dr. Andri R.

Winoto, SpOT
 General aspect of infection
• Infection
– A condition in which pathogenic organisms
multiply and spread within the body tissue
• Port de entry
– Direct (wound)
– Indirect (blood, urinary tract, etc)
 General aspect of infection
• Classic sign
– Redness
– Swelling
– Heat
– Loss of function
 General aspect of infection
• Acute pyogenic infection
– Pus
– Abscess
– spread
• Chronic infection
– Granulation tissue
– Lymphadenopathy
– Splenomegali
– Tissue wasting
 OSTEOMYELITIS
• Acute/chronic inflammatory
process of the bone and its
structures secondary to
infection with pyogenic
organisms.
 OSTEOMYELITIS

• Can be examined from several perspectives:

- Patient age (neonatal, childhood, adult).
- Causative organism (pyogenic or granulomatous).
- Nature of onset (acute, subacute, chronic).
- Route of infection (hematogenous, direct, contiguous
spread).
 ACUTE OSTEOMYELITIS
• presents the clinical picture of
infection in its early stage and
usually includes systemic effects
• US:1 per 5,000 children
• Acute hematogenous
osteomyelitis → children.
• Direct trauma and contiguous
focus osteomyelitis →
adults/adolescents
 Pathophsiology
• Hematogenous osteomyelitis
• Direct or contiguous
inoculation osteomyelitis
Acute Haematogenus
Osteomyelitis
 Acute Hematogenous Osteomyelitis

• Acute infection of the bone caused

by the seeding of the bacteria
within the bone from a remote
source.
• Primarily in children
• The most common site is the rapidly
growing and highly vascular
metaphysis of growing bones.
Acute Hematogenous Osteomyelitis

• Almost invariably in children

• adult→resistance low
 Causal organism
• Common :
– Staphylococcus aures
– Gram-positive cocci
• Under 4 years
– Gram negative
– Haemophilus influenza
• Others
– Anaerobic organism
– Mix infection
 Predilection
• Babies:
– Long bone
– Spread near very end of bone→ anastomose
• Children
– Long bone
– Metaphyse
• Adult
– More common in vertebrae
 PATHOPHYSIOLOGY
Characteristic pattern :
– Inflammation
– Suppuration
– Necrosis
– Reactive new bone
formation
– Resolution and healing
Inflammation:
• Vascular congestion
• Exudation
• Infiltration by polymorphonuclear leucocytes
• Intraosseous pressure rise rapidly

Cause :
– Intense pain
– Obstructive to blood flow
– Intravascular thrombosis

Impending ischemia
Suppuration ( second or third day )
• Pus form within the bone

through the volkmann canals

subperiosteal abscess

• Pus spreads along the shaft

• Re enter the bone at another level
• Burst into the surrounding soft tissue
• In children through the physis epiphysis joint
• Older children through the periosteum joint
• Adult medullary cavity
 Acute Haematogenous Osteomyelitis

Initially small focus of bacterial inflammation

(hyperaemia and edema in
cancellous bone and marrow of the metaphyseal region
of a long bone)
⇓
Rigid close space
⇓
Rise intraosseous pressure
⇓
Severe and constant local pain
⇓
Pus form
⇓
Increasing local pressure
⇓
Vascular thrombosis
⇓
Necrosis of the bone
Untreated infection

Blood stream local

Bacteraemia increased local pressure

penetrated thin cortex compromised the
periostoeum internal circulation

Septicemia

(malaise,anorexia,fever) local tenderness dead bone

subperiosteal abcses
if uncontrolled bone necrosis sequestrum
cellulitis
soft tissue absces new bone
formation
Spread in other bone/organ joint septic arthritis
involucrum
Pathogenesis :
Acute Haematogenous
Osteomyelitis
Acute Haematogenous
Osteomyelitis
Modified classification of the radiographic :
Diagnosis

