POSTGRAD. MDI). J., (1966), 42, 74 Postgrad Med J: first published as 10.1136/pgmj.42.484.74 on 1 February 1966. Downloaded from THE DIAGNOSIS OF ACUTE OSTEOMYELITIS OF THE ALAN MORGAN, ALAN K. YATES, M.B., Ch.B. (Brist.), F.R.C.S. Eng.* M.B., Ch.B. (Sheff.), F.R.C.S. Eng.** The Royal Infirmary and Children's Hospital, Sheffield. OSTEOMYELITIS of the pelvis has a sparse biblio- involved and does not include other graphy, probably because of its relative of ithe pelvis involved by subsequent infrequency in general orthopaedics. spread of the disease. Froener (1889) istated that less than 10%/ of In agreement with other authors we find cases occured in the pelvis in a series of 545 that the is most commonly affected. The cases of acute osteomyelitis; Butler (1940) ilium forms the largest portion of the bony gives an incidence of 8% in 500 cases of acute pelvis. lits blade has an abundant blood supply osteomyelitis seen at the London Hospital. with a large nutrient artery entering its inner Von Bergmann (1906) found 63 cases of surface, and in the adult it is the only bone of osteomyelitis of the ilium in 71 cases of osteo- the pelvis containing haemopoetic marrow. myelitis of the pelvis. Krasnobajiv (1925), The was more commonly involved Simmons (1915), Bearse (1923), Flickinger than in other series, but i,n no patient was the (1927) and Buosanti (1924) each give an in- primarily infected, although it was in- cidence of osteomyelitis of the ilium of bet- volved by extension in several cases. (Fig. 1). ween 2% and 7%. Young (1934), in his review of osteomyelitis of the ilium, to which he Clinical Presentation Protected by copyright. added three cases of his own, stated that "acute Although the correct diagnosis was made osteomyelitis of the pubis and ischium is so rare ultimately the condition often eluded diagnosis it is hardly necessary to give it consideration". during weeks or even months of investigation. His paper is the last comprehensive review of On studying ,the case reports it became pelvic osteomyelitis, but referred only to the evident ,that certain features could be grouped ilium. into clinical syndromes which were related in This paper concerns the diagnosis of acute general to the anatomical site of infection. osteomyelitis of the pelvis lin 18 patients seen Most patients initially had symptoms and in the Orthopaedic Departments of the Royal signs of toxaemia but dlid not come to hospital Infirmary and Childrens' Hospital in Sheffield until localising signs, such as a limp, appeared between 1948 and 1964. Thirty case records some days later. A few patients suffered from of pelvic osteomyelitis were found among 616 septicaemia for a long period while the infective cases of acute osteomyeliltis of all bones seen nidus remained hidden. during this period, but only 18 were documented The following is a suggested classification sufficiently well for study. This gives an in- based on our observations: http://pmj.bmj.com/ cidence of 5% of osteomyelitis occurring in the 1. Septicaemic pelvis. Osteitis pubis due to surgery or trauma 2. Clinical Syndromes has not been included. Although this condition (a) joint Syndrome. is more common than acute haematogenous (b) Abdominal Syndrome. osteomyelitis of the pelvis it is a separate en- (c) Buttock Syndrome. tity. The principles of treatment of pelvic (d) Sciatic Syndrome. osteomyelitis do not differ from those of osteo- on October 2, 2021 by guest. myeitis in other bones and will not be Septicaemic discussed. These patients have symptoms and signs of toxaemia, usually with a positive blood culture, Anatomy but with no obvious infective nidus. Careful The incidence of involvement of individual examination of the skeleton is essential in all bones of the pelvic ring in this series of 18 cases of unexplained septicaemia. It is pertinent cases is as follows: Ilium, 14; Ischium, 4; that eight of our patients had initial septicaemic Pubis, 0; Total, 18. This refers to the initial symptoms on admission. Present address: The following case history is illustrative. *United Case no. 1. J.S. aged 31 years. Admitted initially Cardiff Hospitals, Llandouigh Hospital, under medical care with a pyrexia of unknown Cardiff. origin. He had been ill for one week with malaise, **Guy's Hospital, London, S.E.I. pyrexia and rigors. There was no relevant antecedent February, 1966 MORGAN and YATES: Osteomyelitis of the Pelvis 75 Postgrad Med J: first published as 10.1136/pgmj.42.484.74 on 1 February 1966. Downloaded from Protected by copyright.

