Acute Haematogenous Osteomyelitis

8/18/2019 Acute Haematogenous Osteomyelitis

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ACUTE HAEMATOGENOUS

OSTEOMYELITIS

DR THIT LWIN

FACULTY OF MEDICINE &HEALTH SCIENCES

UMS


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• almost invariabl a !is"as" o# $%il!r"n

' i# a!(lt ar" a##"$t"!)

*lo+ r"sistan$" $on!ition ",

-!"bilit) !is"as"! or !r(,.

/imm(nos(00r"sion

' tra(ma !"t"rmin" t%" sit" o# in#"$tion

' (s(al $a(sal or,anism1 staphylococcus

' l"ss o#t"n $a(sal or,anism1 streptococcus pyrogenes

-s. pneumoniae


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• $%il!r"n 23 "ars o# a," - Haemophilusinfluenzae

' o$$asional or,anism41 Escherichia coli

-Pseudomonas aeruginosa

-Proteus mirabilis

1ana"robi$ Bacteroides fragilis

' (n(s(al or,anism ar" mor" li5"l to b" #o(n! in

%"roin a!!i$ts an! imm(n" $om0romis"! 0ati"nts

' 0ati"nts +it% si$5l"1$"ll !is"as" ar" 0ron" to

in#"$tion b S almonella


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• so(r$" o# in#"$tion1 minor s5in abrasion) a

boil) as"0ti$ toot%

1in#"$t"! (mbili$al $or! -n"+born.1(r"t%ral $at%"t"r) in!+"llin, art"rial lin")

or !irt srin," & n""!l"

' or,anism inva!" t%" bloo! str"am & (s(alls"ttl" in t%" m"ta0%sis

' 0r"!il"$tion #or m"ta0%sis4

1 0"$(liar arran,"m"nt -%air10in loo0s.1r"lativ" vas$(lar stasis

1 #lar" str($t(r" -"asil tra(ma)


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• in o(n, in#ant) or,anism $an "asil lo!," in

"0i0%sis- #r"" anastomosis.

' in#"$tion ma s"ttl" n"ar t%" v"r "n! t%" bon"

an! ,ro+t% !ist(rban$"s "asil #ollo+"!

'In $%il!r"n) m"ta0%s"al in#"$tion is (s(al4 t%",ro+t% !is$ a$t as a barri"r to s0r"a!

' in a!(lt) %a"mato,"no(s in#"$tion

is mor" $ommon in v"rt"bra' -batson v"no(s 0l"6(s valv"1l"ss v"no(s 0l"6(s.


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7ATHOLOGY

• !"0"n! on * a,"

/ sit" o# in#"$tion 8 vir(l"n$" o# or,anism

3 %ost r"s0ons"

' %o+"v"r) t%"r" is $%ara$t"risti$ sta,"4i. inflammation

ii. suppuration

iii. necrosisiv. new bone formation

v. resolution


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i. inflammation

1 "arl sta," -im0"n!in, is$%"mia. 1 a$(t" r"a$tion +it% vas$(lar $on,"stion)

#l(i! "6(!ation) 7MN l"($o$t"s in#iltration

1 intraoss"o(s 0r"ss(r" ris" $a(s" obstr($tionto bloo! #lo+ an! intravas$(lar t%rombosis


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ii suppuration:

- b /n!

or 8r!

!a) 0(s #orms +it%in t%" bon"1 0(s ,o alon, t%" 9ol5mann $anal to s(r#a$" o# bon"

-s(b0"riost"al abs$"ss.


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1 s(b0"riost"al abs$"ss s0r"a! alon, t%" s%a#t r"1

"nt"r t%" bon" at anot%"r l"v"l or b(st into so#t

tiss("

1in#ant 4in#"$tion "6t"n! into t%" :oint

1 ol!"r $%il!r"n4 0%sis is barri"r to !ir"$t

s0r"a!) b(t 0(s ma !is$%ar," t%ro(,%

0"riost"(m to :oint- m"ta0%sis is

intra$a0s(lar.


