Normal boneNormal bone

Infectious Diseases of Infectious Diseases of BoneBone

1.1. OsteomyelitisOsteomyelitis

2.2. Pott’s DiseasePott’s Disease

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

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)

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 , Proteus E. coli , Pseudomonas , Proteus

- -Salmonella typhi in Pt with sickle cell diseaseSalmonella typhi in Pt with sickle cell disease

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

Definition:Definition: Acute osteomyelitis is an acute Acute osteomyelitis is an acute inflammation of bone caused by an infecting inflammation of bone caused by an infecting organismorganism

ACUTE HAEMATOGENIUS ACUTE HAEMATOGENIUS OSTEOMYELITISOSTEOMYELITIS

Haematogenous osteomyelitis is predominantly seen in Haematogenous osteomyelitis is predominantly seen in children and involves the highly vascular long bones children 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 to In 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

1-Inflammation: Initial inflammation with vascular Initial 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

2-Suppuration: Pus within the bones forces its way Pus within the bones forces its way through the Haversian system and forms a through the Haversian system and forms a subperiosteal abscesssubperiosteal abscess in 2-3 days. in 2-3 days.

3-Sequestrum:3-Sequestrum: Vascular obstruction and infective Vascular obstruction and infective thrombus decrease or obstruct the periosteal and thrombus decrease or obstruct the periosteal and endosteal blood supply, causing endosteal blood supply, causing bone necrosisbone necrosis and and sequestrum formation in approximately 7 days. sequestrum formation in approximately 7 days.

4-Involucrum:4-Involucrum: This is new bone formation from the This is new bone formation from the stripped surface of periosteum. stripped surface of periosteum.

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.

Clinical featuresClinical features

Children:.Children:. presents withpresents with

--Severe painSevere pain, , Malaise andMalaise and aa FeverFever

--Local redness, swelling, warmth and oedema are Local redness, swelling, warmth and oedema are later signslater signs

--Lymphadenopathy is common but non-specificLymphadenopathy is common but non-specificAdultsAdults:.:.

--Mild fever and BackacheMild fever and Backache

--Others….chills, irritability, swelling and redness Others….chills, irritability, swelling and redness over the affected boneover the affected bone

Clinical featuresClinical features

--In Pts with DM, PVD, Peripheral neuropathy In Pts with DM, PVD, Peripheral neuropathy there may be no pain or fever the only there 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

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

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 the to 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

22--RadiologyRadiology

PLAIN X-RAYPLAIN X-RAY: :

-- In 1In 1stst wk x-ray shows no abnormality of the bone; By the 2 wk x-ray shows no abnormality of the bone; By the 2ndnd wk wk there may be a faint extra-cortical outline due to periosteal new there 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

MP of acute osteomyelitisMP of acute osteomyelitis

Inflammation of boneInflammation of bone

Acute osteomyelitisAcute osteomyelitis

1.1. PathologicalPathological fracturefracture2.2. Spread of infection: eg. Arthritis (joint Spread 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 & septicaemia4.4. Chronic suppurative osteomyelitis: including Chronic suppurative osteomyelitis: including

sequestrum formation and skin sinus formation sequestrum formation and skin sinus formation 5.5. Damage to the growth plate causing subsequent Damage to the growth plate causing subsequent

growth deformitygrowth deformity

Complications of osteomyelitisComplications of osteomyelitis::

Pott's diseasePott's disease

Pott's diseasePott's disease is a presentation of extra is a presentation of extra pulmonary tuberculosis that affects the spine, a pulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral kind of tuberculous arthritis of the intervertebral joints.joints.

The lower thoracic and upper lumbar vertebrae The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected. are the areas of the spine most often affected.

Pott’s DiseasePott’s Disease

Tuberculosis of the spine in an Egyptian mummy

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 with Spinal mass, sometimes associated with numbness, paraesthesia or muscle weakness of numbness, paraesthesia or muscle weakness of the legsthe legs

DiagnosisDiagnosis

Blood tests – elevated erythrocyte sedimentation Blood 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

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

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)

Tuberculous in long bonesTuberculous in long bones

Commonly around the knee, affects metaphysis and Commonly around the knee, affects metaphysis and epiphysis, rarely diaphysisepiphysis, rarely diaphysis

Well-defined lytic areaWell-defined lytic area

Tuberculous arthritisTuberculous arthritis

The hip and knee are the The hip and knee are the

most commonly affected most commonly affected

peripheral joints. peripheral joints.

Characterized by joint space Characterized by joint space

narrowing and erosions which narrowing and erosions which

may lead to extensive destruction may lead to extensive destruction

of the articular cortex. of the articular cortex.

