HAEMATOGENOUS OSTEOMYELITIS - Postgraduate Medical … · FIG. i.-Unsuccessful Treatment of Acute...

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ACUTE HAEMATOGENOUS OSTEOMYELITISDiagnosis and Treatment

By J. TRUETA, M.D.(Barcelona), D.Sc.HoN.(Oxon.)and

M. AGERHOLM, B.M., B.CH.(Oxon.)Oxford

There has been a remarkable change in thecourse and in the prognosis of acute haemato-genous osteomyelitis during the last four years.Until recently this disease was one of the mostdangerous and crippling infections of childhoodand early youth. Now it need be no more dan-gerous or crippling than a cellulitis, though it maybe of longer duration.The change is. due to penicillin, the internal

antiseptic for which surgeons have longed whentreating cases of acute osteomyelitis. It has madenecessary a complete revision of the acceptedprinciples and methods of treatment, a revisioncomparable with that in all branches of surgerywhich followed much earlier antibacterial ad-vances. The introduction of antisepsis and laterof asepsis at the end of the last century demandeda new attitude of mind towards surgical inter-ference. After Lister surgeons could operate onsterile tissue knowing that it would remain sterile,and the idea of ' laudable pus ' had to be discarded.Similarly after the discoveries of Fleming andFlorey the principle of wide incision to obtain' drainage ' of pus in acute osteomyelitis has now tobe discarded.The old picture of acute osteomyelitis is worth

recalling. The prospect for a patient with in-fection of the larger bones was a dreary one(Fig. i); weeks of severe toxaemia and swingingtemperature punctuated by operations on theoriginal and the metastatic foci; repeated an-aesthetics for evacuation of abscesses, for dailydressings and for changes of plaster; possibly adiaphysectomy or even an amputation; and alwaysthe danger of a septic arthritis. Then after theacute stage might follow a long tale of chronicsepsis; sinuses, dermatitis, recurrent abscessformation and sequestration treated by sauceriza-tion. And when healing was at last obtained re-constructive operations were often necessary forthe deformities of the disease and its treatment:for irregular bone growth from damaged epiphyses(Fig. 2), for diaphysectomy with failure to re-generate (Fig. 3), and for damaged joints (Fig.4). Finally, no patient could ever be re-garded as secure from recurrence at the original

focus or in another bone. More fortunate caseswith early healing and full function were in theminority, and even they were not safe fromrecurrence, especially after trauma.The significant difference between this dis-

appearing picture and the present one was therelative impotence of the doctor against the in-fection. However early his diagnosis and howevercareful his treatment, he could do little to alter thecourse of the disease. He immobilized the part,maintained the patient's resistance by transfusion,vaccine and diet, and drained abscesses as theyoccurred. All the time he had to consider theneeds of the bone as secondary to the preservationof life, for too often surgery designed to save thebone resulted in a generalized spread of theinfection. On the other hand radical operationssuch as diaphysectomy, aiming at the preservationof life, often caused permanent disability. In anydiscussion on the surgical treatment, the mortalityrate had to be the final criterion and the effects ofany particular treatment on the bone itself had totake second place. The mortality rate varied from5 to 25 per cent. and the disability rate might be ashigh as 50 per cent.The introduction of the sulphonamides in 1936

had no spectacular effect, though some benefitfollowed their use; the course of the fever wasshorter, metastases were fewer, bone destructionwas less and healing was earlier. But still somecases were quite unaffected, and though thesurgeon could be just a little bolder and moreoptimistic, the treatment was not materiallyaltered.

Results with PenicillinPenicillin was first used in this disease at Oxford

in I94i by the Floreys and among others, by oneof us. Its value was obvious even though themethod of administration was not established.The Floreys wrote:

' The evidence is that with adequate dosage itis possible to eliminate all infection, and onemay look forward to the time when osteomyelitistreated early will no longer be a surgicalcondition.'

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230 POST GRADUATE MEDICAL JOURNAL May 1948

All the published results since then have beenmost favourable. The mortality rate has been re-duced to less than i per cent., and the disabilityrate varies from i to i o per cent. Most of theseresults were obtained when penicillin was scarce,when, dosage and duration of treatment were stillbeing investigated, and when the part of surgerywas uncertain.

