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Medical

1. Osteomyelitis By P. J. Okoth P.J. Okoth 1

2. Define osteomyelitis Classify osteomyelitis Discuss acute osteomyelitis Discuss chronic osteomyelitis P.J. Okoth 2 Learning objectives

3. Osteomyelitis is infection of bone by pyogenic organisms It occurs in acute and chronic forms P.J. Okoth 3 Introduction

4. Acute haematogenous osteomyelitis P.J. Okoth 4

5. Define acute haematogenous osteomyelitis Discuss the aetiology of acute haematogenous osteomyelitis Describe the pathology of acute haematogenous osteomyelitis Outline the clinical features of acute haematogenous osteomyelitis State the investigations in acute haematogenous osteomyelitis State the differential diagnosis State the complications of acute haem . Osteomyelitis Outline the management of acute haem osteomyelitis P.J. Okoth 5 Learning objectives

6. Recognize the importance of having a high index of suspicion for osteomyelitis Recognize the value of blood cultures to isolate an organism before starting antibiotics Realize the importance of giving high-dose intravenous antibiotics P.J. Okoth 6 Objectives…

7. Acute haematogenous osteomyelitis is an infection of bone by pyogenic organisms which have gained access to bone through the bloodstream. It is one of the most important diseases of childhood. Acute implies that infection has been present for a short period (less than 2 weeks) P.J. Okoth 7 Definition

8. The common causative organisms are: Staphylococcus aureus – commonest Streptococcus pyogenes Pneumococci Salmonella (mainly in sicklers) Brucella Klebsiella Haemophilus influenzae and Escherichia coli in neonates. P.J. Okoth 8 Aetiology

9. Organisms enter the bone via bloodstream from a septic focus, e.g. boil, furuncle, carbuncle, cellulitis, intravenous canula or I.V line Infection begins at the metaphysis where the organisms have settled. A minor injury to a bone may render it vulnerable to infection by organisms circulating in the blood. P.J. Okoth 9 Pathology

10. The organisms induce an acute inflammatory reaction , producing pain and swelling. Pus is formed in the medullary cavity. It finds its way to the surface of bone to form a sub- periosteal abscess . Later the abscess may burst into soft tissues and may lead to formation of a sinus . Sequestrum (dead bone) formation results from septic thrombosis of vessels and periosteal stripping cutting off blood supply to the bone. P.J. Okoth 10 Pathology…

11. New bone is laid down beneath the stripped-up periosteum , forming a layer of new bone called involucrum The epiphysial cartilage is a barrier to spread of infection to the joint. However, joint may be infected if the metaphysis lies partly within a joint cavity, causing acute pyogenic arthritis . Even when a joint is not infected it may swell from an effusion of clear fluid ( sympathetic effusion ) P.J. Okoth 11 Pathology…

12. Mainly a disease of children, especially boys Most commonly affects the tibia, femur and humerus. Onset is rapid May be history of recent boils or minor injury Severe pain over the affected bone Swelling of affected limb Inability to use the limb/ child failing to move one limb Fever Other constitutional symptoms: malaise, refusal to feed, vomiting, diarrhoea P.J. Okoth 12 Clinical features

13. On examination: Febrile 39-40 degrees Celcius Exquisite tenderness over the affected bone, over the metaphysial area Overlying skin is warmer than normal The soft tissues are indurated Fluctuant abscess may be present Sympathetic effusion in neighbouring joint P.J. Okoth 13 Clinical features…

14. Blood for culture and sensitivity – must be done immediately, before any antibiotic is given. Local X-ray No alteration from normal in early stages After two or three weeks there may be diffuse rarefaction of metaphysis and new bone outlining the raised periosteum Full haemogram + ESR – marked polymorphonuclear leucocytosis High ESR P.J. Okoth 14 Investigations

15. Pyogenic arthritis of adjacent joint Acute osteomyelitis is distinguished from pyogenic arthritis by the following features: The point of greatest tenderness is over the bone rather than the joint A good range of joint movement is retained Distended joint (sympathetic effusion) does not contain pus. Cellulitis Trauma – fracture or STI P.J. Okoth 15 Differential diagnosis

16. Rheumatic fever Sickle cell disease crisis Vitamin C deficiency in infants (scurvy) Syphilitic metaphysitis in infants Osteogenic sarcoma P.J. Okoth 16 Differential diagnosis…

17. Septicaemia or pyemia Pyogenic arthritis Retardation of growth from damage of epiphysial cartilage Chronic osteomyelitis P.J. Okoth 17 Complications

