osteomylitis Taiz University,faculty of medicine and health sciences By Dr : Mohammed Alfohaidi

1. Normal boneNormal bone

2. Infectious Diseases ofInfectious Diseases of
BoneBone
1.1. OsteomyelitisOsteomyelitis
2.2. Pott’s DiseasePott’s Disease

3.  Definition:Definition:
This is inflammation of bone and bone marrow,This is inflammation of bone and bone marrow,
can occur in any age group which may be acute,can occur in any age group which may be acute,
subacute or chronicsubacute or chronic
OSTEOMYELITISOSTEOMYELITIS
Classification:Classification:
 Non- bacterial osteomyelitis:Non- bacterial osteomyelitis:
 Viral osteomyelitisViral osteomyelitis
 SarcoidosisSarcoidosis
 Radiation osteomyelitisRadiation osteomyelitis

4.  Bacterial osteomyelitis:Bacterial osteomyelitis:
 Acute suppurative osteomyelitisAcute suppurative osteomyelitis
 Acute haematogenous osteomyelitisAcute haematogenous osteomyelitis
 Acute non-haematogenous osteomyelitisAcute non-haematogenous osteomyelitis
 Chronic osteomyelitis:Chronic osteomyelitis:
 Chronic non-specific osteomyelitisChronic non-specific osteomyelitis
 Chronic specific osteomyelitis ( TB & Syphilis)Chronic specific osteomyelitis ( TB & Syphilis)

5. Etiology(CausesEtiology(Causes((
11--HaematogenosHaematogenos….from blood stream <bacteremia>….from blood stream <bacteremia>
2-Direct invasion2-Direct invasion….from skin puncture in operation or open….from skin puncture in operation or open##
33--InjectionInjection….around a bone….around a bone
44--Pts withPts with….conditions or taking drugs that weaken immune system….conditions or taking drugs that weaken immune system
The causal organism in both adults and children areThe causal organism in both adults and children are:.:.
--S. aureus…. 70-90S. aureus…. 70-90%%
--other etiological less often : GABS… Strept. pyogenes , S. pneumonia , H. influenza ,other etiological less often : GABS… Strept. pyogenes , S. pneumonia , H. influenza ,
E. coli , Pseudomonas , ProteusE. coli , Pseudomonas , Proteus
--Salmonella typhi in Pt with sickle cell diseaseSalmonella typhi in Pt with sickle cell disease

6. Factors predisposing to bone infectionFactors predisposing to bone infection
--Malnutrition and general debilityMalnutrition and general debility
--Diabetes mellitusDiabetes mellitus
--Corticosteroid administrationCorticosteroid administration
--Immune deficiencyImmune deficiency
--Immunosuppressive drugsImmunosuppressive drugs
--Venous stasis in the limbVenous stasis in the limb
--Peripheral vascular diseasePeripheral vascular disease
--Loss of sensibilityLoss of sensibility
--Iatrogenic invasive measuresIatrogenic invasive measures
--TraumaTrauma

7. Definition:Definition: Acute osteomyelitis is an acuteAcute osteomyelitis is an acute
inflammation of bone caused by an infectinginflammation of bone caused by an infecting
organismorganism
ACUTE HAEMATOGENIUSACUTE HAEMATOGENIUS
OSTEOMYELITISOSTEOMYELITIS
 Haematogenous osteomyelitis is predominantly seen inHaematogenous osteomyelitis is predominantly seen in
children and involves the highly vascular long boneschildren and involves the highly vascular long bones
<Metaphysis> especially those of the lower limbs.<Metaphysis> especially those of the lower limbs.
 In adults, haematogenous spread is more common toIn adults, haematogenous spread is more common to
the thoracolumbar spine than elsewhere…also feet ,the thoracolumbar spine than elsewhere…also feet ,
pelvis. that may be dt lowered resistant , local trauma ,pelvis. that may be dt lowered resistant , local trauma ,
damage muscle ,..etcdamage muscle ,..etc

8. 1-Inflammation: Initial inflammation with vascularInitial inflammation with vascular
congestion and increased intra-osseous pressure.congestion and increased intra-osseous pressure.
PathologyPathology
(Stages of disease)(Stages of disease)
Inflammation of boneInflammation of bone

