Osteomyeli*s

osteomyeli*s is an infec*on of the bone, a rare but serious condi*on. Bones can become infected in a
number of ways: Infec*on in one part of the body may spread through the bloodstream into the bone,
or an open fracture or surgery may expose the bone to infec*on.
Classifica*on according to:
1)The dura*on - acute, subacute and chronic
2)Mechanism of infec*on -exogenous or hematogenous
3)The type of host response to the infec*on- pyogenic or non pyogenic
Acute Hematogenous osteomyeli*s
Most common type of bone infec*on,
Causes of acute hematogenous osteomyeli*s
bacteraemia
Bacteriological seeding of bone generally is associated with other factors such as localized trauma,
chronic illness, malnutri*on or an inadequate immune system.
Pathophysiology of acute hematogenous osteomyeli*s
In children the infec*on generally involves the metaphyses of rapidly growing long bones
Bacterial seeding leads to an inflammatory reac*on which can cause local ischemic necrosis of bone and
subsequent abscess forma*on.
As the abscess enlarges, intramedullary pressure increases causing cor*cal ischemia, which may allow
purulent material to escape into the subperoisteal space.
A subperisoteal abscess then develops
If leN untreated this process eventually results in extensive sequestrate forma*on and chronic
osteomyeli*s
In children younger than 2 years, blood vessels cross the physes,thus epiphysis may be involved
Limb shortening or angular deformity may occur

Joint may be involved in some cases, hip joint most common.

Sep*c arthri*s resul*ng from acute hematogenous osteomyeli*s generally is seen only in infants and
adults. In children, osteomyeli*s is usually acute, comes on quickly, is easier to treat, and overall turns
out beTer than chronic osteomyeli*s. In adults, osteomyeli*s can be either acute or chronic. People with
diabetes,HIV,or peripheral vascular disease are more prone to chronic
Causes and Risk factors of osteomyeli*s
In most cases, a bacteria called Staphylococcus aureus, a type of staph bacteria, causes osteomyeli*s.
condi*ons and behaviors that weaken the immune system increase a person's risk for osteomyeli*s,
including:
1-Diabetes ,
2 Sickle cell disease,
3- HIV
4- Rheumatoid arthri*s,
5- Intravenous drug use,
6- Alcoholism ,
7-Long-term use of steroids,
8- Hemodialysis,
9- Poor blood supply Recent injury Bone
10- surgery, including hip and knee replacements

Symptoms of Osteomyeli*s
Acute osteomyeli*s develops rapidly over a period of seven to 10 days. The symptoms for acute and
chronic osteomyeli*s are very similar and include:
1-Fever,
2-irritability, fa*gue
3-Nausea
4-Tenderness, redness, and warmth in the area of the infec*on
5-Swelling around the affected bone
6-Lost range of mo*on
7-Osteomyeli*s in the vertebrae makes itself known through severe back pain especially at night.

Osteomyeli*s Treatment
Figuring out if a person has osteomyeli*s is the first step in treatment. It's also
surprisingly difficult. Doctors rely on X-rays, blood tests, MRI, and bone scans
to get a picture of what's going on. A bone biopsy is necessary to confirm a
diagnosis of osteomyeli*s. This also helps determine the type of organism,
typically bacteria, causing the infec*on so the right medica*on can be
prescribed. Treatment of osteomyeli*s depends on appropriate an*bio*c
therapy and oNen requires surgical removal of infected and necro*c *ssue.
Choice of an*bio*c therapy should be determined by culture and sensi*vity
results, if possible. In the absence of such informa*on, broad-spectrum
an*bio*cs should be administered. False-nega*ve blood or biopsy cultures
are common in pa*ents who have begun an*bio*c therapy. If clinically
possible, delaying an*bio*cs is recommended un*l microbial culture and
sensi*vity results are available.
Indica*ons for surgery include:
1- an*bio*c failure,
2- chronic osteomyeli*s with necro*c bone
3- soN *ssue Tumor of muscloskeletal system
Both benign and malignant tumors (neoplasm) may arise from any soN *ssue or bony *ssue of the
extremi*es, pelvis, shoulder
girdle, or the axial skeleton. All tumors arise from one of the different
histological types of *ssue that comprise the musculoskeletal system: bone
(osteoid-forming tumors), car*lage (chondroid-forming tumors), and muscle
and the fibrous connec*ve *ssue (soN *ssue tumors). Only rarely do tumors
arise from the arteries or nerves. If they are malignant, they are considered
sarcomas (e.g., osteosarcoma, chondrosarcoma). Although tumors of the
musculoskeletal system are uncommon, a major concern with bone tumors is
the development of pathologic fractures. In many instances, when the tumor is
in an extremity, complete tumor resec*on is necessary via either limb
salvaging (limb-sparing) techniques or amputa*on.
The management of musculoskeletal tumors requires a mul*disciplinary team
from the *me of diagnosis through medical treatment, recovery,and
rehabilita*on. Physical and occupa*onal therapists are an integral part of that
team. The op*mal goal is to treat the condi*on conserva*vely if appropriate
and, if not, to resects the malignant tumor and preserve a func*onal limb.
However, there are instances in which an amputa*on is the only surgical
op*on.
A sarcoma is a malignant tumor of the mesenchymal cells. Most sarcomas are treated with a
combina*on of chemotherapy, surgical resec*on of the tumor, and some*mes radia*on. SoN *ssue
sarcomas usually can be