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• in a!(lt) 0(s is mor" li5"l to s0r"a! +it%in t%"

m"!(llar $avit' v"t"bral in#"$tion s0r"a! t%ro(,% t%" "n!10lat" an! I9D

into t%" a!:a$"nt v"rt"bral bo!

iii necrosis: !(" to

' 1 rais"! intraoss"o(s 0r"ss(r"

' 1 vas$(lar stasis' 1in#"$tiv" t%rombosis

' 10"riost"al stri00in,


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' ba$t"rial to6ins an! l"($o$ti$ "n;m"s also

involv" in tiss(" !"str($tions

' in#ant4 !ama," to ,ro+t% !is$ an! A9N o#"0i0%sis

' 0i"$"s o# !"at% bon" s"0arat" as seuestra.

' ma$ro0%a,"s an! lm0%o$t"s r"mov" t%"

!"bris b 0%a,o$tosis an! ost"o$lasti$

r"sor0tion) b(t lar," s"


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iv. new bone formation

• b t%" "n! o# /n! +""5) n"+s bon" #orms #rom

!""0"r la"rs o# stri00"! 0"riost"(m

' T%" n"+ bon" t%i$5"n to #orms an invol($r(m

"n$losin, t%" in#"$t"! tiss(" an! s"


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v.resolution

' I# in#"$tion is $ontroll"! an! "arl s(r,i$al

r"l"as" o# 0r"ss(r") t%is 0ro,r"ss $an b"abort"!

' t%" bon" aro(n! t%" ;on" o# in#"$tion is #irst

ost"o0oroti$) t%"n s$l"rosis an! t%i$5"nin,- %0"ra"mia1 #ibrosis & a00ositional n"+

bon" #ormation.

' r"mo!"llin,4 normal $onto(r or !"#orm"! bon"


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a. in#"$tion in t%" m"ta0%sis ma s0r"a! to+ar!s t%" s(r#a$")

to #orm s(b0"riost"al abs$"ss b som" o# bon" ma !i") an! is "n$as"! in 0"riost"al n"+ bon"

as a s"


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' 7at%o0%siolo, o# %a"mato,"no(s s""!in,


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s"


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CLINICAL FEATURES

' 7ati"nt1 $%il!4 r"$"nt %istor o# in#"$tion 1n"onat"4 %istor o# birt% !i##i$(lt 1

a!(lt4 %istor o# (rolo,i$al 0ro$"!(r"

' 7ain

' F"v"r

' M"ta0%s"al t"n!"rn"ss

' Constit(tional !ist(rban$"s $an b" misl"a!in,l mil! in

in#ants' Lo$al t"n!"rn"ss is not v"r mar5"! in a!(lt4 $on#irm"! b

#in"1n""!l" as0iration & $(lt(r"


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DIAGNOSIS:• 61ra4 !(rin, #irst #"+ !as1 !is0la$"m"nt

o# #at 0lan" 4"n! o#/n! +""5s1 #aint "6tra1$orti$al o(tlin" !(" to 0"riost"al n"+

bon" #ormation 4 lat"r1 obvio(s 0"riost"al t%i$5"nin, an!

0at$% rar"#a$tion o# m"ta0%sis an! t%"n b"$om" ra,,"!

!"str($tion' =on" s$an>>mT$1HD7 ?in$r"as"! a$tivit in bot% 0"r#(sion

an! bon" 0%as"

' MRI1$an !i##"r"ntiat" b"t+""n so#t1tiss(" in#"$tion an!

ost"om"litis

' R"!($"! si,nal in T*1+"i,%t"! ima,"s


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first x-ray 2 day metaphyseal mottling

after the symptoms


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• ! days later periosteal "hanges


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• A"#te O$


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investigations

' !ia,nosti$ as0iration o# 0(s #rom

s(b0"riost"al abs$"ss

' i# no 0(s4 ,ram stain sm"ar o# as0irat"