FIG. 1.-Radiograph of case J.S. showing bone FIG. 2.-Typical radiographic appearance of osteo- destruction in !the ilium at the anterior inferior myelitis of the ilium, with separation of a iliac spine spreading to the acetabular roof, sequestrum and spread to the acetabular roof. pubis and ischium. history and no abnormal physical signs were noted. only one case was the pain also referred to the Initial investigations showed a white cell count of 19,500/cu. mm.; 86 % polys. Blood culture grew a . Young (1934), states ithat there is no pure growth of staphylococcus pyogenes. knee reference in osteomyelitis of the ilium. Antibiotic treatment was commenced and was In general this may be true but the case reported continued for eight weeks with varying combinations below was exceptional in our series. of drugs without success. Blood cultures remained positive with increasing resistance of the staphy- In agreement with Butler (1940) the com- lococcus. Extensive investigations were carried out monest initial bony focus was in the region of in an unsuccessful attempt to find the source of the the hip joint, especially the anterior iliac spines http://pmj.bmj.com/ infection. It is interesting to niote that an intravenous pyelogram performed at this time would have (Figs. 1, 2 and 3). One would expect to find revealed the osteomyelitic focus in the left ischium tenderness at this point on examination and if this area had not been obscured by a gonadal where this was specifically looked for, this radiation screen. Nine weeks after admission the was so. However, the focus in one case was in patient started to complain of pain in the left hip and groin. Radiography showed an osteomyelitic the ischium close to the . le3ion in the left ischium. A deep buttock abscess The main distinguishing feature of this lesion developed and he was transferred to orthopaedic from purulent arthritis, where hip movement is care. The abscess was drained and a hip spica on October 2, 2021 by guest. applied. However,,the infection progressed and Fig. 1 limited in all directions, is a differential limi- shows the extensive bony destruction spreading into tation of hip movement. Typically there is the pubis and acetabular roof. The hip is fusing some degree of fixed flexion and loss of full s;pontaneously. internal rotation, but free movement in other Clinical Syndromes directions. Patients may present certain clinical features Ten of our patients showed this picture and which indicate the diagnosis and the site of the the following typical record is reported in osteomyelitis. Four syndromes can be defined. detail: (a) Hip Joint Syndrome Case no. 2. A.L. aged 3 years. This child was admitted with a three day history of pain in the left This syndrome has clinical features like those hip and knee. He had been limping from the onset of septic arthritis of the hip but with certain of the pain, but by the time of,admission was unable exceptions. The pain is felt in the hip and in to walk. He was hot and shivering and generally 76 POSTGRAiDUATE MEDICA,L JOURNAL February, 1966 Postgrad Med J: first published as 10.1136/pgmj.42.484.74 on 1 February 1966. Downloaded from

There were other features which indicated the diagnosis of osteomyelitis of the pelvis. Five patients had the features of the hip syndrome and one of them had a buttock syndrome. (see below). Appendicitis sometimes presents with psoas irritability. These cases differ from osteomye- litis by having early central abdominal pain and the hip signs are those of fixed flexion with increase of the pain on passive extension or hyperextension of the hip joint. The initial bony focus in this group is usually situated in the blade of the ilium. This erodes the inner cortex, forming the abscess deep to FIG. 3.-Early changes on radiography in case A.L. iliacus which can be felt per . The showing the small area of erosion just above the oedematous iliacus itself also contributes to acetabular margin, with periosteal reaction the size of the mass. extending up beyond it. Six cases fell into this group and the following unwell. There was no recent history of sore throat typical record is reported as an example. or contact any with infectious disease. Case no. 3. S.M. aged 20 years. This patient was On examination, he was pyrexial with a tempera- initially admitted as a general surgical emergency ture of 39°C. The throat, ears and chest were normal, with a five-day history of pyrexia and pain initially and there was no rash. The left hip was held in fixed in the right groin and later in the right .