In our own series of 6o cases, followed up sincethe first case in June i944, the results are verysatisfactory compared with ' the bad old days.'Fifty-two of the 6o cases have full function, soundhealing and minimal bone scarring, so that they areunlikely to have any recurrence (Figs. 6 and 7).Four further cases have full function and soundhealing, but with considerable bone scarring whichmay possibly lead to recurrence. The remainingfour cases are less satisfactory. One has restrictionof knee movement (o -go'), one has a persistentminute sinus and two have had one mild recurrenceof inflammation. It is significant that none of theselast four cases was treated by the methodsrecommended here; they taught us what not todo. In fact, we believe that the treatment ofacute osteomyelitis should eventually be ioo percent. successful, i.e., there should be no mortality,no joint involvement, no permanent disability,and bone scarring should be absent or so slightthat there is no risk of faulty growth or recurrence.The essential requirement is early diagnosis.

Penicillin alone can cure the disease if administeredbefore bone damage has occurred, that is, in thefirst stage. Its action in the second and thirdstages is also dramatic, but permanent bonedamage may already have occurred. It is possiblethat the diagnosis will in future be made earlier,for often in the past the practitioner has felt thatdiagnosis was not urgent and waited for it to be-come obvious before transferring the patient tohospital. Fifty per cent. of our patients had beenseen one or more days previously by a doctor andeither the diagnosis had not been made or sul-phonamides had been tried at home until abscessformation demanded intervention. Unfortunatelymost textbooks describe the disease only in thisadvanced stage and we make no apology for dealingwith early diagnosis in some detail.

Early DiagnosisI. PATHOLOGYThere are three stages in the pathology, each

with a corresponding clinical picture (Fig. 7).Stage i. A pyogenic organism carried to the

bone in the blood settles there and multiplies.The organism is usually the staphylococcusaureus, but may be a streptococcus, a pneumo-coccus, or staphylococcus albus. The site isusually the metaphysis of a growing bone, though

it may be any part of any bone at any age. Theinitial bacteraemia is usually symptomless, butthere may be frank septicaemia.As the organism multiplies in the bone a septic

focus develops. This ' boil' may resolve, it mayform a Brodie's abscess, symptomless for the timebeing, or it may advance to Stage 2.

Stage 2. The infection overcomes the localresistance and spreads through the neighbouringtissue:

(a) into the medullary space.(b) through the cortex into the subperiostea

space.(c) across or round the epiphysis into the joint.

Fortunately this is the least common route; thesigns and symptoms are those of septic arthritis.

If the infection spreads into the medulla or be-neath the periosteum, pus tends to collect there.Thus it tends to fill the medulla before invadingthe subperiosteal space, and it tends to fill thesubperiosteal space before perforating into thesoft tissues or the joint. The periosteum is asresistant to infection from within as from withoutand pus may strip it off the entire diaphysis beforethere is either sufficient tension for rupture orsufficient necrosis for perforation.

Stage 3. The pus reaches the soft tissues,spreads along the tissue planes and eventuallyreaches the skin.

It will be seen that until the third stage isreached the infection remains within the perio-steum or even within the cortex, and the pus maythus be relatively inaccessible for clinical examina-tion. Yet if perfect results are to be secured, thedisease must be recognized while the pus is soconcealed. Fortunately, even in the first stage, onesign and one symptom together strongly suggestthe diagnosis.

