Dr Gaurav Jain | Best Orthopedic Surgeon in Indore

Osteomyelitis

Osteomyelitis is a serious bone infection that commonly affects children and requires timely diagnosis and treatment to prevent long-term complications. At our pediatric orthopaedic care center, led by Dr. Gaurav Jain, we specialize in identifying and managing osteomyelitis with advanced medical and surgical options. Understanding the causes, symptoms, and treatment of osteomyelitis is essential for parents and caregivers to ensure the best outcomes for young patients. This page provides detailed information about pediatric osteomyelitis, including its signs, risk factors, diagnosis, and treatment strategies to help you make informed decisions for your child’s health.

Osteomyelitis in the pediatric population is most often the result of hematogenous seeding of bacteria to the metaphyseal region of bone.

Diagnosis is generally made with MRI studies to evaluate for bone marrow edema or subperiosteal abscess.

Treatment is nonoperative with antibiotics in the absence of an abscess. Surgical debridement is indicated in the presence of an abscess.

बच्चों में ऑस्टियोमाइलाइटिस, अक्सर हड्डी के मेटाफिसियल क्षेत्र में बैक्टीरिया का संक्रमण, खून से आता है।
निदान : एमआरआई
मवाद की अनुपस्थिति में एंटीबायोटिक दवाओं के साथ उपचार। मवाद की उपस्थिति में सर्जिकल (मवाद की सफाई)

Incidence
- 1 in 5000 children younger than 13 years old 13 साल से कम उम्र के 5000 बच्चों में से 1

Demographics
- mean age 6.6 years औसत आयु 6.6 वर्ष
- 2.5 times more common in boys लड़कों में 2.5 गुना अधिक आम
- more common in the first decade of life due to the rich metaphyseal blood supply and immature immune system पहले दशक में अधिक
- not uncommon in healthy children स्वस्थ बच्चों में असामान्य नहीं

Risk factors जोखिम
- diabetes mellitus मधुमेह
- hemoglobinopathy हीमोग्लोबिनोपैथी
- juvenile rheumatoid arthritis गठिया
- chronic renal disease गुर्दे की बीमारी
- immune compromise प्रतिरक्षा की कमी
- varicella infection संक्रमण

Mechanism
- local trauma and bacteremia lead to increased susceptibility to bacterial seeding of the metaphysis
- history of trauma is reported in 30% of patients

चोट और बैक्टेरिमिया (खून में संक्रमण) के कारण ,मेटाफिसिस में जीवाणु जमा हो कर वृद्धि करते हैं

Pathophysiology

- Staph aureus
  - is the most common organism in all children
  - strains of community-acquired (CA) MRSA have genes encoding for Panton-Valentine leukocidin (PVL) cytotoxin
  - PVL-positive strains are more associated with complex infections, multifocal infections, prolonged fever, abscess, DVT, and sepsis
  - MRSA is associated with increased risk of DVT and septic emboli
- Group B Strep
  - is most common organism in neonates
- Kingella kingae
  - becoming more common in younger age groups
- Pseudomonas
  - is associated with direct puncture wounds to the foot
- H. influenza
  - has become much less common with the advent of the Haemophilus influenza vaccine

- Mycobacteria tuberculosis
  - children are more likely to have extrapulmonary involvement
  - biopsy with stains and culture for acid-fast bacilli is diagnostic
- Salmonella
  - more common in sickle cell patients

pathoanatomy

acute osteomyelitis
- most cases are hematogenous
- initial bacteremia may occur from a skin lesion, infection, or even trauma from tooth brushing
- microscopic activity
  - sluggish blood flow in metaphyseal capillaries due to sharp turns results in venous sinusoids which give bacteria time to lodge in this region
  - the low pH and low oxygen tension around the growth plate assist in the bacterial growth
  - infection occurs after the local bone defenses have been overwhelmed by bacteria
  - spread through bone occurs via Haversian and Volkmann canal systems
  - purulence develops in conjunction with osteoblast necrosis, osteoclast activation, the release of inflammatory mediators, and blood vessel thrombosis
- macroscopic activity
  - a subperiosteal abscess develops when the purulence breaks through the metaphyseal cortex
  - septic arthritis develops when the purulence breaks through an intra-articular metaphyseal cortex (hip, shoulder, elbow, and ankle) (NOT KNEE)
- Infants <1 year of age can have infection spread across the growth plate via capillaries causing osteomyelitis in the epiphysis and septic arthritis

chronic osteomyelitis
- periosteal elevation deprives the underlying cortical bone of blood supply leading to necrotic bone (sequestrum)
  - sequestrum
    - the necrotic bone which has become walled off from its blood supply and can present as a nidus for chronic osteomyelitis
- an outer layer of new bone is formed by the periosteum (involucrum)
  - involucrum
    - a layer of new bone growth outside existing bone seen in osteomyelitis
- chronic abscesses may become surrounded by sclerotic bone and fibrous tissue leading to a Brodie's abscess

