Osteo Myelitis

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OM classification systems

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waldvogel
cierny-mader

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types of OM in waldvogel classification

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acute hematogenous
chronic hematogenous
direct extension

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how does bacteria gain acess in HOM

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from generalized septicemia

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HOM occurs where primarily

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in children at rapidly growing and highly vascular metaphysis of bone

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when do we see vertebral body involvement with HOM

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in older patients and IV drug users

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bacterial causes of HOM in newborns <4mo

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S aureus, enterobacter s., group A and B strep, proteus, E. Coli

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bacterial causes of HOM in children 4mo-4yr

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S aureus, group A strep, H influenza, Enterobacter S.

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bacterial causes of HOM in children, adolescents 4-adults

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S. aureus, group A strep, H influenza, enterobacter S

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bacterial causes of HOM in adults

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S. aureus, ocassionally enterobacter and streptococcus S.

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bacterial cause of HOM in drug addicts

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pseudomonas S

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bacterial cause of HOM In immunocompromised

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candidia and aspergillus

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sequestra

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islands of dead bone

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involucrum

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periosteal new bone

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cloaca

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opening in bone through which dead bone is extruded

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direct extension OM

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infectious agent gains access secondary to a contiguous focus of infection such as cellulitis, a puncture wound, or after surgical intervention

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direct extension is often

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polymicrobial

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direct ext is very common where

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in small bones of foot

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bacterial causes of direct ext OM generally

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s. aureus, enterobacter and pseudomonas s.

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bacterial cause of direct ext OM from puncture wound through shoe

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S. aureus and psuedomonas

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bacterial cause of direct ext OM in sickle cell patients

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S aureus, and salmonellae S

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subacute pyogenic OM

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insidious development with slow progression and almost no symptoms or systemic rxn

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what might be only signs of subactue pyogenic OM

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local bone pain and tenderness

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most common bacteria with subacute pyogenic OM

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S. aureus

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what is revealed on subacute pyogenic OM on radiograph

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brodies abcess

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brodies abscess

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metaphyseal bone abscess

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stage 1 cierny mader classification

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medullary OM

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stage 2 cierny mader classification

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superficial OM

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stage 3 cierny mader classification

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localized OM

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stage 4 cierny mader classification

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diffuse OM

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what is the classification factor of A in cierny mader

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normal host

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what is the classification factor B in cierny mader

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compromised host

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what is the classification factor Bs

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compromised host like diabetes

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what is the classification factor BL

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local factor compromise like cigarette smoking

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what is classification factor Bsl

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both compromised and local

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what is classification factor C

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untreatable osteo due to morbidity/mortality of trmnt

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characteristic of cierny mader stage 1

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confinded to surface of bone

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characteristic of cierny mader stage 2

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infection extending to superficial cortex of bone

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characteristics of cierny mader stage 3

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full thickness osteo involving the entire cortex of bone

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characteristics of cierny mader stage 4

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osteo that involves the cortex and medullary canal

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stage 1 is usualy in what population

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children

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what is stage 1 usually a result of

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minor blunt trauma

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what does stage 2 often result from

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infected ulceration

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how is stage 3 treated

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can be surgically removed without loss of bone integrity

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what is lost in stage 4

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osseous integrity

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what is typical in stage 4

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soft tissue necrosis

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gold standard lab for OM

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direct bone biopsy

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labs ordered with OM

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CBC with diff
C-reactive protein
ESR
blood cultures

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what are radiographic findings 2-3 days post onset

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soft tissue inflammation adjacent to bone

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when can you see earliest osseous changes on radiograph with OM

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7-10days

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what are CT scans good for

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detecting sequestra and defining brodies abscess

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when can radionucleotide bone scans reveal lesions

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within 72 hrs of clinical onset

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most widely used radioisotope in clinical nuclear medicine

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technetium 99m

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what scan is more specific for inflammatory process

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labeled WBC scans

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uses for Tc-99m MDP scan

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infection, trauma, tumor

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how does Tc-99m MDP scan work

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affixes via chemisorption attaching to hydroxyapatite crystals in bone and calcium crystals in mito

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where is uptake increased with Tc-99m MDP

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areas of increased blood flow, new bone formation, and where there is no interruption of sympathetic flow

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phase 1 of scan

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images obtained every 3-6 sec after injection to assess relative blood flow

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phase 2 of scan

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taken immediately after angiogram showing soft tissue activity due to hyperemia or ischemia

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phase 3 of scan

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obtained 3-4 hrs after injection reflects bone uptake of radionuclide due to osteoblastic activity

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phase 4 of scan

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obtained 24 hr after injection

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which phase is the most sensitive for OM

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phase 4 because the ration of bone to soft tissue uptake is higher

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Tc-HMPAO WBC scan uses

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infection

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how does Tc-HMPAO work

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it is lipophilic and crosses membrane of leukocyts once inside become hydrophilic and trapped inside

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when are images taken in Tc-HMPAO

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can be three phases but most take one set at 2hrs

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what is modality of choice in children

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Tc-HMPAO WBC scan

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what are the uses of Gallium-67 citrate scan

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chronic infection, neoplasms, inflammatory disorder localization, fungal infection

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what does Ga-67 bind to

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WBC, plasma proteins, transferrin, ferritin, lactoferrin and siderophores

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when are images taken with Ga-67

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6, 24, 48, 72 hrs

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Ga-67 not suitable for what population

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pediatric patients

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what is the use of indium-111 scan

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acute infections

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what does In-111 bind to

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cytoplasmic components of WBC

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where are images taken with In-111

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2 and 24hrs

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In-111 is not suitable for who

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pediatric patients

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how are all the scans used in practice

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both scans are used together Tc-99 first and Ga-67 later

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+ Tc-99 and - Ga-67

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chronic OM

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(-) Tc-99 and (+) Ga-67

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cellulitis

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(+) Tc-99 and (+) Ga-67

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acute osteomyelitis/septic arthritis

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(-) Tc-99 and (-) Ga-67

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normal scan

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what is MRI used for

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differentiating cellulitis from OM

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what is identifying feature of OM on MRI

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bone marrow edema

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treatment for cierny mader stage 1

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2wk IV antibiotics followed by 2-4 wks of oral antibiotics

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treatment for cierny mader stage 2

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2 weeks of IV anitbiotics and surgical debridement followed by 2-4 wks of oral anitbiotics

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treatment for cierny mader stages 3 and 4

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aggressive surgical debridement followed by 4-6 wks of IV antibiotics

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treatment acute hematogenous OM

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6wks IV antibiotic therapy
surgical debridement if no resolution in 24-48hrs

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treatment chornic and direct extension OM

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surgical debridement is necessary to remove all the infected bone

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what do most patient present with when you think OM

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cellulitis or open wound