9. 2-Suppuration: Pus within the bones forces its wayPus within the bones forces its way
through the Haversian system and forms athrough the Haversian system and forms a
subperiosteal abscesssubperiosteal abscess in 2-3 days.in 2-3 days.
3-Sequestrum:3-Sequestrum: Vascular obstruction and infectiveVascular obstruction and infective
thrombus decrease or obstruct the periosteal andthrombus decrease or obstruct the periosteal and
endosteal blood supply, causingendosteal blood supply, causing bone necrosisbone necrosis andand
sequestrum formation in approximately 7 days.sequestrum formation in approximately 7 days.
4-Involucrum:4-Involucrum: This is new bone formation from theThis is new bone formation from the
stripped surface of periosteum.stripped surface of periosteum.

10. 5-Resolution or progression to complications5-Resolution or progression to complications:: With antibiotics and surgical
treatment early in the course of disease, osteomyelitis resolves without any
complications.

11. Clinical featuresClinical features
Children:.Children:. presents withpresents with
--Severe painSevere pain,, Malaise andMalaise and aa FeverFever
--Local redness, swelling, warmth and oedema areLocal redness, swelling, warmth and oedema are
later signslater signs
--Lymphadenopathy is common but non-specificLymphadenopathy is common but non-specific
AdultsAdults:.:.
--Mild fever and BackacheMild fever and Backache
--Others….chills, irritability, swelling and rednessOthers….chills, irritability, swelling and redness
over the affected boneover the affected bone

12. Clinical featuresClinical features
--In Pts with DM, PVD, Peripheral neuropathyIn Pts with DM, PVD, Peripheral neuropathy
there may be no pain or fever the onlythere may be no pain or fever the only
symptoms may be the area of skin break-downsymptoms may be the area of skin break-down

13. DIAGNOSISDIAGNOSIS
11--Complete Medical HistoryComplete Medical History…. Ask about…. Ask about
--Recent infections elsewhereRecent infections elsewhere
--Past medical Hx, family medical HxPast medical Hx, family medical Hx
--Medication usageMedication usage
22--Physical ExaminationPhysical Examination …. Look for…. Look for
-Area of tenderness, redness, swelling-Area of tenderness, redness, swelling
--Decrease or painful range of motionDecrease or painful range of motion
--Open soresOpen sores

14. INVESTIGATIONSINVESTIGATIONS
11--LaboratoryLaboratory:.:.
Blood Tests:Blood Tests: - CRP..- CRP.. elevated within 12–24 hrselevated within 12–24 hrs
--ESR ..ESR .. elevated within 24–48 hourselevated within 24–48 hours
- WBCs ..- WBCs .. elevated *leucocytosiselevated *leucocytosis**
--Hb ..Hb .. may be diminished *Anemiamay be diminished *Anemia**
Blood cultures...Blood cultures... are +ve in less than half of casesare +ve in less than half of cases
Needle aspiration:Needle aspiration: to identify the type of infection and assist with theto identify the type of infection and assist with the
initial choice of antibiotic, and tests for sensitivityinitial choice of antibiotic, and tests for sensitivity
Biopsy:Biopsy: to cultural and Abx sensitivityto cultural and Abx sensitivity

15. 22--RadiologyRadiology
PLAIN X-RAYPLAIN X-RAY::
--In 1In 1stst
wk x-ray shows no abnormality of the bone; By the 2wk x-ray shows no abnormality of the bone; By the 2ndnd
wkwk
there may be a faint extra-cortical outline due to periosteal newthere may be a faint extra-cortical outline due to periosteal new
bone formationbone formation
--Later there is patchy rarefaction of the metaphysisLater there is patchy rarefaction of the metaphysis

16. MP of acute osteomyelitisMP of acute osteomyelitis
Inflammation of boneInflammation of bone

17. Acute osteomyelitisAcute osteomyelitis

18. 1.1. PathologicalPathological fracturefracture
2.2. Spread of infection: eg. Arthritis (jointSpread of infection: eg. Arthritis (joint
inflammation), myositis (muscle inflammation)inflammation), myositis (muscle inflammation)
or neuritis (nerve inflammation)or neuritis (nerve inflammation)
3.3. Blood spread: causing toxaemia & septicaemiaBlood spread: causing toxaemia & septicaemia
4.4. Chronic suppurative osteomyelitis: includingChronic suppurative osteomyelitis: including
sequestrum formation and skin sinus formationsequestrum formation and skin sinus formation
5.5. Damage to the growth plate causing subsequentDamage to the growth plate causing subsequent
growth deformitygrowth deformity
Complications of osteomyelitisComplications of osteomyelitis::

