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Hello, everyone. Um, doctor question will be and today I'm gonna be giving a presentation on acute osteomyelitis. A bit of a background about me. I, I'm currently working as a general doctor in the department of um, I work with the NHS. My L object is for in store. Hopefully, at the end, students should be able to define osteomyelitis and have an idea of how osteomyelitis can be differentiated from chronic osteomyelitis, acute osteomyelitis can be differentiated from chronic osteomyelitis. You should be able to outline the risk factors, the causes and the basic part of his of active osteitis. Hopefully, with that information, you know, the common clinical presentation and the common examination find that can be seen in my life and identify the common radiological findings and radiological investigations are usually can use in the diagnosis of art and to add everything together for the user information and to outline the management plan. And I'll be using the following outline. I'll start with the introduction and briefly talk about the classification of ketosis. Go through exactly what about the relevant anatomy and how it affects, talk about the agen. Then I'll move next to a more clinical items like clinical features, some common investigations that you don't laboratory um with urological, give you a general overview of treatment and some common complications. Mhm. Osteomyelitis is an inflammatory condition of bone caused by an infected micro cancer. I think D gives you a lot of information about what exactly is human life is from the name osteomyelitis. So basically saying that look, this is an inflammatory function of bone osteomyelitis, the bone marrow oritis indicating inflammation. So it's class, it's usually caused by infective microorganism. The most common microgan with Osteomyelitis is staph or when this inflammatory condition develops an infection and this infection and this infection occurs, it can lead to progressive bone loss, bone destruction and necrosis. I saw my light diagnosis can be made by using a range of imaging modalities from plain radiographs to MRI S CT scans, ultrasound and bone skin treatment usually include a mix of supportive measures, medical management using antibiotics and internal situations. Surgical intervention, generally, Osteomyelitis can be classified based on its timing and the mechanism of spread. It can be classified into acute either cause less than two weeks. Usually in Acu Osteomyelitis that tends to be marked systemic symptoms. It could be so a later cause between 2 to 6 weeks, sometimes you know, several months and it could be chronic where it lasts for better than six weeks or it occurs after six weeks and it evolves over a month to this classically, that is usually today, we are primarily concerned with acute representation for the disease involved and they also be classified based on the mechanism of spread. This is intergene contig focus or direct inoculation usually via mechanism, not spread. Hematogenous and contagious focus. Are it? So mechanisms which sometimes direct in population also classified under contig focus in hematogenous spread, developed as a result of a bacteremia and seeding from a side. So there is an infection bacteremia or septicemia. Developed. This infective organism travels in the distance. It's probably an infection of the lung, the fruit anywhere in the body pos possibly and comes and seeds in the bone and leads to a major response of the bone and bone marrow. Whereas in continuous glucose, there, there has been a surrounding infection and wound and from around the bone that lead to the development of an infection colonization spread of bacteria mig around the bone. It's contiguous because because it develops all the infected process is not, is not distant, it's not coming from the distance side, but it develops around the bone is also the is also classically local for it develops a lot of or even a micro bacteria. Enzymes are introduced directly by this. Regarding the epidemiology of acute osteomyelitis. This incident in developed countries is about 2% per year and it's been found to have a bimodal distribution where we have acute hematogenous osteomyelitis common in Children with contagious osteomyelitis. Typically developing in adolescent and adult or osteomyelitis commonly affects the metaphyseal grow in Children. I'm the vertebrae common, commonly occurring in the lumbar spine. In the older adults. It affects the metaphyseal region of long bones. The femur most common a about 27% of patients IV in 22% of cases and the are in 5% of case. I'll be trying to show this in the next slide. So here we have so a cross section of a bone. So the epiphysis and the ages of the bone and also the b blood supply. This is the classic feature of a long one in, in the child. What is the take from here? And what is what of not is how the vessels are arranged around the nephro forming like a head pain. As you can see the arteries and the new comes around the me and the neocapillary network tends to form like the hair. This is responsible for the pathophysiology of this condition. This is important in the part for the part of this condition because as blood flows around this, he in the region of capillaries, it tends to slow down and stasis developed the stasis. The stasis allows for is a very good site for bacterial growth colonization and the development of Osteomyelitis. So the arrangement of blood vessels around the disease increases the risk of development. That was turning the of