Bone pathology
2nd yr undergraduate
presentation
Topics
Osteomyelitis
Fracture
healing
Osteomyelitis
Inflammation of bone and marrow
Classification
1) The duration - acute, subacute and
chronic
2) Mechanism of infection
exogenous or haematogenous
3) The type of host response to the
infection- pyogenic or non pyogenic
Epidemiology
Most common type of bone
infection, usually seen in children
Decrease in incidence, could be
due to higher standard of living and
improved hygiene.
Bimodal distribution- younger than
2 years, and 8-12 years
More common in males
Routes of spread
Hematogenous spread: most common
cause; usually long tubular bones of
children; usually metaphyseal in children
and adults, although involvement of flat
bones is more common in adults
Direct extension: less common, may be
associated with trauma or rarely
iatrogenic implantation of infectious
material
DM, immunodeficiency, IV Drug abuse .
Pyogenic osteomyelitis
Acute osteomyelitis usually occurs in children
Usually a haematogenous infection from
distant focus
Organisms responsible include:
Staph. aureus
Strep. pyogenes
H. influenzae
Gram-negative organisms
Salmonella infections are often seen in those
with sickle-cell anaemia
Infection usually occurs in metaphysis of long
bones
Bacteria
Staphylococcus
aureus in 80% to
90% of cases
E.coli, Pseudomonas, and Klebsiella
in patients with genitourinary tract
infections and IV drug abusers.
In neonates: Hemophilus influenza
and group B streptococci
In patients with sickle cell disease
Salmonella infection
Organisms once localized in bone
Bacteria proliferate and induce inflammatory reaction and
cause cell death.
Bone undergoes necrosis within first 48 hours
Bacteria and inflammation spread within the shaft of the
bone and may percolate throughout the haversian
systems and reach the periosteum
Subperiosteal abscess
Segmental bone necrosis sequestrum (dead piece
of bone)
Rupture of periosteum leads to an abscess in the
surrounding soft tissue and the formation of draining
sinus.
Pathophysiology
Over time, host response develops
After first week of infection chronic inflammatory
cells become more numerous
Cytokines from leukocytes stimulates osteoclastic
bone resorption ingrowth of fibrous tissue
deposition of reactive bone in the periphery
Reactive woven or lamellar bone which forms
sleeve of living tissue surrounding dead bone is
called as involucrum.
Brodie abscess: is a small
intraosseous abscess that frequently
involves the cortex and is walled off
by reactive bone
Sclerosing osteomyelitis of Garre:
typically develops in jaw and is
associated with extensive new bone
formation
Clinical features
Child usually presents with pain, malaise
and fever
Often unable to weight bear
Early signs of inflammation are often few
Bone is often exquisitely tender with
reduced joint movement
Late infection presents with soft-tissue
swellings or discharging sinus
Diagnosis can be confirmed by aspiration
of pus from abscess or metaphysis
50% of patients have positive blood
cultures
Radiology
X-rays can be normal during first
3 to 5 days
In the second week radiological
signs include:
Periosteal
new bone formation
Patchy rarefaction of metaphysis
Metaphyseal bone destruction
PATHOLOGY
Acute Infiltration of PMNs
Congested or thrombosed vess
Chronic Necrotic bone
Absence of living osteocyt
Mixed inflmmatory cells
predominate
Granulation & fibrous tissu
Osteomyelitis-gross & microscopy
Sequestrum (necrotic
bone)
Involucrum (new bone)
Complications
Pathological
fracture
Secondary amyloidosis
Endocarditis
Sepsis
Dev.of SCC in sinus tract
Chronic Osteomyelitis
Non specific
Develops in 15-30%
Due to lack of treatment, inadequate
antibiotic treatment or incomplete
surgical debridement of necrotic bone
Specific
TB osteomyelitis
Syphilitic osteomyeltis
TB osteomyelitis:
Dissemination of tuberculosis outside
the lungs can lead to the appearance of
skeletal TB:
Skeletal Tuberculosis:
Tuberculous osteomyelitis involves mainly
the thoracic and lumbar vertebrae (known
as Pott disease) followed by knee and hip.
There is extensive necrosis and bony
destruction with compressed fractures
(with kyphosis) and extension to soft
tissues, including psoas "cold" abscess.
Tuberculous osteomyelitis of the bone is secondary
hematogenous spread from a primary source in the lung
or GI tract.
It most commonly occurs in the vertebrae (body) and
long bones.
Once established, the bacilli provoke a chronic
inflammatory reaction.
Small patches of caseous necrosis occur, and these
coalesce to form larger abscesses.
The infection spreads across the epiphysis into the
joints.
The infection may track along soft tissue to appear as a
cold abscess at a distant site (eg: psoas abscess in case
of spinal tuberculosis).
Spinal tuberculosis. Magnetic resonance imaging of the spine
revealing osteomyelitis involving T10 and T11 vertebral bodies
and disc space (A; arrow) and an adjacent multiloculated
paravertebral abscess (B; arrow).
Syphilitic osteomyelitis:
The transplacental spread of
spirochetes from mother to the
fetus results in congenital
syphilis.
Long bones, such as the tibia,
are mainly affected.
Congenital syphilis has 2 forms:
Periosteitis and osteochonditis.
Syphylitic Osteomyelitis
Regarding acquired syphilis, bone lesions are
manifestations of tertiary syphilis.
Gummatous lesions appear as discrete punched-out
radiolucent lesions in medulla or destructive
lesions within the cortex.
The surrounding bone is sclerotic, and no discharge
is present.
Bones frequently affected are those of nose, palate,
skull and extremities, especially the long tubular
bones such as tibia.
Histology : edematous granulation tissue
containing numerous plasma cells and necrotic
bone.
Sabre tibia
Fracture healing
Stage of # healing
Reactive phase
Reactive phase
Reparative phase
Reperative phase
Remodeling phase
Getting back original shape of the
bone .
Mainly done by osteoclastic
activation.
