Organisms can reach a bone by one of three routes:
• Blood stream (Haematogenous).
• From without (open fractures).
• Direct spread. e.g. chronic ulcer leg.
Acute Haematogenous Osteomyelitis
• Bacteria: Most commonly staplylococcus.
• Source of infection: Septic focus especially tonsillitis, upper respiratory infection.
• Predisposing factors:
- General: Lower vitality.
- Local : Trauma.
• Bone affected: Long bones especially lower limb bones.
• Site of initial lesion. (Metaphysis):
- Immature bone.
- Vascular arrangement.
- Liable to trauma.
Local pathological changes:
• Stage of suppuration.
• Stage of sequestration.
• Stage of Involucrum formation.
Pattern in Various Age
|Adjacent Joint||Frequent||? Intra capsular||May Occur|
Complications of Acute Haematogenous Osteomyelitis:
- Septic arthritis.
- Pathological fracture.
Diagnosis Acute Haematogenous Osteomyelitis
Children, infants predominate.
Mild trauma may be obtained. Followed in one to three days by fever, severe pain, general malaise.
• General: Fever, rapid pulse, toxaemia.
• Local: Local swelling, aedema, local tenderness, warmth, redness of the skin. Effusion of the near by joint.
• Radiography: Normal x-ray during the first 3 weeks, later rarefied the bone and periosteal new bone formation.
• E.S.R ↑.
• Blood culture may be +ve.
• Rheumatic arthritis.
• Pyogenic septic arthritis.
Treatment of acute osteomyelitis
- Morbidity is Lowered if acute osteomyelitis is treated shortly after its onset.
- Rest in bed. (General)
- Systemic Antibiotics
- An antibiotic is effective before this pus forms.
- An antibiotics cannot sterilize avascular tissues and pus that should be removed.
- Local splintage
- Drainge (Bone Drilling).
Indication for surgery:
• Clinical diagnosis of abscess formation.
• Severely ill child (Toxaemia).
• Failure of I.V. antibiotic treatment.
• Surgery should not further damage of already ischaemic bone.
• If pus removal, then antibiotics can prevent reformation and primary closure is safe.
• Antibiotics should be continued after surgery.
Osteomyelitis after open fracture
• At the fracture site.
• Usually subacute.
• Union of the fracture is delayed.
- External fixator for immobilization of the fracture.
- Drainge & dressing.
- Local antibiotics.
Bone Infection Resulting From Adjacent Inflammation (Periosteitis)
I. as a sequel to acute osteomyelitis
Factors of choronicity:
- History of acute osteomyelitis, bone is thickened, tender, discharging sinus.
- Bone cavity
• The bone is thickened with patchy and irregular scelerosis surrounding the bone cavity.
• A sequestrum shows as a dense loose fragment.
• Pathological fracture.
• Irregular growth.
• Amyeloid disease is rare.
Antibiotics alone are of little value
1. Operative Drainge:
2. Excision of certain bone
• Carcinoma of the sinus.
• Amyloid disease.
• Complete bed ridden patient.
II. Brodie’s Abcess
• A chronic bone abscess usually of small size & situated in metaphysis of long bone, the abscess may be sterile. There is dense sclerosis around the cavity.
III.Chronic sclerosing (Garre’s type)
• A non suppurative type. There is diffuse thickening of bone with encroachment on medullary canal (no sequestration or sinus formation).
IV. Salmonella Osteomylitis
• A positive Widal test
• A positive culture of blood
• A high agglutination titre reaction of 1/80.
Pyogenic infection of joints
Staphylococci route of infection
• Direct extension.
• From without (open injury).
• Intra-articular injection.
Any joint may be infected (knee, hip).
1. Synovitis: It becomes Red, Swollen, Exudate forms
2. Chondrolysis: Articular cartilage by:
• Digestive action of proteolytic enzymes released from dead polymorphic leucocytes.
• Excessive plasmin.
• Direct action of bacterial toxins.
3. Bone involvement.
4. Ligaments: Are softened and stretched.
5. Capsule: Rupture
- Pathological dislocation.
Pathological dislocation due to:
• Muscle spasm.
• ↑ intra-articular pressure.
• Laxity ligaments.
• Destruction of joint surfaces.
• Recovery of joint mobility.
History: Rapid onset with rigors, fever,
• Inability to walk.
• Swelling, deformity, pain tenderness, local signs of inflammation, limitation of joint movments, muscle spasm.
After one month à Rarefaction of bone ends diminshed joint space, irregular joint surfaces and subchondral sclerosis.
• ↑ E.S.R.
• Aspiration of the joint.
• Acute osteomyelitis.
• Rheumatic arthritis.
• T.B arthritis (muscle atrophy is marked)
• General: Rest, fluid, antibiotics.
Nursing care plan for Osteomyelitis
- Examination of body areas that reveal infection such as redness and increased warmth or swelling
- Assess the level of patient anxiety and an the potential of acute Osteomyelitis to become chronic
- Assess the patient gait or any presence of abnormal gait
- Prevent any direct infection
- Early debridement of necrotic tissue after surgery to lessen the possibility of any infection
- Administration of prophylactic antibiotics for patients with open fracture
- Provide heat application to lessen discomfort
- Provide oral fluids to prevent dehydration
- Proper positioning to decrease discomfort
- Use sterile dressing to prevent infection
- The involved extremity should be handled very carefully to prevent fractures
- Patient, family education