1. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Musculoskeletal Disorders

2. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osteomyelitis

3. Osteomyelitis Severe infection of the Severe infection of the  Bone  Bone marrow  Surrounding soft tissue Caused by a variety of microorganisms Caused by a variety of microorganisms Most common infecting microorganism Most common infecting microorganism

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology Antibiotics in conjunction with surgical treatments have decreased mortality rate and complications Antibiotics in conjunction with surgical treatments have decreased mortality rate and complications Infecting microorganisms can invade by Infecting microorganisms can invade by  Indirect entry  Direct entry

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Direct Entry Can occur at any age Can occur at any age Open wound where microorganisms can gain entry to body Open wound where microorganisms can gain entry to body May also occur in presence of foreign body May also occur in presence of foreign body  

6. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Direct Entry Sequestrum continues to be an infected island of bone, surrounded by pus Sequestrum continues to be an infected island of bone, surrounded by pus Difficult for blood-borne antibiotics or white blood cells (WBCs) to reach sequestrum Difficult for blood-borne antibiotics or white blood cells (WBCs) to reach sequestrum Sequestrum can move out of bone and into soft tissue Sequestrum can move out of bone and into soft tissue

7. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Direct Entry Once outside bone Once outside bone  Sequestrum may Revascularize and then undergo removal by normal immune process Revascularize and then undergo removal by normal immune process Be surgically removed through debridement of necrotic bone Be surgically removed through debridement of necrotic bone  If necrotic sequestrum is not resolved, it may develop a sinus tract resulting in chronic, purulent cutaneous drainage

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Indirect Entry Frequently affects growing bone in boys <12 years old ---Why??? Frequently affects growing bone in boys <12 years old ---Why???   Most common sites of indirect entry Distal femur Distal femur Proximal tibia Proximal tibia Humerus Humerus Radius Radius

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Indirect Entry Adults with increased risk Adults with increased risk  Vascular disorders  Genitourinary and respiratory infections  Spread infection from blood to bone  Vascular-rich bone sites Pelvis Pelvis Tibia Tibia Vertebrae Vertebrae

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Development of Osteomyelitis Fig 64-1

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute Osteomyelitis Initial infection Initial infection  Infection of <1 month in duration  Both systemic and local

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations Acute Osteomyelitis Systemic Systemic  Local Local  Constant bone pain that worsens with activity  Swelling, tenderness, warmth at infection site  Restricted movement of affected part  Later signs: drainage from sinus tracts

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of Chronic Osteomyelitis Chronic – an infection that persists for longer than 1 month Chronic – an infection that persists for longer than 1 month Infection that has failed to respond to initial course of antibiotic therapy Infection that has failed to respond to initial course of antibiotic therapy Systemic signs ______ Systemic signs ______ Signs and Symptoms Signs and Symptoms  Constant bone pain  Swelling  Tenderness  Warmth at site  Continuous Drainage

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies Bone or soft tissue biopsy Bone or soft tissue biopsy  Definitive way to determine causative microorganism Patient’s blood and/or wound culture Patient’s blood and/or wound culture  Frequently positive for presence of microorganism Lab Studies Lab Studies  WBC  Erythrocyte sedimentation rate (ESR)

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Radiologic Studies Radiologic signs Radiologic signs  Usually do not appear until 10 days to weeks after start of clinical symptoms Radionuclide bone scans Radionuclide bone scans  Helpful in diagnosis and usually positive in areas of infection Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) Computed tomography (CT) Computed tomography (CT)  Help identify extent of infection, including soft tissue involvement

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Osteomyelitis Patients are often discharged to home care or skilled nursing facility (SNF) with IV antibiotics delivered via Patients are often discharged to home care or skilled nursing facility (SNF) with IV antibiotics delivered via  

17. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Osteomyelitis Vigorous and prolonged intravenous (IV) antibiotic therapy Vigorous and prolonged intravenous (IV) antibiotic therapy  Treatment of choice for acute osteomyelitis  As long bone ischemia has not occurred  Cultures or bone biopsy should be done if possible Delaying antibiotic treatment may require surgical debridement and decompression Delaying antibiotic treatment may require surgical debridement and decompression

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Osteomyelitis Antibiotic therapy may be continued for at home for _ to _ _____ or as long as _ __ _ ______ Antibiotic therapy may be continued for at home for _ to _ _____ or as long as _ __ _ ______ Variety of antibiotics may be prescribed Variety of antibiotics may be prescribed  Penicillin, nafcillin (Nafcil)  Neomycin, vancomycin  Cephalexin (Keflex)  Cefazolin (Ancef)

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Chronic Osteomyelitis Adults with chronic osteomyelitis may be prescribed oral therapy + fluoroquinolone for 6 to 8 weeks instead of IV antibiotics Adults with chronic osteomyelitis may be prescribed oral therapy + fluoroquinolone for 6 to 8 weeks instead of IV antibiotics Oral antibiotics may be given after acute IV therapy to ensure resolution of infection Oral antibiotics may be given after acute IV therapy to ensure resolution of infection Monitoring patient’s response Monitoring patient’s response

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Thank you Thank you