resected and the limb preserved; however, in cases in which the tumor also involves the bone, a bony
resec*on and replacement may be necessary.
Amputa*on is some*mes performed for soN *ssue sarcomas if a residual
func*on limb cannot be maintained, because of involvement of the
neurovascular structures.
Limb Salvage Surgery
Limb-sparing procedures typically have three phases: tumor resec*on,bone
reconstruc*on, and soN-*ssue reconstruc*on for wound closure. One example
of a limb salvage procedure is the total femur replacement. Pa*ents
undergoing this procedure achieve good long-term prosthe*c survival;90%
have limb survival. A major determining factor in outcome is the oncologic
diagnosis and associated complica*ons. Confounding factors affec*ng pa*ent
outcomes include the presence of metastases, chemotherapy, and radia*on
therapy.
Early postopera*ve rehabilita*on is essen*al to minimize the risks associated
with immobility and to promote independence with func*onal ac*vi*es.
Transfer and gait training in the presence of restricted weight bearing, ROM
(range of mo*on) and strengthening exercises for the involved and uninvolved
extremi*es, posi*oning for comfort, edema management, contracture
preven*on.
Limb-preserving surgery allows pa*ents to retain their limb, allowing for close-
to-normal func*on, ambula*on, and appearance.
pa*ents with sarcomas.
A staging system for musculoskeletal tumors
Histological grading and surgical staging:
G,: low-grade-few mitoses and uniform cell type, have a low probability of metastasis (25%). The
majority of these tumors can be managed by rela*vely conserva*ve surgical procedures and do not
require chemotherapy.
G2:high-grade-many mitoses and atypical cells, have a significantly higher incidence of metastases and
require more radical surgical procedures and possibly neoadjuvant and/or adjuvant chemotherapy. All
Ewing tumors are classified as high-grade.
Site:
T,: lesion confined within a compartment
T2:lesion has spread beyond compartment
Metastasis
Mo:no metastasis
M1:metastasis
There are three grades, each divided into a and b subgrades.
la: low grade intracompartmental (G,, T,, M.)

Ib: high grade extracompartmental (G,,T2,M。)

lla: low grade intracompartmental (G2,T,,M。)

Ilb: high grade extracompartmental (G2, T2, M。)

Illa: intracompartmental, metatsta*c (G,-2, T,, M,)

Treatment of Tumors
The prognosis for musculoskeletal tumors has improved with the addi*on
of various chemotherapies and other interven*ons. Some of these
therapies are used in conjunc*on with amputa*on and wide excisions.
adjuvant therapy: a method of treatment (i.e., radia*on or
chemotherapy) combined with another treatment (surgery) to
improve therapeu*c success. Neoadjuvant therapy specifies the
adjuvant therapy (usually chemotherapy) is given prior to surgical
interven*on.
marginal resec*on: surgical removal of tumor through the capsule and its suitable for management of
the majority of benign tumors. they are not sufficient for local control of malignant or benign
“aggressive” lesions.
wide resec*on: surgical removal of tumor capsule and surrounding
margin of normal *ssue. its sufficient for all bone
sarcomas, although the exact amount of *ssue necessary to achieve a
safe, wide margin has not been established and likely depends on the type
of *ssue that forms the margin. Fascia, for instance, is considered to be a
beTer margin than fat, and thus a thinner fascial margin can be accepted
compared to a faTy margin. It is presumed that pretreatment with
chemotherapy and/or radiotherapy allows the surgeon to resects less
normal *ssue with the tumor than if no pretreatment is given.
radical resec*on: removal of an en*re anatomic compartment, which
includes tumor, tumor capsule, and all muscle, bone, nerve, and artery
found within that compartment. This process usually requires an
amputa*on. A radical margin is rarely necessary.
of the