18. The key to successful treatment is a high index of suspicion, leading to early diagnosis by blood culture. Efficient treatment must be begun at the earliest possible moment Treatment is categorized as: General treatment Local treatment P.J. Okoth 18 Treatment

19. General treatment: Systemic high-dose intravenous antibiotics Antibiotics must be started blind after cultures have been taken because if the disease can be sterilized within the first 48 hours of onset, complete resolution can be guaranteed. A combination of flucloxacillin and fusidic acid is recommended. Antibiotics should be continued for at least 4 weeks even when the response has been rapid. P.J. Okoth 19 Treatment…

20. For children under 5 and neonates, flucloxacillin (250mg/kg per day in 4 divided doses) and ampicillin (150mg/kg per day in divided doses to cater for Haemophilus influenzae ) are recommended. Treatment is changed according to culture and sensitivity results as soon as the causative organism is identified and sensitivity ascertained. Bed rest Analgesics/ antipyretics P.J. Okoth 20 Treatment …

21. Local treatment: Operation: if the diagnosis is reached more than 48 hours after onset of symptoms, it should be assumed that there is a collection of pus and surgery is required to drain it. Done under GA. Skin is opened over most tender red area. Incision is made down to the bone and subperiosteal pus is evacuated. One or two drill holes may be made into the cortex to improve medullary drainage Wound may safely be sutured in most cases Splint the limb until infection is overcome P.J. Okoth 21 Treatment…

22. Chronic osteomyelitis P.J. Okoth 22

23. This is infection of bone by pyogenic organisms present for more than 2-3 weeks. It is nearly always a sequel of acute osteomyelitis Ocasionally the infection is subacute or chronic from the beginning. Infected compound fractures often become chronic. P.J. Okoth 23 Chronic osteomyelitis

24. Staphylococcus aureus is the usual causative organism Other bacteria responsible include: Streptococci ( haemolytic ) Pneumococci Salmonella Staph albus P.J. Okoth 24 Cause

25. Commonest in the long bones Often confined to one end of long bone, but it may affect the whole length. The bone is thickened and generally denser than normal. May be honeycombed with granulation tissue, fibrous tissue, or pus. Sequestra are commonly present within cavities in the bone There may be a sinus track leading to the surface. The sinus tends to heal and break down recurrently. Never heals completely if sequestrum is present. P.J. Okoth 25 Pathology

26. Main symptom is usually a purulent discharge from a sinus over the affected bone. Discharge may be continuous or intermittent Pain may be the predominant feature that brings patient to hospital. Flare-up of infection – local pain, pyrexia, and the formation of an abscess, then reappearance of a sinus. May present with pathological fracture P.J. Okoth 26 Clinical features

27. O/E May be pale from chronic illness May be febrile in flare-up bone is palpably thickened, with overlying scars or sinuses May be obvious limb deformity P.J. Okoth 27 Clinical features

28. Radiographic examination: Thickened bone Irregular and patchy sclerosis (may give a honeycombed appearance) Periosteal reaction ( involucrum ) Irregular cortex Sequestrum (seen as a dense loose fragment,with irregular but sharply demarcated edges, lying within a cavity in the bone) Obliterated medullary cavity P.J. Okoth 28 Investigations

29. Haemogram + ESR – high ESR and Hb may be low. Radioisotope scanning – may show increased uptake in the vicinity of the lesion CT scanning – may be of value in diffuse disease for localisation of abscess cavities and sequestra (allowing for accurate planning of operative treatment) P.J. Okoth 29 Investigations …

30. Pathological fracture Amyloid disease – may follow long-continued chronic osteomyelitis with persistent discharge of pus Development of squamous celled carcinoma in a sinus Joint stiffness and contractures Anaemia of chronic illness Bone deformity leading to limb deformity Growth disturbance P.J. Okoth 30 Complications

31. Specific treatment: Surgery Antibiotics Acute flare-up – antibiotics as in acute osteomyelitis with incision and drainage of abscess Sequestrectomy / saucerisation to remove sequestra and to open up abscess cavities. Irrigate through vacuum drainage with rifocin for 7-14 days P.J. Okoth 31 Treatment

32. Supportive treatment: Rest the limb / splint Splintage after sequestrectomy / saucerisation to prevent pathological fractures Analgesics Good nutrition Clinic follow-up P.J. Okoth 32 Treatment…

33. The End! Thank You P.J. Okoth 33