नवीन संक्रमण

ज्यादातर खून का संक्रमण का हड्डी में आ जाना
प्रारंभिक बैक्टरेरिया का संक्रमण : त्वचा के घाव, संक्रमण, या यहां तक कि टूथ ब्रशिंग से आघात से भी हो सकता है
सूक्ष्म गतिविधि
- मेटाफिसियल केशिकाओं में सुस्त रक्त प्रवाह तीखे मोड़ के कारण बैक्टीरिया को इस क्षेत्र में रहने का मौका मिलता हैं
- ग्रोथ प्लेट के आसपास कम पीएच और कम ऑक्सीजन तनाव बैक्टीरिया के विकास में सहायता करता है
- प्रतिरोधक तंत्र में कमी
- हड्डी के माध्यम से फैलता हैवेरियन और वोल्कमैन नहर प्रणालियों के माध्यम से होता है
- मवाद का बनना : ओस्टियोब्लास्ट(हड्डी बनाने वाले कोशिका) नेक्रोसिका (क्षति), ऑस्टियोक्लास्ट (हड्डी तोड़ने वाले कोशिका) का सक्रियण, सूजन करने वाले मध्यस्थों की रिहाई और रक्त वाहिका में खून का थक्का जमना के संयोजन के साथ विकसित होता है
मैक्रोस्कोपिक गतिविधि
- मवाद हड्डी की सतह को भेद कर बाहर आ जाता है
- यदि हड्डी के पास कोई जोड़ होता है है तो मवाद जोड़ में जमा हो जाता है (कूल्हे, कंधे, कोहनी और टखने) (घुटने नहीं)

जूना / पुराना हड्डी का संक्रमण

पेरीओस्टियम (हड्डी को घेरने वाली झिल्ली ) मवाद के इक्कठा होने से हड्डी से अलग हो जाती है ,जिससे हड्डी की रक्त की आपूर्ति कीबाधित हो जाती है और हड्डी का क्षरण होता है जिसे सीक्वेस्ट्रम कहते है
- सीक्वेस्ट्रम (परिगलित हड्डी )
  - परिगलित हड्डी : कीटाणु के लिए नए घर की तरह काम करती है
- परिगलित हड्डी के ऊपर नई हड्डी की एक बाहरी परत पेरीओस्टेम द्वारा बनाई जाती है, जिसे involucrum कहते है

जब जूना / पुराना हड्डी का संक्रमण, को रोकने के लिए, स्करोटिक हड्डी और रेशेदार ऊतक का निर्माण करती है , जिससे ब्रॉडी एब्सेस बोलते है

Acute osteomyelitis
- see pathoanatomy above

Subacute osteomyelitis
- uncommon infection with bone pain and radiographic changes without systemic symptoms
- increased host resistance, decreased organism virulence, and/or prior antibiotic exposure
- radiographic classification
  - types IA and IB show lucency
  - type II is a metaphyseal lesion with cortical bone loss
  - type III is a diaphyseal lesion
  - type IV shows onion skinning
  - type V is an epiphyseal lesion
  - type VI is a spinal lesion

Chronic osteomyelitis
- see pathoanatomy above

History
- limb pain
- recent local infection or trauma
- obtain immunization history regarding H. influenza
- ask about prior antibiotic use, as it may mask symptoms

Symptoms
- limp or refusal to bear weight
- generally not toxic appearing
- +/- fever

Physical exam
- inspection & palpation
  - edematous, warm, swollen, tender limb
  - evaluate for point tenderness in pelvis, spine, or limbs
- range of motion
  - restricted motion due to pain

अंग दर्द
हाल ही में स्थानीय संक्रमण या आघात
एच. इन्फ्लूएंजा के संबंध में टीकाकरण इतिहास
पूर्व एंटीबायोटिक उपयोग के बारे में पूछें, क्योंकि यह लक्षणों को छुपा सकता है
लंगड़ा या वजन सहन करने से इनकार
आम तौर पर विषाक्त नहीं दिखना
+/- बुखार