osteo of Osteomyelitis. Um the part, the part distribution tends to defer a bit depending on the age. Yeah. Uh some pathogens that occur more frequently in infant, others in Children above a year and in adults. Although the common occurring pathogen and the common occurring parts across all age group is still stuff or in Children, you also tend to see group B streptococci occurring two over a year of the and check coccal pneumonia can be also common in adults. We also tend to have coagulate negative stuff profile and it will be negative but also causing acute, close to my life. Some risk factors are outlined here in the slide to show you that some risk factors increase in patients to osteomyelitis. Trauma is a common risk factor, especially for for contagious purpose, surgery, open fractures, classically improving, increasing the risk we have in Children for tract infection, particularly with group B group A strepto diabetes increases the risk. Another what you have not in is immunosuppressive illnesses increases the risk of bacteremia CD and acute hemoglobinous ophth in the developing world. One of the risk factors, the sickle cell disease where an organism that is commonly implicated in a sickle cell disease suffers with that acute bacterial oitis. This slide, it's I know it's a bit, there's a lot, a lot on it, but I will just focus specifically on the part and talk later on about linker features and investigation going forward. I may come back to this as a reference like so, so yeah, we have the classic mechanism of spread where there could be a where uh the blood carries bacteria from the distance site of infection of the bone. We have continuous spread where inside of infection see bacteria to the bone. Also, men also something I would mention from contagious spread is that it could also be so it could be spread from the surrounding infection of the joint from septic arthritis. That is something that should be important to know the complications of surgical therapies could be active of uh osteomyelitis. And one of the complications of osteitis sometimes can be set to the. And then here we have direct in either from trauma, can treating injuries or fractures or in situations where we have medical procedures from frac excision or aspirations that lead to interruption of bacteria and the development of inflammatory response and infection in all of these situations. A systemic immune or a localized immune response in the activation of the cellular immune response. We have micro for using, for being optimistic to produce immune cells. Um even with your cells, what develops is the these inflammatory cells try to fight off and they lead to the development of intermediate. All of these develops to cause a a local inflammatory reaction in the bone that may lead to bone destruction, whatever is of side effects, worsening, bone destruction, bone necrosis and most of the inflammatory signs that we tend to see fever, swelling, the warmth and the redness which I'll talk to her. About later on in this life, the classic picture of a patient presenting atherosis would be uh a child who presents with local symptoms. He's unable to wait here. He's complaining of pain in his bone or touching his bone or demonstrating and pointing towards around. But he's one of the long bones right out the forearm of limbs. If you look at the area, there, there will be redness. If you try to touch it, it's gonna be tender. If you try to feel around, it's gonna be warm, there will be a swelling, noticeable swelling you and there may be systemic symptoms. You have fever or loss of appetite in those commonly a hemoglobin or they also similarly bone pain, redness, tendons and in general local, local and or systemic inflammatory symptom affecting a particular limb. But we also see vertebral involvement, local back pain and spasms of a muscle as a response to infection in the history. And at this point where you, where you've seen this classic picture, if you begin to try to assess for risk factors, some of the risk factors that we have mentioned in this class, uh examination usually excess the vital signs. There may be fever or tachycardia which would lean towards the systemic involvement, but generally with acute hematogenous osteomyelitis presenting in Children, they're usually quite well a non dozy child presenting with his mom with those features mentioned earlier, but usually no, although they can present they can also be quite unwell with sepsis. And these associate on inspection and palpation, you would see a warm tender limb which is often the swollen and tomatoes are signs for inflammatory response. You know those uh you may, you should evaluate for 0.10 point towards an area of the spine or pelvis that shows maximum pain involvement that can also occur in Children and whatever limb or whatever area is affected, it will be restricted motion. So, come on laboratory investigation, that would be the initial investigation. The first step would be full blood count where sometimes you can see a raise white cell count. And I would like to just put, put in a caveat together. Sometimes the white cell count could be just slightly elevated or normal. Um Then we we also normal in a few months or so the uh genes a diagnosis but they are unnecessary confirmation. The classic, the classic picture is that where you see a mark of acute, the gold standard for diagnosis would be blood bone cultures although however, they are not done. So most of the time when we say the go the gold standard for that, we usually just mean blood culture and it should