' bloo! $(lt(r"4

' W=C $o(nt an! C1r"a$tiv" 0rot"in

' stool $(lt(r" #or salmonella 4 0ati"nt +it%

si$5l"1$"ll !is"as"


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DIFFERENTIAL DIAGNOSIS

' CELLULITIS4 so(r$" o# in#"$tion ma not obvio(s

' STRE7TOCOCCAL NECROTI@ING MYOSITIS4

MRI +ill r"v"al m(s$l" s+"llin, an! si,n o# tiss("

n"$rosis

' ACUTE SU77URATI9E ARTHRITIS4

1t"n!"rn"ss is mor" on t%" :oint lin"

1in#ant bot% ma "6ist

' ACUTE RHEUMATISM4 0ain is l"ss s"v"r"

4$ar!itis) r%"(mati$ no!(l") "rt%"ma mar,inat(m


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TREATMENT

' if suspected on clinical ground! blood samples

should be ta"en and treatment startimmediately waiting for confirmation.

Fo(r 0rin$i0l"s

* s(00ortiv" tr"atm"nt #or 0ain an!!"%!ration

/s0linta," o# a##"$t"! 0art

8 antibioti$ t%"ra0

3 s(r,i$al !raina,"


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Supportive treatment

• anal,"si$ #or 0ain4 ,iv" r"0"at"! int"rval

+it%o(t +aitin, #or t%" 0ati"nt to as5 #or t%"m

' intrav"no(s #l(i!4 #"v"r an! s"0ti$"mia an!

$a(s" s"v"r" !"%!ration


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splintage

' to 0r"v"nt :oint $ontra$t(r"

' 7last"r ba$5 slab or %al#1$lin!"r ma b" (s"

- !onBt obs$(r" t%" a##"$t"! ar"a.

' antibioti$s4

' 1$%oi$" o# antibioti$ 4 bas"! on !ir"$t"6amination o# 0(s an! b"st ,("ss


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• also !"0"n! on 0ati"nt a,") r"nal #(n$tion)

!",r"" o# to6i"mia) an! 0r"vio(s %istor o#

all"r,

' $%il!r"n an! a!(lt4 iv #l($lo6a$illin an!

#(si!i$ a$i! (ntil $1r"a$tiv" val(" r"t(rn to

normal-*1/ +""5s. 1

a#t"r t%is oral #or 81 +""5s

' $%il! 23 "ars4 start +it% iv $"0%alos0orin

1 alt"rnativ" is a(,m"ntin


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' 0ati"nt +it% si$5l"1$"ll !is"as"4 tr"at"! +it%

$%loram0%"ni$ol or $o1tromo6a;ol" $ombin"

+it% a(,m"ntin

' imm(no$om0romis"! 0ati"nt4 start +it%

,"ntami$in an! $"0%alos0orin


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#$%&'%(E:

• i# 0(s is as0irat"! in !ia,nosti$ as0iration4

1s%o(l! b" !rain b o0"n o0"ration (n!"ranas"t%"sia an! !rill t%" m"!(llar $avit +it% #"+%ol"s

1 +i!"s0r"a! !rillin, !o mor" %arm t%an ,oo!' i# t%"r" is "6t"nsiv" intram"!(allar abs$"ss4!raina," is b $(ttin, a small +in!o+ in t%" $ort"6

-Sa($"ri;ation.

' s0lint

' #(ll +"i,%t b"arin, is (s(all a#t"r 813 +""5s


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COM7LICATIONS4

• s"0ti$"mia1 rar"

' m"tastati$ in#"$tion4 ma b" m(lti#o$al1 ma involv"! ot%"r bon"s) :oints)

s"ro(s $avit) brain or l(n,

' s(00(rativ" art%ritis4 $ommon in OM #"moraln"$5

' alt"r"! bon" ,ro+t%4 in#ant1,ro+t% arr"st

1 ol!"r $%il!r"n 1t%" bon" ,ro+ too lon,)!(" to %0"ra"mia

' $%roni$ ost"om"litis


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sa($"ri;ation


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Acute Haematogenous Osteomyelitis

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