• Clinical.
• Laboratory.
• Radiological.
 Clinical feature
• In children
– Fever, malaise, severe pain
– Pulse rate > 100
– lymphadenopathy
– Look : redness, swelling
– Feel : tenderness, warm
– Rom : restricted because of pain
 Clinical feature
• In infant
– Simply fail to thrive, drowsy but irritable
– History of birth dificulty, umbillical catheter,
inflamed iv infusion
– Metaphyse tenderhess, rom restrict
 Clinical feature
• In adult
– Commonest site of infection is the thoracolumbar
spine
– History of urology procedure followed by mild
fever, backache
– Background of immunodeficiency illness
 Source of Infection
• AHO : slight trauma, mild bacteriaemia
• Source : tonsils, middle ear,lungs,intestine canal,
U.G. Tract, boil,excoriasis, small wound
• Strongly predispose in certain fevers :
– smallpox, malaria, scarlet fever, measles, diphtheria,
influenza(lessen the resistance of bone marrow,favour
the development pyogenic organisms)
• Typhoid fever – followed by chronic osteomyelitis
or acute osteomyelitis if pyogenic infection
superadded
Salmonela osteomyelitis with spread from metaphysis to diaphysis
 RADIOGRAPHY
• First is suggested by overlying
soft-tissue edema at 3-5 days
after infection.
• Bony changes are not evident for
14-21 days and initially manifest
as periosteal elevation followed
by cortical or medullary
lucencies.
 Diagnostic imaging (X-ray)
• 1st day plain x-ray show no abnormality
• End of 2nd week there may extra-cortical
outline ( periostal new bone formation)
• Periostal thickening
• Combination regional osteoporotic with
segment increase density
 Diagnostic imaging (ultrasound)
• Subperiostal collection of fluid in early stage,
but it can’t distinguish between haematoma
and pus
 Diagnostic imaging (radioscintigraph)
• with 99mTc-HDP
• Highly sensitive investigation
 Diagnostic imaging (MRI)
• Extremely sensitive
• Can differentiate
between soft tissue
infection and
osteomyelitis
 Laboratory finding
• The most certain way to confirm the clinical
diagnostis is to aspirate the pus from the
metaphyseal subperiostal abscess or adjacent
join
 Laboratory findinng
• Pus : gram stain, bacteriology exam, antibiotic
sensitivity
• White cell count
• Crp, esr
• Blood culture
 LABORATORY
• The WBC count may be elevated, but it
frequently is normal.
• The C-reactive protein level usually is
elevated and nonspecific; it may be more
useful than the erythrocyte sedimentation
rate.
• The erythrocyte sedimentation rate usually
is elevated (90%); this finding is clinically
nonspecific.
 LABORATORY
• Culture or aspiration findings: normal in 25%
of cases.
• Blood culture results are positive in only 50%
of patients with hematogenous osteomyelitis.
 DIFFERENTIAL DIAGNOSIS
• Cellulitis
• Streptococcal Necrotizing Myositis
• Acute suppurative
• Acute Rheumatism
• Sickle-cell crisis
• Gaucher Disease
 TREATMENT
4 ASPECTS:
1. Supportive treatment for pain
and dehidration
2. Splintage of the affected part
3. Antibotic therapy
4. Surgical drainage
 TREATMENT
• Kultur + Sensitivity Test
• The primary treatment :
Bakterisidal, Parenteral, Dosis tinggi