19. Pott's diseasePott's disease
 Pott's diseasePott's disease is a presentation of extrais a presentation of extra
pulmonary tuberculosis that affects the spine, apulmonary tuberculosis that affects the spine, a
kind of tuberculous arthritis of the intervertebralkind of tuberculous arthritis of the intervertebral
joints.joints.
 The lower thoracic and upper lumbar vertebraeThe lower thoracic and upper lumbar vertebrae
are the areas of the spine most often affected.are the areas of the spine most often affected.

20. Pott’s DiseasePott’s Disease

21. Tuberculosis of the spine in an Egyptian mummy

22. Clinical presentation:Clinical presentation:
1.1. Back painBack pain
2.2. FeverFever
3.3. Night sweatingNight sweating
4.4. AnorexiaAnorexia
5.5. Weight lossWeight loss
6.6. Spinal mass, sometimes associated withSpinal mass, sometimes associated with
numbness, paraesthesia or muscle weakness ofnumbness, paraesthesia or muscle weakness of
the legsthe legs

23. DiagnosisDiagnosis
 Blood tests – elevated erythrocyte sedimentationBlood tests – elevated erythrocyte sedimentation
rate (ESR)rate (ESR)
 Tuberculin skin testTuberculin skin test
 Radiographs of the spineRadiographs of the spine
 Bone scanBone scan
 CT of the spineCT of the spine
 Bone biopsyBone biopsy
 MRIMRI

24. Pott’s Disease; X-ray Pott’s Disease; MRI

25. ComplicationsComplications
 Vertebral collapse resulting in kyphosisVertebral collapse resulting in kyphosis
 Spinal cord compressionSpinal cord compression
 Sinus formationSinus formation
 Paraplegia (called Pott's paraplegia)Paraplegia (called Pott's paraplegia)

26. Tuberculous in long bonesTuberculous in long bones
 Commonly around the knee, affects metaphysis andCommonly around the knee, affects metaphysis and
epiphysis, rarely diaphysisepiphysis, rarely diaphysis
 Well-defined lytic areaWell-defined lytic area

27. Tuberculous arthritisTuberculous arthritis
 The hip and knee are theThe hip and knee are the
most commonly affectedmost commonly affected
peripheral joints.peripheral joints.
 Characterized by joint spaceCharacterized by joint space
narrowing and erosions whichnarrowing and erosions which
may lead to extensive destructionmay lead to extensive destruction
of the articular cortex.of the articular cortex.

28. HEREDITARYHEREDITARY
BONE DISORDERSBONE DISORDERS
1.1. AchondroplasiaAchondroplasia
2.2. Osteogenesis imperfectaOsteogenesis imperfecta
3.3. osteopetrosisosteopetrosis

29. AchondroplasiaAchondroplasia
 Clinically:
 Long bones are short and thick  short
extremities  dwarfism
 Cranial and vertebral bone spared 
relatively large head and trunk
 Normal intelligence, life span and
reproductive ability

30. AchondroplasiaAchondroplasia

31. Osteogenesis imperfectaOsteogenesis imperfecta
1-Generalized osteopenia: brittle
bones, resulting in recurrent
fractures and skeletal deformity
2-Most patients have an
abnormally thin sclera with
blue hue
Abnormally thin sclera with blue hueAbnormally thin sclera with blue hue

32. 3. Laxity of joint ligments leads to hypermobilty
4. Involvement of the bones of the inner and
middle ear produces deafness
5. Some patients have dentinogenesis imperfecta:
small, fragile and discolored teeth due to
deficiency of dentin
6. The skin may be abnormally thin and the skin
is susceptible to easy bruising

33. Osteogenesis imperfectaOsteogenesis imperfecta
Brittle bones
Laxity of joint ligamentsLaxity of joint ligaments

34. Dentinogenesis imperfectaDentinogenesis imperfecta

35. OsteopetrosisOsteopetrosis
 Marble bone
 Hereditary defect leading to thick sclerotic
bones
Pathology:
-Increased bone density and thickening of bone
cortex
-The thickened bones are brittle and fracture easily