2. SIGNS AND SYMPTOMSClinical Picture in Stage i-A ' boil' in the bone(a) The symptom of acute osteomyelitisThe patient complains of pain over or near the

focus. The pain is not at first well localized, butit is severe, constant and often described as ' deep '

or even ' in the bone.' Quite young children aregood witnesses if not frightened by too hastyhandling, and vagueness may be corrected if theyare told to point with one finger to the painfulpart. A child with acute infection of the uppertibia may say that his foot hurts, but he willpoint to the upper end of the tibia, and there willbe found the sign.(b) The sign of acute osteomyelitisThe bone over the focus is exquisitely tender;

this tenderness is constant both in position andintensity. It can usually be distinguished fromtenderness of the overlying tissues, and with care



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FIG. i.-Unsuccessful Treatment of Acute Osteomyelitis before Penicillin. The leg of a boy with acute osteo-myelitis io weeks after admission to hospital in 1942. A month later acute osteomyelitis of the humerusdeveloped. Note the gross oedema, the unhealthy skin and the exposed bone. The foot was eventually am-putated.

HISTORY OF J.W., AGED I I, AFTER ADMISSION TO HOSPITAL IN I938.March, I938. Admitted with acute osteomyelitis of R. and L. Ulna, lower L. Tibia, and R. Os calcis.June, 1938. Sequestrectomy both ulnae.Sept., I938. Abscess L. Radius-curettage.Nov., 1938. Abscess L. femur-sequestra discharged.Jan., 1939. Abscess R. foot (small bones of tarsus).June, 1939. Abscess R. upper humerus. L. humerus discharged sequestra.July, I939. Abscess L. femur, discharged sequestra.Sept., I939. Abscess R. ankle-incision and curettage. L. clavicle-incision and curettage.Jan., 1940. Abscess L. femur.April, 1940. Curettage R. ankle (bony ankylosis of ankle and subastragaloid joint).June, 1940. Abscess R. mandible.Sept., 1940. Abscess R. instep.Dec., 1940. Five abscesses over humerus and tibia.Aug., 194I . Abscess R. ankle.Mar., 1942. Abscess L. femur-saucerization.Feb., 1943. Abscess R. ankTe.Oct., 1943. Abscess L. femur.April, I944. ALL HEALED.Sept., I945. Osteotomy of tibia for deformity at ankle-wound broke down.July, 1946. ALL HEALEI}.



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FIG. 2.-Deformity due to a damaged epiphysis afteracute osteomyelitis of the tibia and femur. Notethe marked valgus deformity of the knee and theirregular bone structure of the tibia.

FIG. 3.-Deformities from loss of the diaphysis of along bone.

(a) Gross radial deviation of the hand follow-ing loss of the radial diaphysis 8 yearspreviously at age of 2.

(b) Dislocation of the radius following loss ofthe ulnar diaphysis I4 years previouslywhen z years old.



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MayJ 1948 TRUETA: Acute Haetnatogenous Osteomvelitis 233|

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FIG. 4.-Ankylosis of the knee from septic arthritissecondary to acute osteomyelitis of the tibia.

FIG. 5.-Results after the introduction of penicillin.Leg of a boy admitted for acute osteomyelitis ofthe tibia. There was sound healing after 2 months.This picture was taken 8 months after admission,when there was sound healing, no tenderness andfull movement at the ankle. Contrast with Fig. i.Two years later he was symptom free, with fulljoint movement.

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FIG. 6.-R.S., aged 12, ten weeks after admission tohospital with acute osteomyelitis of the lower R.femur. At operation pus was found without andwithin the bone; the wound healed by first inten-tion following primary suture. Apart from thelinear scar there is now no detectable abnormalityand a full range of movement at the knee.



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FIG. 8.-Radiograph of the tibia of a boy aged I2 withacute osteomyelitis of 6 days history. Beforeoperation the bone appeared normal. The drill-holes show the extent of the intra-osseous abscessfound at operation the same day. Pus underpressure was found at all but the lowest drill-hole.

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FIG. 9.-Tibia exposed at operation. A large collectionof pus was found under the periosteum. A holewas found in the cortex but no pus was dischargingthrough it. Pus is seen oozing out of drill-holesmade above the spontaneous hole. 'One hole isnot enough.'