⇒Benzylpenicillin, 1-2 gr iv/im; 100-200mg/kgBB/hr

⇒Cephalosporin: Ceftriaxon, 2gr iv; 75 mg/kgBB/hr
⇒Aminoglicoside

3 minggu parenteral, 3 minggu per oral

 COMPLICATIONS
• Death
• Metastatic Infection
• Suppurative arthritis
• Altered bone growth
• Chronic osteomyelitis
• Fracture
• Overlying soft-tissue cellulitis
• Bacteremia
Post-traumatic osteomyelitis
• Port de entre: open fracture
• Most common cause in adult
• Staph. aures, E. colli , Proteus , Pseudomonas
• Anaerobic infection
• Clinical feature
 Treatment
• Cleans and debridement
• Provision of drainage by leaving wound open
• Immobilization an antibiotic
• Regular wound dessing
• Repeated excision of all dead and infection
tissue
Post-operative osteomyelitis
• Port d’entrée : operation procedure
• Incidence : 0,5 – 10 %
• Greater in immunosupresant people
• Organism from direct/indirect
 Classification of postoperative
infection
• Early infection
– Superficial
– Deep
– Deep and superficial
• Late infection
– Following early infection
– Covert infection appearing later
– Following a long period of normality
 Early postoperative infection
• Within 1 month
• Persistent pain, fever
• Skin over implant is inflamed
• Discharge, tendernes, pain on moving
• Esr, wbc raise
• Bacteriology positive
 Intermediet postoperative infection
• Between 1 month until 1 year
• Wound problem
 Late post operative infection
• Several year
• Symptom never become acute
• X-ray : periosteal bone reaction and cortical
destruction
 Prevention
• Prevention is better than cure
• Risk can reduce by:
– Avoid operations on immune deficiency px
– Eliminate focus infection before ox
– Steril ox
– Prophylactic ab
– Handling tissue gentle
– High quality implant
– Ensuring close fit and secure fixation
 treatment
• Ox without implant
• Appropriate antibiotic
• Drained
• Remove implant
• revision
 Chronic Osteomyelitis.
• Despite adequate drainage of pus and intensive
antibiotic therapy, with acute osteomyelitis, develop
chronic osteomyelitis.
• With cavities, sequestra, and sinusis.
• S. aureus are the common micro-organism.
 Radiological:
• Plain X-ray and CT.
• To identify the number and extent of infected
cavities and location of sequestra.
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 Hematogenous osteomyelitis of the tibia in an8-year-old A, normal roentgenographic
findings at 4 days after acute clinical onset B, early localized destruction in metaphysis
(arrow) at 12 days, C Extensive diaphyseal destruction and involucra at 9 weeks
D, Massive new bone associated with progress of healing at 8 months
 Late and untreated
osteomyelitis of the
femur the disease
beginning in the
lower metaphysis.

The original shaft has

formed an extensive
sequestrum

Chronic osteomyelitis of fibula,

involucrum, squester, cloaca
RO:
RO:6mo 12mo
24mo
 Surgery : fibula bone graft to the ulna

Distraction of radius
Better Function ADL
 Treatment:
• Antibiotic.

• Local treatment.

• Surgery.
• Eradication of infection is difficult.
• Complications associated with infection and
treatment are frequent.
 Antibiotic:
• Antibiotic treatment should begin as soon as
blood, synovial fluid, and appropriate culture
materials have been obtained.
• Neonate: empiric therapy: oxacllin in
combination with gentamicyn or cefotaxime.
• In child < 4 years: oxacillin and cefotaxime or
cefuroxime.
• Child > 4 years: Oxacillin.
• Immunocompromised: Oxacillin.
 Surgery:
• Once diagnosis is made, the treatment of
Chronis osteomyelitis is often required of
surgery.
• Complete removal of all infected /
devascularized tissue.
• The timing of surgical intervention is
controversial.
 Complicatoins:
• Pathologic fracture.
• Septic arthritis with joint destruction.
• Physeal damage.
• Non union or segmental bone loss.
• Leg length discrepancy.
• Malignant transformation (< 1%)
50 yr old woman Chronic Debridement External
osteomyelitis fixation fibular bone graft
Osteomyelitis – Tx conservative Antibiotic
 SEPTIC ARTHRITIS (SA)
• Septic Arthritis (SA) requires urgent
treatment.
• The duration of symptoms prior to treatment
is the most important prognostic factor for
outcome.
“Once osteomyelitis, osteomyelitis forever”
THANK YOU!!!