Osteomyelitis    

Lecture:  5th  female  /  4th  male    

Email:  [email protected]    
Date:  6-­‐1-­‐2014      
 Osteomyelitis    
 

Infectious  (septic  )  arthritis  

  — It  is  serious  because  it  can  cause  rapid  joint  destruction  and  permanent  
  deformities.  
  — A  medical  emergencies  caused  by  bacterial  invasion  of  a  joint,  resulting  
  in  inflammation  of  the  synovial  lining.  
  — If  the  organisms  enter  the  joint  cavity,  effusion  and  pus  are  formed,  with  
General  information   destruction  of  bone  and  cartilage.  
— Both  genders  are  affected  equally   Hip  
—  The  infection  involves  only  a  single  joint  
— usually  the  knee-­‐followed  in  order  by  hip,    
 shoulder,  elbow,  wrist,  and  sternoclavicular  joints.  
—  Joint  aspiration  is  typically  purulent  
— Culture  allows  identification  of  the  causal  agent.  
  Femur  
  • Any  concurrent ‫ ﻣﺗﺯزﺍاﻣﻥن‬ bacterial  infection.  
  • Serious  chronic  illness  (cancer,  rheumatoid  arthritis,  SLE,..etc.)    
  • Alcoholics  and  elderly  people  run  a  higher  risk  of  developing  septic  
Pathogenesis   arthritis.  
(risk  factors)   • Diseases  that  depress  the  autoimmune  system  or  with  prior  
immunosuppressant  therapy.  
• I.V.  drug  abuse,  by  heroin  addicts,  for  example.  
• Other  factors:  recent  articular  trauma,  joint  surgery  and  intra-­‐articular  
injections.  
 
  — Any  bacteria  can  be  causal:  
◦  Haemophilus  influenzae  predominates  in  children  under  age  2  
  years  
◦  S.  aureus  is  the  main  causative  agent  in  older  children  and  
Bacteria  commonly  involved   adults  
◦ Gonococcus  is  prevalent‫ ﺳﺎﺋﺩد‬ during  late  adolescence  and  young  
  adulthood.    
◦ Individuals  with  sickle  cell  disease  are  prone‫ ﻋﺭرﺿﺔ‬ to  infection  
with  Salmonella  at  any  age.  
 
  —  sudden  onset  of  pain  
  —  redness,  and  swelling  of  the  joint  with  restricted  range  of  motion.    
  — Fever,  leukocytosis,  and  elevated  erythrocyte  sedimentation  rate  
  — Infectious  arthritis  must  be  rapidly  diagnosed  and  treated  promptly  to  
Clinical  features:   prevent  irreversible  and  permanent  joint  damage.  
   
 
 
 
 
 
  — Septic  arthritis  can  lead  to  ankylosis  and  even  fatal  septicemia.    
Complication   — However,  prompt  antibiotic  therapy  and  joint  aspiration  or  drainage  
cures  most  patients.  
 
 
 

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Osteomyelitis    
 
 
 
 
Pyogenic Osteomyelitis  

Osteon  
means:  Bone    
Myelo  means:   itis  means:  
Marrow     InSlammation      

Osteomyelitis  
is  an  
inSlammation  
of  bone  and  
marrow  
 

In  common  use  it  is  virtually  synonymous  with  infection caused  by  certain  
mycobacteria  and  pyogenic  bacteria  “bacteria  capable  of  causing  acute  
inflammation  and  abscess  formation  “
 It  can  be  secondary  to  systemic  infection  but  more  frequently  occurs  as  a  
primary  isolated  disease.  
Osteomyelitis  almost  always  caused  by  bacteria  (osteomyelitis  that  
caused  by  viruses,  parasites,  fungi  is  rare)  
It  can  be:    
Ø Acute.  
Ø Chronic    
Ø Special  type  :  Tuberculosis  Osteomyelitis  

 
 
 
 
 
 
 

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 PYOGENIC  OSTEOMYELITIS  
Osteomyelitis     It’s  acute  osteomyelitis  always  caused  by  bacteria.
 