शारीरिक परीक्षा

- निरीक्षण और तालमेल
  - सूजन, गर्म, सूजा हुआ, कोमल अंग
  - श्रोणि, रीढ़, या अंगों में बिंदु कोमलता के लिए मूल्यांकन करें
- गति की सीमा
  - दर्द के कारण प्रतिबंधित गति

Serum labs
- WBC count
  - elevated in 25% of patients and correlates poorly with treatment response
- C-reactive protein
  - elevated in 98% of patients with acute hematogenous osteomyelitis
  - becomes elevated within 6 hours
  - most sensitive to monitor therapeutic response
  - declines rapidly as the clinical picture improves
  - CRP is the best indicator of early treatment success and normalizes within a week
    - failure of the C-reactive protein to decline after 48 to 72 hours of treatment should indicate that treatment may need to be altered

- ESR
  - elevated in 90% of patients with osteomyelitis
  - rises rapidly and peaks in three to five days, but declines too slowly to guide treatment
  - less reliable in neonates and sickle cell patients
- plasma procalcitonin
  - new serologic test that rises rapidly with a bacterial infection, but remains low in viral infections and other inflammatory situations
  - elevated in 58% of pediatric osteomyelitis cases
- bone aspiration
  - helps establish a definitive diagnosis
  - 50% to 70% of affected patients have positive cultures
- blood culture
  - is positive only 30% to 50% of the time and will likely be negative soon after antibiotics are administered, even if treatment is not progressing satisfactorily
Aspiration
- assists in diagnosis and management
  - helps guide antibiotic selection when organism identified (50% of the time)
  - proceed with surgical drainage if pus is aspirated
- technique
  - large bore needle utilized to aspirate the subperiosteal and intraosseous spaces under fluoroscopic or CT-guidance
  - start antibiotics after aspiration

Biopsy and culture
- consider when diagnosis not clear (i.e. subacute osteomyelitis) and need to rule out malignancy

Treatment

Nonoperative treatment
- antibiotic therapy alone एंटीबायोटिक
  - indications
    - early disease with no subperiosteal abscess or abscess within the bone हड्डी के भीतर कोई मवाद का ना होना या प्रारंभिक बीमारी
    - surgery is not indicated if clinical improvement obtained within 48 hours यदि 48 घंटों के भीतर नैदानिक सुधार प्राप्त होता है तो सर्जरी की आवश्यकता नहीं होती है

- - modalities
    - antibiotics
      - begin with empiric therapy
        generally, nafcillin or oxacillin, unless high local prevalence of MRSA (then use clindamycin or vancomycin)
        mechanism of action for vancomycin involves binding to the D-Ala D-Ala moiety in bacterial cell walls
        if gram stain shows gram-negative bacilli - add a third generation cephalosporin
      - convert to organism-specific antibiotics if organism identified
        mycobacterium tuberculosis
        treatment for initial 1 year is multiagent antibiotics and rarely surgical debridement due to risk of chronic sinus formation
      - duration
        typically treat with IV antibiotics for four to six weeks, आम तौर पर चार से छह सप्ताह के लिए IV एंटीबायोटिक दवा दी जाती है
        controversial duration
      - intravenous versus oral
        often a case by case decision with input from infectious disease consultation

Operative treatment
- surgical drainage, debridement, and antibiotic therapy, सर्जिकल ड्रेनेज, डिब्रिडमेंट, और एंटीबायोटिक थेरेपी
  - indications
    - deep or subperiosteal abscess हड्डी में मवाद का इक्कठा होना
    - failure to respond to antibiotics एंटीबायोटिक दवाओं का जवाब देने में विफलता
    - chronic infection जूना / पुराना संक्रमण
  - contraindications
    - hemodynamic instability, as patients should be stabilized first - however sometimes operative treatment of the underlying infection helps stabilize the patient हेमोडायनामिक (नाजुक स्तिथि) अस्थिरता, क्योंकि रोगियों को पहले स्थिर किया जाना चाहिए - हालांकि कभी-कभी अंतर्निहित संक्रमण का ऑपरेटिव उपचार रोगी को स्थिर करने में मदद करता
  - example of institution algorithm treatment pathway

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