergency which needs in patient admission . The management can be discussed as general and local GENERAL MANAGEMENT Conservative management is mainstay of treatment . The mneomics RESTS sums up the conservative line of treatment Rest in bed, protect affected part with splints to alleviate pain and spasm. Elevation-of part ,warm and moist packs to reduce swelling. Systemic treatment-blood transfusion, iv fluid to correct shock and hypovolaemia . Treatment-with antibiotics to reduce toxicity . Antibiotics given are penicillins , ciprofloxacin etc. Surgery

28. LOCAL MANAGEMENT Focus here is on well timed surgery if one of following indication are present Abscess formation Severely ill Failure to respond to intravenous antibiotics for more than 48 hrs. Exact treatment varies according to the bones involved, the severity of the infection and the immune status of the patient.

29. During acute osteomyelitis following measures are suggested Proper splinting of affecting joints in functional positions. Limb elevation to control oedema. Cryotherapy in initial stages followed by thermotherapy in later stages .These measure help to reduce pain and spasm. Unaffected joints put in active vigorous exercises After complete cessation of pain, mild isometrics exercise are prescribed for affected joints. Mobilise joint and strengthen the muscles like active assisted , active and resisted exercise after disease is completely arrested. Ambulation and weight transfer done slowly commenced initially with help of assistive advice. PHYSIOTHERAPY MANAGEMENT

30. SUB-ACUTE OSTEOMYELITIS Is caused by staphylococcus aureus . Patient complaint of pain without constitutional symptoms. Temperature may be increased or normal. It is not detected until at least two weeks has elapsed. Blood culture is positive in 60% of cases WBC and ESR raised in 50 % of cases CAUSES Increased host resistances Lowered bacterial resistances If Anti- biotics are administrated before symptom appear.

31. A Brodie abscess is a subacute osteomyelitis with a predilection for the ends of long bones and the carpus and tarsus. Plain radiographic findings include the following: a central area of radiolucency with a surrounding thick rim of reactive bone sclerosis, which may persist for months; pathognomonic tortuous parallel lucent channels extending toward the growth plate; a variable degree of periosteal new-bone formation; and associated soft-tissue swelling.

32. A Brodie abscess is characterized by a double line at the site of the lesion due to the high signal intensity of granulation tissue surrounded by low signal intensity of bone sclerosis on T2-weighted MRIs. The lesion has low-to-intermediate signal intensity that is outlined by a hypointense rim on T1-weighted MRIs. Treatment of Brodie’s abscess in the metaphysis includes surgical curettage

33. CLINICAL FEATURES pain, limp swelling occasionally local tenderness INVESTIGATION X ray Bone scan Biopsy(50%) grow organism TREATEMENT Antibiotics given for 6 month Surgery

34. Chronic osteomyelitis

35. Chronic osteomyelitis Is a severe, persistent, and sometimes incapacitating infection of bone and bone marrow. It is often a recurring condition because it is difficult to treat definitively. M ay arise as a result of an inappropriately treated acute trauma, soft tissue spread in the immunosuppressed patient, diabetics, and i.v drug abusers .

36. This disease may result from (1) inadequately treated acute OSM (2) a hematogenous type of osteomyelitis; (3) trauma , (4) iatrogenic causes such as joint replacements and the internal fixation of fractures; (5) compound fractures; (6) infection with organisms, such as Mycobacterium tuberculosis and Treponema species (syphilis ); and (7) contiguous spread from soft tissues, as in diabetic ulcers or ulcers in peripheral vascular disease

37. Clinical presentation chronic forms of osteomyelitis usually occur in adults. Generally, these bone infections are secondary to an open wound, most often an open injury to bone and surrounding soft tissue. Localized bone pain, erythema and drainage around the affected area are frequently present. The cardinal signs of subacute and chronic osteomyelitis include draining sinus tracts, deformity , shortening or lengthning of bones and local signs of impaired vascularity , range of motion and neurologic status . The incidence of deep musculoskeletal infection from open fractures has been reported to be as high as 23 percent. 6 Patient factors, such as altered neutrophil defense, humoral immunity and cell-mediated immunity, can increase the risk of osteomyelitis