36. X-ray findings:
 Symmetrically generalized osteosclerosis
 Long bones may have broadened metaphyses,
resulting in an "Erlenmeyer flask" deformity

37. Osteopetrosis X-ray findings
Osteosclerosis
Erlenmeyer
flask
shaped
deformity
 Symmetrically generalized
Osteosclerosis
 Long bones may have broadened
metaphyses, resulting in an
"Erlenmeyer flask" deformity

38. Metabolic Diseases ofMetabolic Diseases of
BoneBone

39. OsteoporosisOsteoporosis
 Refers toRefers to increased porosityincreased porosity of skeleton.of skeleton.
 Osteoporotic bones:Osteoporotic bones:
 Thin and fragile and are susceptible to fracture.Thin and fragile and are susceptible to fracture.
 Occurs due toOccurs due to::
 Loss of organic bone matrix and minerals.Loss of organic bone matrix and minerals.
 Resulting inResulting in ::
 DecreasedDecreased bone massbone mass andand densitydensity..
 DecreasedDecreased thicknessthickness of cortical and trabecularof cortical and trabecular
bone.bone.

40. Osteoporotic
vertebral body
Normal
Vertebral body

41. 41
FractureOsteoporosis

42. Types of OsteoporosisTypes of Osteoporosis
 LocalizedLocalized : e.g. disuse of a limb: e.g. disuse of a limb
 GeneralizedGeneralized: involves entire skeleton.: involves entire skeleton.
1.1. Primary:Primary:
 Old age (Senile)Old age (Senile)
 Estrogen deficiency (postmenopausal)Estrogen deficiency (postmenopausal)
1.1. Secondary:Secondary: (due to underlying disease)(due to underlying disease)
 CushingCushing’’s disease (Hypercortisolism)s disease (Hypercortisolism)
 Drugs (Heparin and Steroids)Drugs (Heparin and Steroids)

43. Postmenopausal OsteoporosisPostmenopausal Osteoporosis
 Due to estrogen deficiencyDue to estrogen deficiency
 Estrogen deficiencyEstrogen deficiency  increased resorption ofincreased resorption of
bone by osteoclasts and decreased formationbone by osteoclasts and decreased formation
of bone by osteoblasts.of bone by osteoblasts.

44. Peak bone massPeak bone mass
Osteoporosis
Menopause
•↓ estrogen
•↑ osteoclast activity
Aging
•↓ activity of osteoblasts
•↓ physical activity
Physical activityPhysical activity NutritionNutrition
Genetic factorsGenetic factors

45. Clinical findingsClinical findings::
 Bone painBone pain
 Weight bearing bones predisposed toWeight bearing bones predisposed to
 Compression of vertebral bodies (most common)Compression of vertebral bodies (most common)
 Colles’ fracture of distal radius.Colles’ fracture of distal radius.
 Fracture femoral neck.Fracture femoral neck.
 Loss of height and kyphosisLoss of height and kyphosis

46. 46

47.  Diagnosis:Diagnosis:
 Dual energy X ray absorptiometry (DEXA)Dual energy X ray absorptiometry (DEXA)
to evaluate bone density.to evaluate bone density.

48. OsteonecrosisOsteonecrosis
(Avascular Necrosis(Avascular Necrosis((

49. Osteonecrosis (Avascular necrosisOsteonecrosis (Avascular necrosis((
 Ischemic infarction of bone & bone marrow.Ischemic infarction of bone & bone marrow.
 Causes of ischemia:Causes of ischemia:
 Vascular interruption (fracture)Vascular interruption (fracture)
 Corticosteroids (most common)Corticosteroids (most common)
 Sickle cell diseaseSickle cell disease
 Common sites includeCommon sites include
 Femoral headFemoral head
 Scaphoid bone.Scaphoid bone.