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May 1948 TRUETA: Acute Haematogenous Osteomyelitis 235

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FIG. 7.-Diagrams of the progress of untreated acuteosteomyelitis in a long bone.

can be mapped out with little disturbance of thepatient. There is no need to handle the wholelimb. Only the tip of one finger is used to palpatethe bone gently, beginning some distance awayand gradually approaching the focus. This ' one-finger ' test is invaluable foe accurate localization.If the whole hand is used it is easy to mistake thesite of the focus, and if the forearm or leg isaffected, to mistake the bone involved. For thesame reason a limb should always be supportedso that the examiner does not have to use bothhands at once.

Pain and tenderness are the only local signs ofacute inflammation in the first stage ; there isnormally no swelling, redness or heat, there iscertainly no fluctuation, there may be no loss offunction. These patients have been known towalk into a clinic, apparently fit, with pain as theironly complaint. Too often the clinical examinationis perfunctory, the tenderness is not noticed,radiography is of course negative, and the patientis sent home to develop the signs and symptomsof a florid acute osteomyelitis.

Clinical Picture in Stage 2. Pus in the medullaand the subperiosteal space.The symptom and sign persist, but both are

more marked; pain is more intense, tenderness is

more extensive. With retained pus, systemicsymptoms if not already present appear and varyfrom mild malaise to severe toxaemia and delirium.At this stage the patient often complains of achesand pains in other parts, which may lead thephysician to diagnose rheumatic fever.

Clinical Picture in Stage 3. Pus in the softtissues.When the pus reaches the soft tissues all the

signs of inflammation are at last present; pain,tenderness, heat, redness, loss of function and inthe more superficial bones, even fluctuation. Withthe deeper bones involved, notably the femur andthe humerus, fluctuation may still be undetected,for the pus tends to track along the deeper tissueplanes before coming to the surface. This stageshould never be allowed to occur.

3. FEVER IN ACUTE OSTEOMYELITISIn the first stage the patient's temperature may

be normal, but more often it is slightly raised andoccasionally there is high fever. In fact thepresenting symptom may be fever, and the storyof pain in a bone and the presence of tendernessmay only be elicited on question and examination.In the second and third stages the temperatureis nearly always raised, but the administration ofantipyretics is so common that little attentionshould be paid to an isolated normal reading.Salicylates are sometimes given to eliminaterheumatic fever, but the fever of acute osteo-myelitis may also respond, only to rise again withabscess formation.

4. DIFFERENTIAL DIAGNOSISIn most cases the diagnosis is not difficult once

the possibility of acute osteomyelitis has beenconsidered. Rheumatic fever and septic arthritisare the most confusing, but occasionally tuber-culosis of bone and joint, syphilitic epiphysitis,sarcoma and the subperiosteal haematoma ofscurvy may have to be differentiated.(a) Acute Rheumatism. The hot dry skin of the

septic case is very different from the clammyskin of the rheumatic. Careful examinationwill show that the tenderness is of bone ratherthan of joint. This is confirmed by the lesserdegree of spasm in acute osteomyelitis.Whereas virtually no joint movement is per-mitted by the rheumatic case, usually io0 or200 are allowed in the early stage of acute osteo-myelitis. In the later stages the oedema andswelling of the periarticular tissues contrastswith the wasting round a rheumatic joint.Rheumatic fever has rarely a single focus, butmore than one focus can also occur in acuteosteomyelitis. In acute rheumatism theanaemia is usually rapid and more severe.

B1



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(b) Septic arthritis. The diagnosis from acuteosteomyelitis does not begin and end withaspiration. The two conditions may, ofcourse, be 'present together, especially in in-fants, in whom it may be impossible todetermine which was primary.The following points are useful. In acute

osteomyelitis the tenderness is not equallysevere over the whole joint but is greatest overone particular part of it, either the focus orthe related glands. Again, unless there is alarge ' sympathetic effusion,' the joint is notheld in the position of maximum synovial dis-tension, but is held so as to relax the musclesattached to the affected bone. Thus in acuteosteomyelitis of the pubis without joint in-fection, the hip may be held flexed but it willnot be abducted. Abduction will be the move-ment most resented, while adduction andflexion, which do not stretch the adductorsand consequently do not pull on the pubis,are allowed.

Aspiration of the joint may be useful, pro-'vided its limitations are remembered and itsdangers avoided. Thus:(i) Both bone and joint infection may be

present together and pus in the joint doesnot necessarily mean primary septicarthritis.

