Acute osteomyelitis |Causes| Complications| Clinical features

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Osteomyelitis

Definition 
Osteomyelitis is defined as a suppurative process of the bone caused which is cause by pyogenic organisms or simply a pyogenic infection of the cancellous portion of the bone.
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Classification 
1.Acute Osteomyelitis (less than 2 week)
2.Chronic Osteomyelitis (more than 3 week)

ACUTE OSTEOMYELITIS 

Etiology 
The etiological factors causing osteomyelitis are often best understood if discussed under the subsequent heads.

Agent Factors 
The following myriad of incriminating organisms is liable for its causation:

S-series organisms (“S” denotes severe osteomyelitis) 
• Staphylococcus aureus (60-85%): This is the most common organism causing acute osteomyelitis.
• Streptococcus hemolyticus (8-10%)
• Salmonella: Osteomyelitis is comparatively rare.
– Several bones involved
– Symmetrical involvement of bones
– Severe osteomyelitis
– Spine may be involved
– Sickle cell anemia present
– Stool culture may be positive.

P-series organisms (their mode of entry is thru punctured wounds)

• Pseudomonas
• Pneumococcus.

C-series (C denotes compound fractures) 

• Clostridium welchii
• Coliforms (E. coli).

B-series 

• Brucella bacillus.

H-series 

• Hemophilus influenzae (7 months to 4 years) This is known to cause osteomyelitis in the age group of 7 months to 4 years.

T-series 

• Treponema pallidum (syphilitic osteomyelitis)
• Tubercle bacillus (Mycobacterium)

Fungal osteomyelitis (ABC) 
• Actinomycosis
• Blastomycosis •

Cryptococcosis and coccidiodomycosis 
These usually cause chronic osteomyelitis.

Host Factors 

Age 
In children: The incidence is 88 percent (because more prone for injury and to fall). In adults 12 percent. Hence, it is predominantly a disease of childhood.

Sex 
Male preponderance (? more playful).

Environmental 
Factors General Factors All the above-mentioned general factors bring down the resistance of the patient thereby making them susceptible for infection.

Local Factors 
These are very important in the localizing and the infection to the metaphysis. Hairpin bend of the metaphyseal vessels: This slows down the circulation for a flash , which is sufficient for the organisms to flee out.

Metaphyseal hemorrhage: Results from the bleeding thanks to microscopic trauma. The grume so accumulated acts as a superb culture media for the escaped organisms to grow.

Defective phagocytosis: WBCs here are busy removing the debris of the decalcification because of growth process. Function of eliminating the offending organism is slightly impaired.

Vasospasm: Though vasospasm protective as it arrests and the further bleeding from the traumatized vessels, and it also causes anoxia and failure of antibiotics and other defense cells from reaching the area.

Anoxia: Due to vasospasm, it helps the bacteria grow. Thus, acute osteomyelitis develops because of the combination of agent, host and environment factors.

Clinical Features
Acute osteomyelitis is a clinical catastrophe. It presents in the following manner.

Fever 
This is the most common presenting symptom. The child usually has very high fever and is related to profuse sweating, chills and rigors. Sometimes, the presentation is so acute that the kid could also be in shock and unconscious.

Swelling 
This usually follows the fever and should affect the ends of long bones. The swelling could also be acutely painful and therefore the skin may appear red.

Limitation of Movement 
The child might not move the joint near the affected bone thanks to pain and swelling. In fact, the kid may lie still without moving the joint and this is often sometimes called a state of pseudoparalysis.

Clinical Signs 
This consists of general and local signs.

General Features
General features of anemia, dehydration, pyrexia, pulse , shock and toxicity could also be present.

Local Features 
The local swelling may show increased temperature could also be tender to the touch , and therefore the skin is stretched. Movements of the neighboring joints are decreased and there may be effusion in them too.

Investigations 
The investigations of acute and chronic osteomyelitis is compared for easy remembrance and understanding (Table 38.3). In general, laboratory investigations and bone scan are more useful while radiology is of much help in chronic osteomyelitis.

Management 
In Acute osteomyelitis is an orthopedic emergency. The management are often discussed as general and native .

General Management Conservative management is the mainstay of treatment.

Rest in bed; protect affected spare splints to alleviate pain and spasm.
Elevation of the part, warm and moist packs to scale back the swelling.
Systemic treatment— here blood transfusions, intravenous fluids to correct shock and hypovolemia.
Treatment—with antibiotics discussed below helps to reduce toxicity.
Surgery—properly indicated and timed to prevent complications.

Principles of antibiotic therapy: Here Lack of understanding of the correct antibiotic therapy in acute osteomyelitis leaves a sequel in the form of chronic osteomyelitis. This underlines the importance of correct antibiotic therapy (all A’s).

Appropriate drug—usually the drug chosen may be a broadspectrum bactericidal agent.
Appropriate route—intravenous for the primary 2 weeks and oral for subsequent 4 weeks.
Appropriate dose—of the drug counting on the weight of the patient.

Complications (seen in 5% of the cases)
• Pyemia and Septicemia are the common general complications.
• Septic arthritis due to extension of the neighboring foci of infection into the joint.
• Chronic osteomyelitis develops due to improper and inadequate treatment. The incidence rate is 5-10 percent.
• Pathological fractures and growth disturbances are relatively rare.
• Recurrence rate in acute osteomyelitis: – Metatarsals more than 50 percent. – Around the knee more than 25 percent. – Due to late diagnosis more than 25 percent.
• Mortality rate is less than 2 percent due to early antibiotic therapy.


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