  Staphylococcus  aureus  is  responsible  for  80%  to  90%  the  cases  of  pyogenic  
  osteomyelitis  (  in  normal  people  )  why?    
 
  Staph.  aureus    expresses  receptors  to  bone  matrix  components,  may  be  related  
  to  the  fact  that  facilitating  its  adherence  to  bone  tissue.  
  Bacteria  which  are  common  in  certain  conditions:  
 
CAUSES   — Neonates:    Escherichia  coli  and  group  B  streptococci.  
 
  — Persons  with  sickle  cell  disease:    Salmonella    
   
— Patients  with  genitourinary  tract  infections  or  with  intravenous  
drug  abusers:  E.coli,  Klebsiella  and  Pseudomonas  
 
— Direct  spread  during  surgery  or  open  fractures  (secondary  to  bone  
trauma):  Mixed  bacterial  infections,  including  anaerobes  
   
The  offending  organisms  reach  the  bone  by  one  of  three  routes:    
  — Hematogenous  spread,  (most  common).  
  — Extension  from  a  contiguous  site.  
Routes  of  infection   — Direct  implantation  after  compound  fractures  or  orthopedic  
and  site   procedures          
 
  The  most  common  sites  are:  the  distal  femur  and  proximal  tibia  
 
Risk  factors  include:  
—  childhood  and  adolescence  
— diabetes  mellitus  (especially  involving  the  foot)  
— compromised  immunity  (including  AIDS)    
— sickle-­‐cell  disease              

    Influenced  by  the  vascular  circulation,  which  varies  with  age.  

The  metaphysis  is  quite  vascular  and  hence  is  often  the  site  where  infection  
Sites  of  involvement   localizes.  
  Neonates:  metaphysis,  epiphysis  or  both  
 
   
 
 
Children:  metaphysis  
 
 
Adults: epiphysis  and  subchondral  regions  
 
  Malaise,  fever,  leukocytosis,  chills,  and  throbbing  pain  over  the  affected  region.  
Symptoms  also  can  be  subtle,  with  only  unexplained  fever,  particularly  in  
Clinical  Course  and   infants,  or  only  localized  pain  in  the  adult.  In  many  untreated  cases,  blood  
Diagnosis   cultures  are  positive,  but  biopsy  and  bone  cultures  are  usually  required  to  
  identify  the  pathogen.  Present  may  extremely  stable  in  children  and  infants,  
  who  may  present  only  with  pyrexia  (pyrexia  of  unknown  origin,PUO)  
Diagnosis:  
• Sign/symptoms.  
• X-­‐ray  …changes  consist  lytic  focus  of  bone  surrounded  by  a  zone  
of  sclerosis  
• Blood  cultures  (  In  as  many  as  50%  of  cases,  no  organisms  can  be  
isolated  )  
• biopsy  

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 Osteomyelitis    
 

     
Chronicity  may  develop  with:   Complications:  
 
• delay  in  diagnosis   • Pathologic  fracture.  
  • extensive  bone  necrosis   • Secondary  amyloidosis  
Chronicity  and     • abbreviated  antibiotic   • Endocarditis  
Complications   therapy   • Sepsis  
• inadequate  surgical   • Squamous  cell  carcinoma  if  the  
debridement,   infection  creates  a  sinus  tract.  
• weakened  host  defenses.   • Rarely  sarcoma  in  the  affected  
bone  
• Formation  of  sinus  
• Formation  of  fistula  
 

 
Stages:  
 
   
 
 
  acute   sub  acute   chronic  
 
 
 
 
 
 
 
Avascular
  necrosis Acute osteomyelitis
 
 This    necrosis  of  bone  is    The  primary  site  of  
due  t  o  ischemia.  Ischemia   infection  is  usually  in  the  
may  r   esult  if  the  blood   metaphysial  region,  from  
supply  
  to  bone  is   which  the  infection  may  
interrupted  
  which  may   spread  to  involve  the  
occur     if  there  is  a  fracture   cortex  and  form  a  
particularly  
  in  areas  blood   subperiosteal  abscess;  
supply  
  i s  suboptimal   e.g.   may  spread  into  the  
the  scaphoid  
  and  femoral   medullary  cavity;  or,  
neck    .  Most  other  cases  of   rarely,  may  spread  into  
vascular  
  necrosis  are   the  adjacent  joint  space.
either  
  idiopathic  or  follow  
corticosteroid  
 
administration.
 
