ACUTE HAEMATOGENOUS

OSTEOMYELITIS

DR THIT LWIN
FACULTY OF MEDICINE &
HEALTH SCIENCES
UMS

 almost invariably a disease of children.

if adult are affected,
1.low resistance condition e.g.
(debility, diseased or drug).
2.immunosuppresion
trauma determine the site of infection.
usual causal organism-staphylococcus
less often causal organism
-streptococcus pyrogenes
-s. pneumoniae

 children <4 years of age -Haemophilus

influenzae
occasional organism:
-Escherichia coli
-Pseudomonas aeruginosa
-Proteus mirabilis
-anaerobic Bacteroides fragilis
unusual organism are more likely to be found in
heroin addicts and immune compromised patients.
patients with sickle-cell disease are prone to
infection by Salmonella

 source of infection- minor skin abrasion, a

boil, aseptic tooth
-infected umbilical cord (newborn)
-urethral catheter, indwelling arterial line,
or dirty syringe & needle.
organism invade the blood stream & usually
settle in the metaphysis.
predilection for metaphysis:
- peculiar arrangement (hair-pin loops)
-relative vascular stasis
- flare structure (easily trauma)

 in young infant, organism can easily lodge in

epiphysis.( free anastomosis)
infection may settle near the very end the bone
and growth disturbances easily followed.
In children, metaphyseal infection is usual: the
growth disc act as a barrier to spread.
in adult, haematogenous
infection
is more common in vertebra.

(batson venous plexus valve-less venous plexus)

PATHOLOGY
depend on 1. age
2. site of infection
3. virulence of organism
4. host response
however, there is characteristic stage:
i. inflammation
ii. suppuration
iii. necrosis
iv. new bone formation
v. resolution

i. inflammation
- early stage (impending ischemia)
- acute reaction with vascular congestion,
fluid exudation, PMN leucocytes infiltration.
- intraosseous pressure rise cause obstruction
to blood flow and intravascular thrombosis.

ii suppuration:
- by 2nd or 3rd day, pus forms within the bone.
- pus go along the Volkmann canal to surface of bone.
(subperiosteal abscess)

- subperiosteal abscess spread along the shaft reenter the bone at another level or bust into soft
tissue.
-infant :infection extend into the joint
- older children: physis is barrier to direct
spread, but pus may discharge through
periosteum to joint.( metaphysis is
intracapsular)

 in adult, pus is more likely to spread within the

medullary cavity.
vetebral infection spread through the end-plate and IVD
into the adjacent vertebral body.

iii necrosis: due to

- raised intraosseous pressure
- vascular stasis
-infective thrombosis
-periosteal stripping

 bacterial toxins and leucocytic enzymes also

involve in tissue destructions.
infant: damage to growth disc and AVN of
epiphysis.
pieces of death bone separate as sequestra.
macrophages and lymphocytes remove the
debris by phagocytosis and osteoclastic
resorption, but large sequestra remain
entombed in bone cavities.

iv. new bone formation

by the end of 2nd week, news bone forms from
deeper layers of stripped periosteum.
The new bone thicken to forms an involucrum
enclosing the infected tissue and sequestra.
pus and tiny sequestra may discharge through
perforations (cloacae) in involucrum and track
by sinus to the skin surface.

v.resolution
If infection is controlled and early surgical
release of pressure, this progress can be
aborted.
the bone around the zone of infection is first
osteoporotic, then sclerosis and thickening.
( hyperaemia- fibrosis & appositional new
bone formation)
remodelling: normal contour or deformed
bone.

a. infection in the metaphysis may spread towards the surface,

to form subperiosteal abscess.
b. some of bone may die, and is encased in periosteal new bone
as a sequestrum
c. the encasing involucrum is sometimes perforated by sinuses.

 Pathophysiology of haematogenous seeding

sequestrum

CLINICAL FEATURES
Patient- child: recent history of infection
neonate: history of birth difficulty
adult: history of urological procedure
Pain
Fever
Metaphseal tenderness
Constitutional disturbances can be misleadingly mild in
infants.
Local tenderness is not very marked in adult: confirmed by
fine-needle aspiration & culture.

DIAGNOSIS:
x-ray: during first few days- displacement
of fat plane.
:end of
2nd weeks- faint extra-cortical outline due to periosteal new
bone formation. : later- obvious periosteal thickening and
patchy rarefaction of metaphysis and then become ragged
destruction.
Bone scan99mTc-HDP increased activity in both perfusion
and bone phase.
MRI-can differentiate between soft-tissue infection and
osteomyelitis.
Reduced signal in T1-weighted images.

first x-ray 2 day

metaphyseal mottling
after the symptoms

 14 days later periosteal changes

 Acute OM

investigations
diagnostic aspiration of pus from
subperiosteal abscess.
if no pus: gram stain smear of aspirate.
blood culture:
WBC count and C-reactive protein
stool culture for salmonella : patient with
sickle-cell disease.

DIFFERENTIAL DIAGNOSIS
CELLULITIS: source of infection may not obvious.
STREPTOCOCCAL NECROTIZING MYOSITIS:
MRI will reveal muscle swelling and sign of tissue
necrosis.
ACUTE SUPPURATIVE ARTHRITIS:
-tenderness is more on the joint line.
-infant ; both may exist.
ACUTE RHEUMATISM: pain is less severe
:carditis, rheumatic nodule, erythema marginatum.

TREATMENT
if suspected on clinical ground, blood samples
should be taken and treatment start
immediately waiting for confirmation.
Four principles
1. supportive treatment for pain and
dehydration.
2.splintage of affected part.
3. antibiotic therapy
4. surgical drainage.

Supportive treatment
analgesic for pain: give repeated interval
without waiting for the patient to ask for them.
intravenous fluid: fever and septicemia and
cause severe dehydration.

splintage
to prevent joint contracture
Plaster back slab or half-cylinder may be use
( dont obscure the affected area)
antibiotics:
-choice of antibiotic : based on direct
examination of pus and best guess.

 also depend on patient age, renal function,

degree of toxiemia, and previous history of
allergy.
children and adult: i.v flucloxacillin and
fusidic acid until c-reactive value return to
normal.(1-2 weeks).
after this oral for 3-6 weeks.
child <4 years: start with i.v cephalosporin
- alternative is augmentin.

 patient with sickle-cell disease: treated with

chloramphenicol or co-tromoxazole combine
with augmentin.
immunocompromised patient: start with
gentamicin and cephalosporin.

DRAINAGE:
if pus is aspirated in diagnostic aspiration:
-should be drain by open operation under
anasethesia and drill the medullary cavity with few
holes.
- widespread drilling do more harm than good.
if there is extensive intrameduallary abscess:
drainage is by cutting a small window in the cortex.
(Saucerization)
splint
full weight bearing is usually after 3-4 weeks.

COMPLICATIONS:
septicemia- rare.
metastatic infection: may be multifocal
- may involved other bones, joints,
serous cavity, brain or lung.
suppurative arthritis: common in OM femoral
neck.
altered bone growth: infant-growth arrest.
- older children -the bone grow too long,
due to hyperaemia.
chronic osteomyelitis

saucerization

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