(ii) Macroscopic examination of the fluid canbe very misleading. An apparentlyinnocent fluid may teem with organismsand a flocculent one may be sterile.

(iii) It is unforgivable to introduce infectioninto a joint by exploratory puncture. As-piration must be performed through thepart furthest from the inflamed area. Ifthere is pus in the joint it can be with-drawn from any part of it.

Aids to Diagnosis and Special Investiga-tionsThese are of relatively little value compared with

clinical examination. Some help may be gainedfrom a history of minor infections such as a boil,septic spots, styes or a discharging ear.

BLOOD EXAMINATIONCulture is too slow for diagnosis, but a specimen

should be taken before penicillin treatment begins,to obtain the organism for a sensitivity test.

The white blood count may show a leucocytosis,but a normal or even a low count is not unusual andis not against a diagnosis of acute osteomyelitis.

The red blood count andHb % are not reduced inthe early stages of rheumatic fever. The haemo-

globin level is a useful indicator of the success oftreatment.

The sedimentation rate has been raised in all ourcases to between 30 and I20. Like the Hb. levelit is a valuable indicator of the success of treatment.

RADIOGRAPHYA negative radiograph of a bone which is acutely

painful and tender is very suggestive of acute osteo-myelitis. However extensive the infection there isnot sufficient alteration in the calcium contentof the bone for any change to appear in the radio-graph before ten days from the onset (Figs. 8 and 9).On the other hand a positive radiograph mayreveal tuberculosis of sufficient duration, syphiliticepiphysitis and the periosteal elevation of scurvy.Osteogenic sarcoma should be recognized in theradiograph, but Ewing's tumour at an early stagemay show periosteal elevation compatible with alater stage of acute osteomyelitis. A radiographof the chest is useful when sarcoma or tuberculosisare suggested.

ASPIRATIONAspiration from the focus is rarely positive until

the diagnosis-is quite obvious.It cannot be too strongly emphasized that the

early diagnosis depends mainly on careful clinicalexamination and that in the first two stages thepatient may present only one symptom (pain inbone) and one sign (exquisite tenderness of bone).

TreatmentTreatment has been so altered by penicillin that

we describe here an effective method based on sixprinciples arrived at after studying our own 6ocases and the series of other workers. In our ex-perience complications may follow even a minordivergence from any one principle.

i. Systemic penicillin can by itself resolve theinfection if the organism is sensitive and treat-ment is begun before pus has formed.

2. Systemic penicillin cannot sterilize avasculartissues or pus. Therefore pus and dead tissuealready present must be effectively removed.

3. Systemic penicillin can prevent furtherformation of pus if removal of pus and dead softtissue has been effective. Therefore primarysuture is safe.

4. Bone, especially when diseased, is particularlysusceptible to secondary infection. Therefore anylocal operation must be carried out under fullaseptic conditions and must end with primarysuture without any form of drainage.

5. The bone is damaged directly by the infec-tion and indirectly by interference with its bloodsupply. Therefore every effort must be made to



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May 1948 TRUETA: Acute Haematogenous Osteomyelitis 237

improve the blood supply (a) by relieving pressurewithin and bone, and (b) by restoring contactbetween cortex and periosteum when these havebeen separated by pus.

6. Inflammation is so well concealed in bonethat residual infection cannot be detected. There-fore penicillin and immobilization should not bediscontinued immediately the clinical evidence ofinflammation has disappeared.Treatment along these lines is best described

under four headings: Penicillin treatment, sur-gery, immobilization and after-care.

PENICILLIN TREATMENTThe penicillin must be given systemically, for

the infection is in, part a systemic one (50 percent. of our cases had a positive blood culture)and only by the blood stream can the penicillin bebrought to the infection. Further it seems, thoughthe evidence is not complete, that for pyogenic in-fections of bone the systemic administrationshould aim at the constant presence of penicillin inthe blood. It is probable that the temporary highlevels often so effective in soft tissue infections actby the formation of a local pool of penicillin in thetissue fluids of the inflamed part, so that it acts forlonger than appears from the blood levels. Bonewith its rigid structure lacks this fluid reservoirand must rely on circulating penicillin.The intramuscular drip has in our experience

been most satisfactory for maintaining a constantblood level. It disturbs the patient much less thanintermittent administration arid is considerablymore economical. Our dosage has been as follows:

First three days .. 400,000 units in 24 hoursFourth day .. 300,000 ,. . .Fifth day onwards 200,000 ,. . .A more reasonable system of dosage would be

one based on weight. Buchanan working withintermittent dosage has shown that 4,000 units perlb. of expected body weight per day maintains abacteriostatic level when given:(a) in infants under six months, orally in the first

i oz. of each three- or four-hourly feed, e.g.,6o,ooo units daily in a six months child;

(b) in children from six months to five years,intramuscularly every three hours, e.g.,170,000 units daily in a child of five years.

She found the intramuscular drip moreeconomical. Thus iooooo units per 24 hoursmaintained a constant bacteriostatic level inchildren up to ten years. This dose was increasedup to 500,000 units in exceptional cases. Wealso favour such an increase for the first few daysin acute osteomyelitis.

It is of course important to isolate the or-

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FIG. Io.-Diagram of penicillin drip system (EudripNo. i described by MacAdam et al. in I944).

ganism early, to test its sensitivity and if necessaryto modify the dosage without delay.The drip illustrated in Fig. io is the Eudrip

No. i described by MacAdam in I944. Non-pyrogenic saline as prepared for intravenous in-fusion is used; less pure fluids often cause acellulitis which interferes with absorption. Therubber tubing must be tested for penicillin destruc-tion by incubating the two together for 24 hours.Harmless tubing can then be reserved for use in thedrip apparatus.



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238 POST GRADUATE MEDICAL JOURNAL May T948

The course is continued for a minimum of tendays in cases not operated upon. Otherwise thecourse continues for a minimum of ten days fromthe date of operation or until the stitches are re-moved, whichever is the longer. At the end of tendays a decision is made whether to continue ornot. A boost dose of 5o,ooo units is given beforeany operation as a protection against a possiblebacteraemia and to provide a high concentrationin any subsequent haematoma or effusion. It isinjected intramuscularly on arrival in the theatreand before the application of a tourniquet.

SURGERYThe surgical treatment no longer consists of the

emergency opening of abscesses in a casualtytheatre ; it comprises planned operations withfull aseptic precautions. It aims:

i. to remove as much pus and dead softtissue as possible.

2. to restore the blood supply (a) by releasingthe tension within the bone, and (b) by allowingthe periosteum to renew its contact with thecortex.

3. to avoid secondary infection.Theoretically tension in the bone should be

relieved without delay, but in practice we preferto wait 12-24 hours after treatment with penicillinhas begun. In this period general medicalmeasures are used to improve the patient's con-dition. Patients who are dehydrated and toxic aregiven fluids by mouth and by the penicillin drip,and if necessary subcutaneously or intravenouslyas well. Glucose is important and can be givenby mouth or by intravenous drip. We have notused antitoxins, but they. are probably of value inparticularly toxic cases. Sulphonamides may alsobe used in selected cases on occasion. In additionthe lesion needs adequate immobilization from thestart in order both to relieve pain and to reducetoxic absorption. Immediate operation, even withmassive penicillin dosage, may lead to a stormypost-operative course; wounds tend to be in-flamed and even to break down, in contrast withthe rapid recovery and healthy healing of casesadequately restored before being taken to thetheatre.

Operation is whenever possible done under atourniquet to ensure a bloodless field. If there isfluid in the related joint it is aspirated before theosteomyelitic focus is incised. The centre of theincision is over the point of maximum tendernessand is long enough for adequate exposure. Allpus is removed from the soft tissues and fromunder the periosteum, and any necrotiC soft tissueis excised. The bone is then drilled in two placesand if pus is found further drill holes are made tillnormal marrow is reached or until the epiphysis

or joint capsule is approached. When the surgeonis satisfied with the clearance of pus and sloughs,the wound is closed with interrupted sutures butwithout any form of drainage. The tourniquet isthen removed. The area is immobilized so that thewound can be easily inspected and if a limb isaffected it is elevated.Once it was considered unnecessary to drill the

bone if subperiosteal pus were present, as this wasthought to indicate spontaneous decompression.Decompression, however, is not adequate throughone small hole; pus will come out of neigh-bouring bone under pressure when fresh holesare drilled (Fig. 9). On the other hand extensiveguttering is not recommended, as drill holesdecompress just as extensive an area with muchless bone destruction. Drilled bone may laterappear normal in the radiograph, whereas sclerosisis common at the site of guttering. In the acutestage it is impossible (we use the word advisedly)to distinguish dead from living bone at operation,and excision of bone is now never indicated.

IMMOBILIZATIONEffective immobilization is important and should

be applied early. It may be considered for twostages: the acute stage and the stage of repair.

In the acute stage the part should be im-mobilized, elevated and accessible for inspection.When operation is unlikely, the region must be in-spected daily to see that there is no increase inlocal signs and that the joint is still unaffected. Weinspect wounds on the fourth day for haematomaformation and on the seventh and tenth days fQrminor stitch infection. Full sterile precautions areobserved, though the dressing is done in the ward.

.1 bff.,

FIG. I ia.-For lesions of the shoulder and upperhumerus: a thoraco-brachial plaster spica, thebrachial part bivalved. A strut between elbow andilium prevents collapse.

FIG. i ib.-For lesions of the lower humerus, forearmand hand: a plaster back slab.



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May I948 TRUETA: Acute Haematogenous Osteomyelitis 239

A haematoma can easily be evacuated by insertingforceps between two stitches. There is neverany.indication for the insertion of a drain.

In the early stage the following methods ofimmobilization are satisfactory:(a) For the shoulder girdle and upper humerus

(Fig. iia), a thoraco-brachial plaster with theupper half of the arm part removed. Thisneed not be applied before the second or thirdday, till when a sling with the arm bandagedto the side is adequate.

- I it' .A.

FIG. iic.-Jones' hip frame.

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FIG. iid.-Weight and pulley with groin strap forcounter-traction. (The foot of the bed can beraised if necessary.)

IF

FIG. iIe.-For lesions of the pelvis and upper femur:the posterior part of a bivalved hip spica.

(b) For the lower humerus, forearm and hand, along plaster back slab.

(c) For the pelvis and upper femur, a hip frame(Fig. iic). When one is not available, skintraction to the leg by a weight over a pulley,with counter-traction by a groin strap on theopposite side, is a satisfactory method (Fig.iid), but in serious cases we recommend theposterior half of a high hip spica (Fig. iie). AThomas splint is unsuitable, as it tends to keepthe hip in flexion, lies across the area to beexamined, does not immobilize the hip, andmay confuse the diagnosis by causing tender-ness over the pubis, ilium or ischium.

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FIG. iif.-For lesions of the lower femur, tibia andfoot: a plaster back slab elevated on a Braun'sframe.

(d) For the lower femur, leg and foot, a plasterback slab supported on a Braun's frame(Fig. iif).

In the repair stage immobilization should followstandard orthopaedic principles.

AFTER-CAREThe most difficult decisions are how soon can

treatment be stopped, the penicillin discontinuedand mobilization begun. Chronic inflammationfrom incomplete treatment can be serious and itis best to err on the side of caution. Bone healingis slow and even though infection is overcome morerapidly than in the past, the speed of repair has notchanged. It has been said that pathologicalfractures are more common since penicillin, butthe surgeon who allows too, early mobilizationand weight-bearing is to blame for any such in-crease, not the penicillin.

INDICATIONS OF THE LOCAL CONDITIONFour indicators are useful to decide when

mobilization is safe.i. The temperature chart is the least sensitive

indicator. The chart is usually normal by thesecond week, and only gross reactivation isreflected by a rise.



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2. The sedimentation rate is the most valuableand we rely on it more and more. It may takeseveral months for the rate to fall. to normal in asevere infection and it need not reach normalbefore mobilization is allowed. But if mobilizationis followed by a rise or by a decrease in the rate offall of the weekly sedimentation rate, this shouldbe understood as a warning and immobilizationshould be resumed.

3. The white cell count is sometimes useful andshould also be recorded.

4. Radiography is essential before taking anydecision on mobilization and especially on weight-bearing. A radiograph is taken not only on ad-mission but also as soon as changes can be ex-pected, in order to allow later comparisons. Smallsequestra may be seen but should disappear with-out further surgical treatment. Similarly smallcavities with no sclerosis of the inner wall willalso disappear.

DiscussionCases fall into two distinct groups :-those in

which the infection is well localized and in whichpus formation and bone destruction are negligiblewhen treatment is begun, and those in which theinfection is more advanced, pus has formed andthe bone has been already damaged. In the firstgroup adequate penicillin treatment and im-mobilization cause rapid resolution and usually nobone damage can be detected radiographically. Inthe second group the penicillin must be supple-mented by surgery, since it can neither sterilize thepus nor relieve the mechanical interference withthe blood supply of the bone. After operationthese cases also show rapid resolution, and healingof the sutured wound usually occurs by first in-tention. Neither group should show systemicdisturbance for longer than a week.We recommend open surgery for the second

group of cases. Some workers have been satis-fied with aspiration of pus and prefer to repeataspiration a number of times rather than to risksecondary infection by operation. But this riskis of course negligible when primary suture isdone in a part which can be kept clean and im-mobilized. In infants the immobilization andcleanliness of some regions may be difficult and

aspiration may then be preferable to open opera-tion. Fortunately these cases are the most suitablefor such treatment, as the structure of bone ininfancy allows early escape of the pus into the softtissues.

SummaryThe improvement in results of acute haemato-

genous osteomyelitis during the last four years aredescribed and are attributed to the use of penicillin.The need for early diagnosis is stressed, and the

underlying pathology is shown to be related tothe clinical signs and symptoms.

Treatment is described under four headings:penicillin, surgery, immobilization and after-care.The importance of maintaining without in-

terruption a bacteriostatic level of penicillin inthe blood is urged on theoretical grounds, and theneed for continuing penicillin beyond the period ofobvious inflammation is emphasized. The valueof the intramuscular drip is noted.

Surgery is considered necessary when pus hasalready formed. It aims to remove pus, to relievepressure within the bone and to restore contactbetween periosteum and cortex. Secondary in-fection of the wound is prevented by primarysuture.

Immobilization of the part is essential. In theacute stage it should be combined with elevationand should allow access. In the recovery periodimmobilization follows general orthopaedicprinciples.

It is recommended that the recovery period becarefully watched and that there should be noundue haste in allowing full activity. Radio graphsand regular estimations of the sedimentation rateare considered the most helpful indicators of thelocal condition at this late stage.

BIBLIOGRAPHYAGERHOLM, M. and TRUETA, J. (1946), Lancet, I 877.ALTEMEIER, W. A., and HELMSWORTH, J. A. (1945). Surg.

Gynec. Obstet., 8i, I38.BUCHANAN, JEAN L. (I946), Lancet, 2, 760.BUTLER, E. C. B. (I940), Brit. J. Surg., 28, 26i.FLOREY, H. W., and M. E. (I943), Lancet, I, 387.FLOREY, H. W., and M. E. (i944), Brit. Med. Jour., 2. 169.HIGGINS, T. T., BROWNE, D. J. and BODIAN, M. (1947), Brit.

Med. Jour., I. 757.JAFS, R. (I947) Nordisk Medecin, 36, 2093.MACADAM, I. W. J., DUGUID, J. P., and CHALLINOR,

S. W. (I944), Lancet, 2, 336.MACADAM., I. W. J. (I945) ,Brit. Journ. Surg., 33, i67.



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HAEMATOGENOUS OSTEOMYELITIS - Postgraduate Medical … · FIG. i.-Unsuccessful Treatment of Acute...

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