 
 
 
 
 
 

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Osteomyelitis    
 
 
Medical  prescription:  
• Pain  relief  
• Parenteral  antibiotics  for  at  least  2  weeks,  followed  by  oral  antibiotics  for  
at  least  4  weeks  
• Surgical  decompression  and  removal  of  any  dead  bone  
• Rehabilitation.    
 
 

♣ Tuberculosis  osteomyelitis  
• TB  Osteomyelitis  is  rare  and  always  chronic.  It  affects  the  spine        (vertebrae  )  
and  long  bones  (  metaphysis  and  epiphysis  ).  
• It  may  be  secondary  of  lung  TB  by  (  By  blood  stream  )  

• Usually  blood  borne  

bone  through  the)  

-­‐ originate  from  a  focus  of  active  visceral  disease  

usually  reach  the  
(The  organisms  
Routes  of  entry  

• Direct  extension  
• from  a  pulmonary  focus  into  a  rib  
• or  from  tracheobronchial  nodes  into  adjacent  
vertebrae  
OR  
• spread  via  draining  lymphatics.  
 

1-­‐ of  skeletal  involvement  :  

thoracic  and  lumber  vertebrae  followed  by  the  knees  
common  sites  

and  hips  
most  

2-­‐ Pott’s  disease  is  the  involvement  of  spine  

 
In  patients  with  AIDS  frequently  multifocal  
 

Histopathology   collections  of  epithelioid  histiocytes  and  lymphocytes  

with  caseation  necrosis  
  • Pain  
Clinical  features   • Fever
• Weight  loss
• May  form  an  inguinal  mass  “  psoas  abscess”.  
Complications   • Bone  destruction  
• Tuberculous  arthritis
• Sinus  tract  formation
• Amyloidosis    
 

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Osteomyelitis    
 

♣ Tuberculosis  of  the  vertebral  bodies:  

• clinically  serious  form  of  osteomyelitis  
• Infection  at  this  site  causes    :  
ü vertebral  deformity.  
ü collapse.  
ü posterior  displacement  (Pott  disease).  
ü leading  to  neurologic  deficits.  

 
♣ Pott’s  disease  

   
ℵ The  infection  breaks  through  the  intervertebral  discs  and  
extends  into  the  soft  tissues  (muscles)  forming  Psoas  abscesses.  

  • Because  the  tubercle  bacillus  is  microaerophilic,  the  

 
 
synovium,  with  its  higher  oxygen  pressures,  is  a  common  
  site  of  initial  infection.  The  infection  then  spreads  to  the  
  adjacent  epiphysis,  where  it  elicits  typical  granulomatous  
 
 
inflammation  with  caseous  necrosis  and  extensive  bone  
  destruction.  
 
 
  • Rickets  refers  to  the  disorder  in  children,  in  which  it  
  interferes  with  the  deposition  of  bone  in  the  growth  plates.  
   
 
  • Bone  infection  complicates  an  estimated  1%  to  3%  of  cases  
  of  pulmonary  tuberculosis.  
  • The  patient  presents  with  pain,  swelling,  anemia  and   ‫ﺗﻌﺮﻕق‬
 
  ‫ ﺑﺎﺭرﺩد‬ 
 
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 Osteomyelitis    
 

Morphology
 
 
 
Bone,   acute  osteomyelitis     Bone,  chronic  osteomyelitis    
 

 A  fragment  of  dead  bone  surrounded  by    A

   bone  necrotic  fragment  that  is  
numerous  a  cute  inflammatory  cells   surrounded  by  a  mononuclear  cell  infiltrate
  What  is  the  significance  of  the  empty  
   
Dead  pieces  
  of  bone  is  known  as   lacunae  in  the  bone  fragment?  
the  sequestrum  
  Empty  lacunae  are  a  histologic  hallmark  of  
  may  be  deposited  called  
New  bone   necrosis  of  bone.
Involucrum  
 
