mellss yr4 ortho acute osteomyelitis
TRANSCRIPT
Acute Osteomyelitis
Amalina Aminuddin082012100067
• Infection of bone • Mainly affect
children
Introduction
Predisposing factors • Malnutrition and
general debility• Diabetes mellitus• Corticosteroid
administration• Immunosuppressiv
e drugs
• Venous stasis in the limb
• Peripheral vascular disease
• Loss of sensibility• Iatrogenic invasive
measures• Trauma
• Based on duration:• Acute (< 2 weeks )• Subacute (2-3 weeks
)• Chronic ( > 3
weeks )• Based on route of
infection:• Primary(hematogeno
us)• Secondary
• Based on organism• Pyogenic:
Staphylococci, Streptococcus, Pneumococci, Gonococci, H. influenza ,Kingella kingae E. coli, Salmonella sp,
• Non pyogenic: tuberculosis, syphilis,
Classifications
Pathogenesis Children • Hairpin loops stasis• Low oxygen tension • Structure in the
hypertrophic zone of the physis
Infants • anastomoses between
metaphyseal and epiphyseal vessels
Adults • Direct spread
from infection foci
• Local trauma• Hematogenou
s
Pathology • Depend on:• Patient’s age• Site of infection• Virulence of the
organism • Host response.
Acute inflammati
on
Subperiosteal
abscess
Sequestrum
Involcrum
Cloacae
In infants • More common
epiphysial and adjacent joint spread
• Deformed joint, bizzare new bone formation
In adults • Medullary spread in
long bone
Clinical features In child:
• Recent history of infection
• Severe pain, malaise, fever
• Acute tenderness near one of the larger joints
• ‘Pseudoparalysis’.
Infants • History of birth
difficulties, umbilical artery catheterization or a site of infection
• Fails to thrive• Drowsy but irritable. • Metaphyseal
tenderness and resistance to joint movement
Adults • History of some
urological procedure followed by a mild fever and backache.
• Local tenderness• Easily missed
diagnosis in elderly, and in those with immune deficiency,
Diagnostic imaging
•Plain x-ray•Ultrasonography•Radionuclide scanning•Magnetic resonance imaging
• Bone scan reveals increased tracer uptake in the right tibia
• Sagittal T2 reveals marrow edema in the distal tibia which crosses the physis to invade the epiphysis
Investigations • Aspiration analysis• Blood culture• CRP within 12–24 hours • ESR within 24–48 hours
Differential diagnosisCellulitis
• Widespread superficial redness and lymphangitis.
• MRI• Oral or
intravenous antibiotics
Acute suppurative arthritis • Diffuse tenderness • Joint movement abolished
Streptococcal necrotising myositis• Intense pain ,board-like swelling • MRI :muscle swelling, signs of
tissue breakdown.• Intravenous antibiotics surgical
debridement , amputation
Acute rheumatism •Less severe migratory pain•signs of carditis, rheumatic nodules or erythema marginatum
Sickle-cell crisis • Salmonella
Gaucher’s disease •“Pseudo-osteitis’
•enlargement of the spleen and liver.
Management • Supportive treatment for pain and
dehydration.• Splintage (Simple skin traction ,
plaster slab )• Appropriate antimicrobial therapy.• Surgical drainage.
Age Group Types of antibiotics
Neonates up to 6months
• Flucloxacillin + 3rd gen cephalosporin • Flucloxacillin + benzylpenicillin +
gentamycin
Children 6months-6years
• IV flucloxacillin + cefotaxime / cefuroxime
Older child & previously fit adults
• IV flucloxacillin + fusidic acid • For known strep infection :
benzylpenicillin• Allergic to penicillin : 2nd- or 3rd- gen
of cephalosporin like cefotaxime
Elderly & previously unfit patient
• Combination of flucloxacillin + 2nd-/3rd- gen cephalosporin
Condition Types of Antibiotics
Sickle-cell disease patient• Chloramphenicol, • Third-generation
cephalosporin /fluoroquinolone
Heroin Addicts & immunocompromized patient
• Third-generation cephalosporins
• Flouroquinolone (ciprofloxacin)
Patient to be risk at MRSA with acute hematogenous OM
• IV vancomycin + 3rd- gen of cephalosporin
Drainage • When ?
• Clinical features do not improve within 36 hours• Signs of deep pus • Pus is aspirated
• Drained by open operation under general anaesthesia.
• (no obvious abscess) drill into medullary cavity • (extensive intramedullary abscess) cut a small
window in the cortex.• Close wound without drain, • Reapplied traction ,• Encourage movements (crutches)
Complications • Epiphyseal damage and altered bone
growth• Suppurative arthritis• Metastatic infection • Pathological fracture• Chronic osteomyelitis
Referance • Louis Solomon, David Warwick,
Selvadurai, Apley's System of Orthopaedics and Fractures 9th edition
• Maheshwari & Mhaskar ,Essential Orthopedics, 5th edition
• http://www.nejm.org/doi/full/10.1056/NEJMra1213956