Internal rotation was Protected by copyright. flexion. markedly reduced, the On examination there was tenderness in the right other movements at the hip being only slightly iliac ifossa and fixed flexion with limited internal restricted. The white cell count was 21,000/ cu. mm., rotation of the hip. A diagnosis of acute 50 on appendicitis ESR mm./hr. Blood culture set up admission with psoas irritation was at a a made but operation grew pure growth of coagulase positive normal appendix was removed. Pain persisted in the pyogenes was to staphylococcus which sensitive right groin and the became very there of no hip stiff, being penicillin. Aspiration the hip joint yielded pus. only ten degrees of movement in any direction. An The leg was placed on straight skin traction and area of tender induration appeared -in the region of systemic penicillin treatment commenced. On this the greater trochanter and anterior superior iliac regime the symptoms improved rapidly and the spine. A revised diagnosis of osteomyelitis of the temperature subsided. Over the next or four three head of the femur was made. Radiographs at this days, however, some tenderness developed over the body of the ilium but this subsided simultaneously time showed no bony abnormality. Blood analysis with improvement of hip movements. revealed a white cell count of 7,000/cu. mm. with a A normal differential count. ESR 45 mm./hr. A blood radiograph twelve days after the onset of the culture taken seven days symptoms some after appendicectomy yielded showed erosion of the bone just a heavy growth of coagulase positive above the rim of the acetabulum with a periosteal staphylococcus reaction pyogenes sensitive to streptomycin, tetracycline and extending upwards from this point (Fig. 3). erythromycin but to Only then was the diagnosis of ostoomyelitis made. resistant penicillin. Three weeks later, all the symptoms had completely The leg was placed on skin traction on a Thomas' http://pmj.bmj.com/ changed to an settled. Penicillin was given for a total of six weeks. splint, later abducti,on frame. The initial antibiotic treatment of penicillin was changed Six months later, the hip was clinically normal and to streptomycin when blood culture sensitivities nothing abnormal could be detected on further became available. radiography. Fever and hip irritability persisted for four weeks (b) Abdominal Syndrome during which time the infection extended from the This syndrome has some clinical features ilium into the hip joint and pubis. Radiographs similar to those of acute appendicitis on the revealed complete obliteration of the hip joint space and the hip was immobilised in a spica for a further right side and paracolic abscess on the left. six months. The final picture two years later was of on October 2, 2021 by guest. The patient was often referred to a general painful ankylosis requiring operative arthrodesis. surgeon complaining of pain in one or other (c) iliac fossa. In this series, all had disease on the Buttock Syndrome right side and four had a palpable mass in the This syndrome had separate clinical features right iliac fossa. Two of these patients were of buttock pain, sometimes with radiation down subjected to laparotomy before the correct the back of the down to the level of the diagnosis was made. Weld (1960) described a knee. Hip movements were typically free in the case of osteomyelitis of the ilium which was early stages but when the ischium was the site initially diagnosed as acute appendicitis and of the infective focus there was pain on had a normal appendix removed and Bruckner abduction of the hip. (1952) twice removed a normal appendix in The initial b-ony focus was either in the similar circumstances. posterior part of the or the ischial February, 1966 MORGAN and YATES: Osteoniyelitis of the Pelvis 77 Postgrad Med J: first published as 10.1136/pgmj.42.484.74 on 1 February 1966. Downloaded from