 
   
 
The   morphologic   changes   in  osteomyelitis  depend   on   the   chronicity   and   location   of  
the  infection.    
Ø After  the  first  week  of  infection,  chronic  inflammatory  cells  become  more  numerous.    
Ø Leukocyte  cytokine  release  stimulates  osteoclastic  bone  resorption,  fibrous  tissue  
ingrowth,  and  bone  formation  in  the  periphery.    
Ø Reactive  woven  or  lamellar  bone  can  be  deposited;  when  it  forms  a  shell  of  living  tissue  
around  a  sequestrum,  it  is  called  an  involucrum.    
Ø Viable  organisms  can  persist  in  the  sequestrum  for  years  after  the  original  infection.  
Ø In  infants  (and  uncommonly  in  adults),  epiphyseal  infection  can  spread  into  the  
adjoining  joint  to  produce  suppurative  arthritis,  sometimes  with  extensive  
destruction  of  the  articular  cartilage  and  permanent  disability.    
Ø An  analogous  process  can  involve  vertebrae,  with  an  infection  destroying  intervertebral  
discs  and  spreading  into  adjacent  vertebrae.  

 
 

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Osteomyelitis    
 
 
Brodie  abscess
 
 

Brodie  abscess:    
   Is  a  small  intraosseus  
abscess  that  frequently  
involves  the  cortex  and  is  
walled  off  reactive  bone.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rupture  of  the  
periosteum→soft  tissue  
abscess  formation→  
draining  sinuses.
 

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Osteomyelitis    
 

MCQs:    
 
1.  OSTEOMYLITIS  in  neonates  can  caused  mostly  by  :  
A.  S.aureus.        
B. E.coli.  
C. Staphylococcus.  
D. Streptococcus  group  A.  
2.  Which  patient  is  more  susceptible  to  OSTEOMYLITIS:    
A.  Diabetes  mellitus.  
B. Children.  
C. Heart  disease.  
D. Kidney  failure.  
3. When  TB  affected  bone  that  called:  
A. Osteomyelitis.  
B. Sickle  cell  anaemia.  
C. Diabetes  mellitus.  
D. Pott’s  disease.  
4. OSTEOMYLITIS  is  an  inflammation  disease  which  occur  in:  
A. Bone.  
B. Bone  marrow  space.  
C. Muscles.  
D. Both  A  &B.  
5. Dead  pieces  of  bone  known  as  :  
A.  Involucrum.  
B. Sequesterum.   1.  B    
C. Fistula.   2.  A    
D.  All  answers  are  correct.   3.  D    
4.  D    
6. The  main  cause  of  OSTEOMYLITIS  in  adult  is  :   5.  B    
A. S.aureus.   6.  A    
B. Anthrax.    
C. Clostridium.  
D. Slamonella.  
 
 
 
 

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Osteomyelitis    
 
A special thanks to all the people who made this
possible. And for working hard on the 2 blocks.
 
 
 
 
Rawan Al-Badaie   Waleed Al-Rajban
wa  
Zhour ALHedyan   Othman Abid
Noura Ahmed   Ahmed ALZoman
Yara ALEnezi   Abdullah ALJurais
Shua’a ALSayary Khaled ALSuhaibany
Alanoud ALMuhaideb   Rayan aLOwaisheq
Nawt ALFuweres   Mojahed Otayf
Nada BinDawood   Omar AlDahhas
Rawan ALAbdullah   Abdullah AlAtar
Yasmeen ALShehri  
Jewaher ALAbdullkareem
Areej ALAman  
Reem ALMassoud  
Areej ALRajeh  
Hanen ALJafri
Lulwah ALTurki  
Aisha ALSafi  
Maha ALZeheary  
Khawla ALShahrani
Noura ALBulushi  
Haifa ALOtaibi  
Areej Alenezi  
Shatha ALZahrani
Rasha ALEnezi  
   
 
 
 
 
 
Hopefully you gained knowledge from this team.
See you next term!!

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