Acute

Management

Rev.23 Jul 2011

 I am going to limit this
discussion to
The management
of the
Acute Hematogenous form
in the skeletally immature patient
 Etiology :
What are the structural factors
that predispose immature
bone to develop osteomyelitis?
High to Low Flow

No Local Resistance

Coagulase + Staph
Because of this anatomic factor,
what bones are most commonly
affected ?
• The bones with the largest
growth centers:
• Femur, Tibia, Humerus
60-70%
• Calcaneus ,Fibula ,Radius
5-10 %
 What is the role of trauma
in the etiology of osteomyelitis?

• Local trauma increases the

vulnerability to infection by:

• Altering the local circulation

• Altering the bacterial adhesiveness

 Diagnosis: Clinical

What are the typical clinical symptoms ?

Bone pain
What is characteristic of Which side is involved?
bone pain
Fever
Irritability Yes
Deep Soft Tissue signs
(Little Superficial =
Erythema)
? ?
 Diagnosis:
What imaging techniques are useful ?

Plain X-Rays
Ultrasound
Radio nucleotide
Scans
C-T Scans
MRI
What are the classic findings on the
plain X-rays?
What
What isWhat
the is this
is this
clinical area of
significance
ofarea ofradiographic
dead bone
periosteal
these newtermed?
bone
changes?
termed?
Seqestrum Involucrum

Too Late
Indicates Dead Bone !
What are the early bony X-ray signs?
Periosteal new bone formation?

There are NO early bone changes!!

The early signs involve only
the soft tissues
What are these soft tissue stages?
• 1.Periosteal Edema
Let us look at our patient with no external signs
Her x-rays were said to be negative

What does
Tell me thisyou
Agree
what ?indicate
see ? ?
 1st Stage:
usually indicates the pus
is still within the bone
What does the 2nd stage
Sub-Periosteal indicate?
Pus
Sub-Periosteal Pus
What is a good non-invasive
Ultrason way to
better define subperiosteal fluid?

• X-Ray • Tc99m Scan Day 2

No Significant Changes
 Ultrasound detects
subperiosteal fluid
• Day One • Day Two

Fever Continued
 What is the role of the
technetium scan?
What does this examination tell you?

Where does it accumulate?

What are the limitations of this exam?

 What are the phases of the
technetium scan ?
• Phase II: • Phase III:
• Immediate Static • Delayed Static

So. What wouldPhase

beIa good indication
arteriogram effect
to use the bone scan ?
simply indicates
increased bloodflow
To look for occult
multicentric lesions
Soft tissue uptake Bone concentration
 What is the Gold Standard
in imaging for osteomyelitis ? !!
MRI
• What specifically does it reveal?
• Demonstrates both soft and bony
changes
• Changes appear early
• Remember changes demonstrate
only increased water in the
tissues!!!
 WhereFor
is itspinal lesionsuseful ?
especially
Disc space infections
• Bone Scan: ill defined • Definite on M R I
 MRI:
Also better defines extremity lesions
Scan: Poor Definition MRI: Better
Definition
 Can imaging diagnose osteomyelitis ?
Not completely,
Imaging only tells where the pathology is !!

• How does one

confirm the true
etiology ???
 Use the Willie Sutton
Approach

Go where the •Aspiration

money is!! • Blood Cultures
Rate of bacterial
harvest equal
 What is the cornerstone
of treatment ?
Intravenous
Antibiotics

• Less Surgical Indications

• Early recognition and initiation of
treatment essential !!!
 What are the basic principles
of osteomyelitis treatment ?
What is the role of antibiotics ? What is the role of surgery ?
 RECOMMENDATIONS (1970)

Osteomyelitis needs a course of

a minimum of Six weeks of
Intravenous Antibiotics

Oral antibiotics
are now the mainstay
 RECENT TRENDS IN
OSTEOMYELITIS THERAPY
• Use of C-reactive protein to diagnose
skeletal infection and monitor therapy

• Outpatient parenteral antibiotic

therapy (O.P.A.T.)
 The C-reactive protein?

• What is its use in the treatment process?

• It more useful than the sedimentation rate
• In osteomyelitis, C-reactive protein elevates
more rapidly with infection onset, and
normalizes more rapidly with treatment than
does the erythrocyte sedimentation rate

• How does it relate to the prognosis ?

• Elevation beyond the fourth treatment day
predicts a complicated course
 RECOMMENDATIONS
(2011)
• The etiology of the infective process must be
determined

• Appropriate initial management of skeletal

infections may require surgical drainage,
especially if associated with concomitant septic
arthritis or chronic osteomyelitis

• Parenteral therapy until pathogen isolated and

susceptibilities known
 RECOMMENDATIONS
Recovery of isolate and initial clinical
improvement allows initiation of oral
therapy only if there has been the
appropriate clinical response
Some want the blood cultures to be
negative as well !!!

The doses may exceed

maximum recommended dose
 RECOMMENDATIONS

• Compliance of oral/outpatient therapy

must be monitored at least weekly during
treatment course

• The follow-up oral treatment is

predicated on individual factors
Six weeks of antibiotics still ?
• Factors determining the duration of
treatment
–short duration of symptomatic
illness pre-treatment (<10 days)
-rapid and complete resolution of
clinical signs of infection within first
week of treatment
-normalization of C-reactive protein
within first week of treatment
 Individualize treatment

• Neonate due to strep = 7-10 days

• Distal Femur in 12 year old = 2-3months
• Determined by :
– Age
– Organism
– Duration of disease
– Amount of dead bone produced
Where does surgery fit into the
management of osteomyelitis ?
The function of surgery Why is this so
is to drain pus important ?
Pus kills periosteum
 Loss of periosteum =
Periosteal destruction by pus
loss of capacity to regenerate new bone

2y.o. male with

life threatening general
Staph sepsis

Permanent defect
develops

Local pus
remained
for two weeks
 Need to debride all the dead
bone within the intramedullary cavity

Decreases the duration

of the post-operative fever spikes
Special types of Osteomyelitis
 Neonatal Osteomyelitis
• What is unique about • How are the symptoms
the osseous growth different ?
area of the neonate ? • Less Clinical Findings

• The anatomy
different ? •How does this affect
the morbidity?

•Different results
•Damage often
done by the
time clinical
Causing destruction
Vessels allow findings are
to the
the bacteria to spread
reproducing
to the cellscells
reproducing apparent
 Neonatal Osteomyelitis
Different Sequelae
• Two pound Premie • One Year Later
 Neonatal
Osteomyelitis What is the difference as to
how various organisms affect the bone ?
• Group B Streptococcus
• Staphylococcus ?
in neonate
• Bone Destruction
• Diffuse bone cellulitis
 Unusual Locations
What is unique about the femoral neck ?

What are thenecrosis

Avascular sequelae ?
Unusual Locations
Osteo Talus
Septic Ankle ???

2 Mo
Later
Unusual Locations

What is unique about the anatomy of

the pediatric vertebrae ?
Infection
crosses the
disc

Endochondral ossification Vessels Penetrate Disc Space

in the endplates
What is the clinical presentation ?

Clinically,
resists flexion
Disc Space Infections
•Early: what are the x-
ray changes ?
None
Late: what are the
x-ray changes ?
Narrowing and sclerosis
What special type does this
represent?
Sub-Acute
• Low Grade
Symptoms
• Often Prior
Antibiotics
• Treatment:
– Aspiration plus
antibiotics
– May require
surgical drainage
 Diaphyseal osteomyelitis
What type of bone tumors do we have here?
(simulating tumors)
• Osteogenic Sarcoma ? • Ewings Sarcoma ?
 Thank you
for your attention