HEREDITARY HEREDITARY BONE DISORDERSBONE DISORDERS

1.1. AchondroplasiaAchondroplasia

2.2. Osteogenesis imperfectaOsteogenesis imperfecta

3.3. osteopetrosisosteopetrosis

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

AchondroplasiaAchondroplasia

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

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

Osteogenesis imperfectaOsteogenesis imperfecta

Brittle bones

Laxity of joint ligamentsLaxity of joint ligaments

Dentinogenesis imperfectaDentinogenesis imperfecta

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

X-ray findings: Symmetrically generalized osteosclerosis Long bones may have broadened metaphyses,

resulting in an "Erlenmeyer flask" deformity

Osteopetrosis X-ray findings

Osteosclerosis

Erlenmeyer flask

shaped deformity

Symmetrically generalized

Osteosclerosis Long bones may have broadened

metaphyses, resulting in an

"Erlenmeyer flask" deformity

Metabolic Diseases of Metabolic Diseases of BoneBone

OsteoporosisOsteoporosis

Refers to Refers 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 in Resulting in :: Decreased Decreased bone massbone mass and and densitydensity.. Decreased Decreased thicknessthickness of cortical and trabecular of cortical and trabecular

bone.bone.

Osteoporotic vertebral body

Normal Vertebral body

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FractureOsteoporosis

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)

Postmenopausal OsteoporosisPostmenopausal Osteoporosis

Due to estrogen deficiencyDue to estrogen deficiency

Estrogen deficiency Estrogen deficiency increased resorption of increased resorption of bone by osteoclasts and decreased formation bone by osteoclasts and decreased formation of bone by osteoblasts.of bone by osteoblasts.

Peak bone massPeak bone mass

Osteoporosis

Menopause •↓ estrogen•↑ osteoclast activity

Aging•↓ activity of osteoblasts•↓ physical activity

Physical activityPhysical activity NutritionNutrition

Genetic factorsGenetic factors

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

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Diagnosis:Diagnosis: Dual energy X ray absorptiometry (DEXA) Dual energy X ray absorptiometry (DEXA)

to evaluate bone density.to evaluate bone density.

Osteonecrosis Osteonecrosis (Avascular Necrosis(Avascular Necrosis((

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 include Common sites include Femoral head Femoral head Scaphoid bone.Scaphoid bone.

OsteonecrosisOsteonecrosis

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OsteonecrosisOsteonecrosis

PAGET’S DISEASEPAGET’S DISEASE

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

Stages of paget disease1. Osteolytic: osteoclastic activity predominates

2. Mixed ostelytic-osteoblastic

3. Osteosclerotic: osteoblastic activity predominates " burnout stage"

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Etiology:1. Possible slow virus infection

2. Possible genetic predisposition

Clinical features:1. Asymptomatic in most cases

2. Bone pain and deformities

3. Fractures

4. Warmth of overlying skin due to hypervascularity

Forms of involvement:1. Monosteotic (15%): involving one bone

2. Polyosteotic (85%) : involving multiple bones

Common sites include the skull, pelvis, femur and vertebrae

PATHOLOGYPATHOLOGY Microscopically Microscopically : :

Haphazard arrangement of cement lines, creating a Haphazard arrangement of cement lines, creating a mosaic pattern mosaic pattern

Skull involvement:Skull involvement:1.1. Increase head sizeIncrease head size2.2. Foramina narrowing causes impingement of cranial Foramina narrowing causes impingement of cranial

nerves, often leading to deafnessnerves, often leading to deafness3.3. Involvement of facial bones may produce a lion-like Involvement of facial bones may produce a lion-like

faciesfacies

X-rays: Bone enlargement with lytic and sclerotic areas

Lab investigation: Highly elevated serum alkaline phosphatase

Complication: Osteosarcoma Others sarcomas

Osteolytic changes of the skullOsteolytic changes of the skull

Mosaic pattern of lamellar boneMosaic pattern of lamellar bone

BONE TUMORSBONE TUMORS

BENIGN TUMORS OF BONEBENIGN TUMORS OF BONE

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. Enchondroma Enchondroma

OsteomaOsteoma

Definition:Definition: Benign neoplasm that frequently involves the skull Benign neoplasm that frequently involves the skull

and facial bonesand facial bones

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> females2.2. Age: 5-25 yearsAge: 5-25 years3.3. 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

Osteoid osteomaOsteoid osteoma

OsteoblastomaOsteoblastoma

Similar to an osteoid osteoma but is larger Similar to an osteoid osteoma but is larger (>2cm) and often (>2cm) and often involves vertebrae involves vertebrae

Osteochondroma Osteochondroma (Exostosis(Exostosis((

Definition:Definition: Benign boney capped with cartilage that originates from Benign 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 it They may be asymptomatic or it causes pain, deformity or it can undergo malignant transformation (rare)can undergo malignant transformation (rare)

OsteochondromaOsteochondroma

OsteochondromatosisOsteochondromatosis

Multiple hereditary exostosis in which there is Multiple hereditary exostosis in which there is multiple symmetric osteochondromasmultiple symmetric osteochondromas

EnchondromaEnchondroma Definition:Definition:

Benign cartilaginous growth within the medullary Benign 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 no Typically solitary and asymptomatic and require no treatmenttreatment

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