be taken before antibiotics are started and they are positive in about 60% of cases. Ideally, serial blood cultures, uh an option to improve sensitivity and basic radiological investigations for acute osteomyelitis. The MRI is the imaging modality of choice because it tends to develop, to identify bone marrow changes by early changes around the bone marrow bone. Although in clinical practice, ideally, plain x rays are still common first by, we really have limited use in. This is one of the differences. You, you have to take note of between a and initis. You tend to see changes on plan xray. Oh my. You usually have to wear an MRI the shoes that give them provides better soft tissue to give you to pick up any changes in one month. All that I I can sometimes be requested for uh CT scans, ultrasound scan, especially in Children to detect there's quite a and bone scans and sometimes I do well for theological investigation, you'll get more detail starting with plain x rays, the findings you usually see that it should be noted that like I said earlier, elephants usually would be normal. Um It does show some soft tissue edema which to be honest would be difficult to tied to a diagnosis of acute. It takes about 5 to 7 days for new per perio bone to form. And in about a week, 10 days to two weeks, you may begin to see osteolysis around two weeks. Fe is make sure re refraction where there is reduction in metaphyseal bone density or even an abscess. So the ok x-ray of uh ankle, you see just shows an area of osteolysis. So ideally this x-ray would be a 14 day, 10 day, 14 day x-ray showing an area of oitis just around, yeah, tingling, you still tingling, MRI findings which uh the modality of the imaging modality of those are usually quite highly sensitive, especially when you go to here, we have two imaging modalities. One is an X ray and the other B is an MRI. So we're gonna compare the two scenarios. This is an X ray and MRI of the right knee, a child. The PA is showing around the dystopia model here. Uh where the lesion with a sclerosic ring wipe thickens. Oh yeah, not many social license psoriasis. Um It actually goes to here in the MRI. You can see this I it is much more well defined. You can see the enhancement and bone marrow edema that gives you a clever picture and you diagnosis of it. Ultrasound can also be used for modalities in the diagnosis of a tumor, particularly in Children on screen. Here, we see an ultrasound of the proximal he just demonstrating the focal pain of the humeral cortex. Um with so for the diagnosis in this situation, generally, we have two classifications. We we are non operative management options. We are operating management options for acute osteitis, not for different management. It's usually indicated in L disease where it is, there are no su after this antibodies are usually tried or no. If there has been no improvement, the options for surgery explored the mainstay of non operative management of a the antibodies. Generally, BP should be taken before it started. Empirical anti are used based on the the hospitals local usually would be one um when based on the results of the cultures, they can then subsequently modify the treatment duration is is for six weeks because sure that you, you, you get good clearance. Um Usually you, no you should begin improvements within 48 hours or no measures are supportive measures that are usually used uh adequate pain, lead immobilization to reduce inflammation and improve swelling and management or whatever is part of the present that you may delay wound healing. Of what I was in the condition. It's uh it's usually indicated if there's been failure to respond to antibiotic treatment. You based on the radiological features, he suspects deep or suffers if despite antibody treatments that is actually in and on monitoring, there's progressive bone destruction. Ok. Thank you. Generally, operative management involves drainage of some of these abscesses, debridement of wounds. Um Antibody therapy in this slide, I just outlined um a decision algorithm for the management of osteoarthritis. What is what you have notes here is that based on the clinical he what in what if it's ready available, we should obtain an MRI without contrast. And based on the MRI findings, you can make a decision whether to aspirate or not. If you suspect that there may be some therapy if you want to keep me by a month because this patient will likely have to need to get a surgery. And if the decision to make surgery is done, you incise your gate you right. When you clean the area and more in the tissue biopsy and send some of his, send his bone for c and obvious and continue antibiotic, empirical antibiotic therapy to the results. But if the decision is made not to, oh, you start on antibiotics on a regular antibiotics and send those for culture based on this culture result, you can have complications of acute osteomyelitis. Uh First, it can progress to chronic osteomyelitis if not properly treated or if there is resistance, of course, response to antibiotics, the deep venous thrombosis can as a result of antiinflammatory response, the immobilization that developed as a result of the heart sepsis where the systemic infection it could be continuous spread. Like I said earlier, septic arthritis can increase the rate of a um A can also in quality, we can have um we of bone as a result of infection. There could be fractures that may be. So you have many references and then always ask me questions in the comments section of what I'm happy to answer. And I hope that the phone is quite