tuberosity and the outer cortex of bone was Case no. 5. J.S. aged 22 years. The patient was eroded with an abscess enlarging into the 36 weeks pregnant. It was her first pregnancy which has proceeded normally to date. She was ladmitted overlying soft tissues. complaining of backache associated with malaise of Physical examination revealed a localised four to five days duration. The symptoms had area of tenderness often with a palpable mass become more severe during the preceding twenty-four in the region of the infection. These findings hours and the pain had moved into the buttock with radiation down the back of the thigh, 'the outer made early diagnosis with accurate localisation aspect of the calf and lateral side of the . of the infective focus possible. In our series On examination, she looked ill with a temperature these cases were correctly diagnosed at the time of 39.2°IC. Although the sciatic pain was very severe, of first examination. the straight leg raising was normal and there were Six cases had clinical features of this group, no abnormal neurological signs in the legs. aind the following is a typical record. Investigations revealed a white cell count of 25,000/cu. mm. with a polymorphonucleocytosis. Case no. 4. J.H. aged 15 years. The patient Intramuscular penicillin was commenced after a blood complained of increasing right buttock pain for six culture had been taken. In the next forty-eight hours days with general malaise. There was no 'history of the pain became more severe, 'there being localised recent trauma. tenderness over the sacro-iliac joint. Tihe temperature On examination, the patient had a fever of 38.60C. remained high. There was free movement of the but some At this time the decision was taken to aspirate the discomfort was experienced on flexion and abduction joint and simultaneously perform a 'Caesarian section. of the right hip and exquisite tenderness was present The joint contained a large amount of pus which over the . Laboratory investigations on culture grew a coagulase positive staphylococcus revealed: !a normal haemoglobin; WBC normal 'but pyogenes as did the blood culture. As a result of with a relative polymorphonucleocytosis. ESR 43 the culture sensitivities, erythromycin being the drug mm./hr. Blood culture revealed a heavy growth of of choice, was commenced. Subsequently the patient coagulase positive staphylococcus pyogenes sensi,tive made a rapid recovery and her baby thrived. A Protected by copyright. to penicillin. radiograph taken three weeks later showed an area Treatment was by leg traction and intramuscular of sclerosis in the ilium just anterior to the sacro-iliac penicillin. The patient was afebrile in seven days joint which was regarded as the initial focus of and the local symptoms and signs had completely infection. A year later the joint had spontaneously resolved in eleven days. The patient was discharged fused. home on the sixteenth day with no abnormal signs. Radiographs had appeared normal and a proven diagnosis ;had not been established. Discussion Four months later a sinus developed in relation to The classification of the ischial tuberosity which now showed signs of osteomyelitis of the bony infection on radiography. T'he patient persist- pelvis into clinical syndromes clarifies a con- antly refused oper-ative treatment and after a dition of recognised diagnostic difficulty. prolonged course of anitibiotics the sinus permanently Osteomyelitis of the spine presents a similar healed with no residual disability one year later. problem, and Puig (1946) clarified diagnosis in a like manner, with his classification into (d) Sciatic Syndrome meningeal, abdominal and hip syndromes. Only one case occurred in this but series, The clinical features in patients with http://pmj.bmj.com/ similar cases have been described in the osteomyelitis of the pelvis vary to such an literature. The syndrome is characterised by extent that they may be referred to one of pain along the distribution of the sciatic nerve several hospital departments, e.g. general associated with the systemic signs of a purulent medicine i(septicaemic syndrome), general infection and localised tenderness over the surgery (abdominal syndrome), paediatric region of the sacro-iliac joint. This is indicative (limping child), or even orthopaedic. The of suppurative artihritis of the sacro-iliac joint. incidence of this disease is low and unless pelvic Avila (1941) described seven cases in whom osteomyelitis is borne in mind by the examining on October 2, 2021 by guest. these features were constant. Riendle Short doctor the correct diagnosis may be missed (1931) described a similar case. during the early stage when the correct treat- Suppurative arthritis of the sacro-iliac