50. OsteonecrosisOsteonecrosis

51. 51
OsteonecrosisOsteonecrosis

52. PAGET’S DISEASEPAGET’S DISEASE

53.  Definition:
 Localized disorder of bone
 Due to: Excessive bone resorption followed by
disorganized bone replacement
 Resulting in: Thickened but weak bone that is
susceptible to deformity and fracture

54.  Stages of paget disease
1. Osteolytic: osteoclastic activity predominates
2. Mixed ostelytic-osteoblastic
3. Osteosclerotic: osteoblastic activity predominates
" burnout stage"

55. 55

56.  Etiology:
1. Possible slow virus infection
2. Possible genetic predisposition

57.  Clinical features:
1. Asymptomatic in most cases
2. Bone pain and deformities
3. Fractures
4. Warmth of overlying skin due to hypervascularity

58.  Forms of involvement:
1. Monosteotic (15%): involving one bone
2. Polyosteotic (85%) : involving multiple bones
 Common sites include the skull, pelvis, femur
and vertebrae

59. PATHOLOGYPATHOLOGY
 MicroscopicallyMicroscopically ::
 Haphazard arrangement of cement lines, creating aHaphazard arrangement of cement lines, creating a
mosaic patternmosaic pattern
 Skull involvement:Skull involvement:
1.1. Increase head sizeIncrease head size
2.2. Foramina narrowing causes impingement of cranialForamina narrowing causes impingement of cranial
nerves, often leading to deafnessnerves, often leading to deafness
3.3. Involvement of facial bones may produce a lion-likeInvolvement of facial bones may produce a lion-like
faciesfacies

60.  X-rays:
 Bone enlargement with lytic and sclerotic areas
 Lab investigation:
 Highly elevated serum alkaline phosphatase
 Complication:
 Osteosarcoma
 Others sarcomas

62. Osteolytic changes of the skullOsteolytic changes of the skull

63. Mosaic pattern of lamellar boneMosaic pattern of lamellar bone

64. BONE TUMORSBONE TUMORS
BENIGN TUMORS OF BONEBENIGN TUMORS OF BONE

65. Classification of benign tumors of boneClassification of benign tumors of bone::
1.1. OsteomaOsteoma
2.2. Osteoid osteomaOsteoid osteoma
3.3. OsteoblastomaOsteoblastoma
4.4. OsteochondromaOsteochondroma
5.5. OsteochondromatosisOsteochondromatosis
6.6. EnchondromaEnchondroma

66. OsteomaOsteoma
 Definition:Definition:
 Benign neoplasm that frequently involves the skullBenign neoplasm that frequently involves the skull
and facial bonesand facial bones

67. Osteoid osteomaOsteoid osteoma
 Definition:Definition:
 Benign,Benign, painful growthpainful growth of the diaphysis of a long bone,of the diaphysis of a long bone,
often the tibia or femuroften the tibia or femur
 Clinically:Clinically:
1.1. Males> femalesMales> females
2.2. Age: 5-25 yearsAge: 5-25 years
3.3. Pain that is worse at night and relieved by aspirinPain that is worse at night and relieved by aspirin
 X-rayX-ray::
Central radiolucency surrounded by sclerotic rimCentral radiolucency surrounded by sclerotic rim

68. Osteoid osteomaOsteoid osteoma

69. OsteoblastomaOsteoblastoma
 Similar to an osteoid osteoma but is largerSimilar to an osteoid osteoma but is larger
(>2cm) and often(>2cm) and often involves vertebraeinvolves vertebrae

70. OsteochondromaOsteochondroma
(Exostosis(Exostosis((
 Definition:Definition:
 Benign boney capped with cartilage that originates fromBenign boney capped with cartilage that originates from
epiphyseal growth plateepiphyseal growth plate
 Clinical presentation:Clinical presentation:
1.1. Adolescent malesAdolescent males
2.2. Firm solitary growths at the end of the long bonesFirm solitary growths at the end of the long bones
3.3. They may be asymptomatic or it causes pain, deformity or itThey may be asymptomatic or it causes pain, deformity or it
can undergo malignant transformation (rare)can undergo malignant transformation (rare)

71. OsteochondromaOsteochondroma

72. OsteochondromatosisOsteochondromatosis
 Multiple hereditary exostosis in which there isMultiple hereditary exostosis in which there is
multiple symmetric osteochondromasmultiple symmetric osteochondromas

73. EnchondromaEnchondroma
 Definition:Definition:
 Benign cartilaginous growth within the medullaryBenign cartilaginous growth within the medullary
cavity of bone, usually involving the hands and feetcavity of bone, usually involving the hands and feet
 Typically solitary and asymptomatic and require noTypically solitary and asymptomatic and require no
treatmenttreatment

75. THANK YOUTHANK YOU