38. Other forms of chronic osteomyelitis Tuberculous osteomyelitis of the bone is secondary spread from a primary source in the lung or GI tract. It most commonly occurs in the vertebrae (body) and long bones. Once established, the bacilli provoke a chronic inflammatory reaction. Small patches of caseous necrosis occur, and these coalesce to form larger abscesses. The infection spreads across the epiphysis into the joints. The infection may track along soft tissue to appear as a cold abscess

39. TUBERCULOUS OSTEOMYELITIS It is rare in the developed country and common in the developing and underdeveloped countries of world. This disease effect the adolescent and young adult more often Most frequently involved are spine and bones of extremities. Tuberculosis lesion appear as the focus of bone destruction . Tuberculosis of spine,potts disease often commences in vertebral body may be aasociated with compression fracture and destruction of intervertebral discs producing permanent damage and paraplegia. Extension of caseous material along with pus from the lumbar vertebrae to the sheaths of psoas muscle produce psoas abscess or lumbar cold abscess .This abscess when burst out they form sinus. Tuberculosis of spine,Pott’s disease often commense in vertebral body and may be associated with compression fracture and destruction of the intervertebral discs,produce permanent damage and paraplegia. Extension of caseous material alongwith pus from the lumbar vertebrae to sheath of psoas muscle produce psoas abscess or lumbar cold abscess,this abscess may burst through skin and form sinus.Long standing cases may develop systemic amyloidesis .

40. Laboratory Investigations • CBC with differential – Elevated WBC count – Left shift: Polymorphonucleocytosis • Blood cultures • ESR (Normal: < 20 mm/hr) – Usually elevated > 35mm • C-Reactive Protein (Normal: < 8 - 10mg/L) – Elevated > 10mg/L

41. Diagnostic Imaging • Plain Radiographs • Ultrasound • Radionuclide (Bone) Scans • C-T Scans • M R I

42. Management of chronic osteomyelitis g GOAL Eradication of the infection by achieving a viable and vascular envoirnment This can be done by radical debridement by way of sequestrectomy and resection of scarred and infected bone and soft tissue. Appropriate antibiotic required. Reconstruction of both bone and soft tissue defect may be needed Principal of treatment Surgery to be undertaken only when fever and infection has subsided,when living bone is distinguished from the dead bone . When surgery is indicated ,culture is done and antibiotics is started at least four days before surgery and is continued for two weeks. Surgery method include Sequestrectomy and saucerisation.Other methods of treatment are Open Grafting,hyperbaric oxygen therapy,closed suction drainage,amputation is done in very rare cases.

43. PHYSIOTHERAPY MANAGEMENT Measure for chronic osteomyelitis Here disease has run its course and left back various sequlae like limb length discrepancies deformities,scarring etc.Efforts are made to combat these problem Limb length discrepancies-corrected by shoe raise and other method Deformities-Corrected by various orthotic devices For scar,contractures etc,sustained passive streching of scarred and contracted tissue. Deep ultrasonic massage for adherant scars. Strengthening isometrics and isokinetic exercises for the muscles Range of motion exercises like active and passive ones for affected and non-affected joints Assistive devices used for ambulation,weight transfers.

44. Manifestations of Osteomyelitis Cardiovascular effects Tachycardia GI effects Nausea and vomiting Anorexia MS effects Limp in involved extremity Localized tenderness Integumentary effects Drainage and ulceration at involved site Swelling, erythema, and warmth at involved site Lymph node involvement Other effects High temperature with chills Abrupt onset of pain Malaise

45. COMPLICATIONS Osteomyelitis may result in following complications Septicemia Acute bacterial arthritis Pathologic fractures Development of squamous cell carcinoma in longstanding cases Secondary amyloidosis in long standing cases Vertebral osteomyelitis may cause vertebral collapse with paravertebral abscess,cord Compression and neurological deficits.

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