joint ment would be most beneficial. is probably secondary to osteomyelitis situated As the infective lesion progresses the clinical posteriorly in the blade of the ilium, the features multiply and syndromes emerge. Most infection spreading later into the joint. The of our patients had features of two syndromes histories of some of the reported cases would but one syndrome predominated, preceded the appear to confirm this. Among the accounts other and was related to the site of the initial in the literature of cases of suppurative sacro- focus of infection. Stress has to be laid on iliitis, a number occurred shortly after childbirth these clinical features as early diagnosis is or abortion. This case appears to be the only only possible by considering them. Radio- one occurring antenatally. graphic changes are late in appearing and the 78 POSTGRADUATE MEDICAL JOURNAL February, 1966 Postgrad Med J: first published as 10.1136/pgmj.42.484.74 on 1 February 1966. Downloaded from infection may be well established and involve a large area of bone before radiographic changes are recognisable. Among the initial routine investigations the white blood cell count was of no diagnostic help, as a raised count was found in only approximately half of our cases. The erythro- cyte sedimentation rate was raised in all cases, suggesting that a normal value would be against a diagnosis of acute osteomyelitis. Blood culture was positive in two-thirds of the patients, and the value of isolating and obtaining the sen- sitivity of the causative organism at an early stage is obvious. This series illustrates that like osteomyelitis in general, osteomyelitis of the pelvis has a far better prognosis since the advent of anti- biotics. Thus, there were no deaths, and spread of the disease to the opposite side of the pelvis which Butler (1940) describes as common, was not seen. However, extensive bony destruction and permanent disability is not infrequent and affects the hip joint in particular, three of our Protected by copyright. patients eventually having a fused hip (Fig. 4). Summary From study of 18 cases of osteomyelitis of the the modes of and pelvic bones, presentation FIG. 4.-Late result of .osteomyelitis of the pelvis difficulties of diagnosis are discussed. A treated iin 1948. T_hehip is fused with 1 -inches classification is suggested based upon this study. of true shortening. A sequestrum of the ilium The presentation may be septicaemia or in one has left a punched out defect in its blade. of four clinical syndromes. These may merge to a greater or lesser degree. The literature on the subject is reviewed, the BRUCKNER, H. (1952): Der Perityphlitische Symp- incidence of the condition similar in this temenkomplex bei re: Beckenschaufelosteomyelitis being verursacht durch Pseudo-appendicitis (lokale series to that noted by other authors. unde echte Kontaktperitonitis) Begleitappendicitis. http://pmj.bmj.com/ That the majority of cases occur in the ilium Bruns'. Beitr. klin. Chir., 184, 359. is confirmed, the reason for this lying not only BUOSANTI, P. (1924): L'Osteomielite acuta dell' ileo in its but also in its nell' infanzia, Arch. ital. Chir., 10, 1. bigger volume, greater BUTLER, E. C. B. (1940): The Treatment, Compli- vascularity. cations and Late Results of Acute Haematogenous As the condition may present in one of Osteomyelitis, Brit. J. Surg., 28, 261. many specialist departments it should be borne FLICKINGER, W. G. (1927): Osteomyelitis of Ilium, in in cases Long. Is. med. J., 21, 95. mind of unexplained septicaemia. FROENER, E. (1889): Beitrage zur Kenntnis der akuten spontanen Osteomyelitis der Kurzen und platten on October 2, 2021 by guest. It is a pleasure to acknowledge the help and Knochen, Bruns'. Beitr. klin. Chir., 5, 79. encouragement of Mr. W. J. W. Sharrard in the KRASNOBAJIV (1925): Nov. khir. Arkh., 10, 354. preparation of this paper. PUIG, G. (1946): Pyogenic Osteomyelitis of Ilium, The cases were under the care of Mr. Sharrard, J. Bone Jt Surg., 28, 29. Mr. F. W. Holdsworth and Mr. D. K. Evans to SHORT, A., RENDLE ,(1931): Acute Osteomyelitis of whom we are also indebted. Ilium, Brit. med. J., ii, 97. SIMMONS, C. C. (1915): The Treatment of Osteo- myelitis, Surg. Gynec. Obstet., 20, 129. REFERENCES VON BERGMAN, A. (1906): Erfahrungen ueber Beckenosteo-myelitis, Arch. klin. