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Osteomyelitis

image of Osteomyelitis
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Abstract

Osteomyelitis is defined as inflammation of the bone cortex and marrow. This chapter looks at pathogenesis of post-traumatic osteomyelitis, diagnosis, treatment of post-traumatic osteomyelitis, factors affecting the development of osteomyelitis, haematogenous and fungal osteomyelitis.

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Figures

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30.1 Pathogenesis of osteomyelitis. (a) Contaminated site following surgery. (b) Host inflammatory response. (c) Biofilm formation and bone death. (d) Bone lysis and plate loosening. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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30.2 Acute osteomyelitis following application of a modified type 2 external skeletal fixator to stabilize an osteotomy of the distal radius and ulna. The limb is swollen and purulent material is discharging through the skin incision on the lateral aspect of the limb.
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30.3 Craniocaudal radiograph of a femur showing gas in the soft tissues (arrowed) overlying a fracture stabilized with a bone plate. Gas production was due to infection with . (Courtesy of AC Stead)
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30.4 Craniocaudal radiograph of a tibia showing chronic osteomyelitis following application of a bone plate. There is lysis of bone under the plate and around the screws, fracture non-union, an irregular periosteal reaction and soft tissue swelling.
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30.5 Mediolateral radiograph of a femur showing chronic osteomyelitis following fracture fixation with an intramedullary pin. There is extensive periosteal new bone on the proximal fragment, fracture non-union and large periosteal spurs on the distal fragment (arrowed).
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30.6 Mediolateral radiograph of a humerus showing chronic osteomyelitis. Although the fracture has healed, a large sequestrum is present (arrowed) surrounded by an involucrum.
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30.7 (a) Craniocaudal and (b) mediolateral radiographs of a ring sequestrum at the site of an external skeletal fixator transfixation pin placement. (c) The circular necrotic bone sequestrum can be identified on closer inspection. (Courtesy of T Gemmill)
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30.8 Mediolateral radiograph of a tibia showing chronic osteomyelitis following extensive soft tissue trauma to the limb. Arrows show an irregular periosteal response.
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30.10 Intraoperative appearance of chronic osteomyelitis of a femur following application of a bone plate for fracture stabilization. (a) Sequestered cortical bone is visible beneath the bone plate (black arrow); viable cortical bone is denoted by the white arrow. (b) The sequestrum is more clearly visible following removal of the bone plate.
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30.11 Excision of part of an involucrum to allow removal of a sequestrum. The bone may require subsequent support with a fixation device if sequestrum removal has significantly weakened the bone (see Figures 30.12 and 30.17 ). Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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30.12 Mediolateral radiograph of a humerus following an attempt to remove a sequestrum. The sequestrum (arrowed) was not found and the weakening of the bone resulted in its fracture.
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30.13 Reaming of the medullary canal (obliterated by new bone formation following infection) to facilitate vascular ingrowth and fracture healing. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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30.14 (a) Chronic osteomyelitis with sequestration of a large segment of the mandible following the insertion of a pin into the mandibular canal to stabilize a fracture. (b) Lateral radiograph of the mandible showing an irregular periosteal response adjacent to the distal end of the pin (arrowed). (c–d) Treatment for the dog involved rostral hemimandibulectomy to remove all dead, infected cortical bone.
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30.15 Craniocaudal radiograph of a tibia following application of a type 1 external skeletal fixator to stabilize an infected fracture. (Courtesy of J Ferguson)
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30.16 (a) Mediolateral radiograph of a femur showing an infected non-union fracture. (b) The fracture healed with a malunion following stabilization with a bone plate.
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30.17 Application of an external skeletal fixator to an infected bone to provide additional support following removal of a sequestrum. The defect has been packed with a cancellous bone graft. Drawn by Vicki Martin Design, Cambridge, UK and reproduced with her permission.
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30.18 (a) Craniocaudal radiograph of the antebrachium 2 years after the application of a bone plate to stabilize a fractured radius. The fracture has healed but there is evidence of low-grade osteomyelitis. An irregular periosteal response is present on the distal radius (arrowed). (b) Following removal of the plate and a prolonged course of antibiotics, the infection resolved.
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30.20 Craniocaudal radiograph of an infected tibial fracture stabilized with an external skeletal fixator. Gentamicin-impregnated beads have been implanted at the fracture site. (Courtesy of S Langley-Hobbs)
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30.21 Mediolateral radiograph of the distal radius and ulna from a dog with haematogenous osteomyelitis. Focal areas of lysis are present in the metaphyses of both bones. (Courtesy of J Houlton)
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30.22 Lateral radiograph of the lumbosacral spine of a 5-month-old dog with discospondylitis at the L7/S1 intervertebral disc space. There is widening of the affected disc space with lysis of the adjacent vertebral endplates.
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30.23 (a) Mediolateral and (b) dorsoplantar radiographs of the metatarsus of a dog with osteomyelitis caused by . There is an irregular periosteal response and areas of lysis of the third metatarsal bone. (Courtesy of M Brearley)

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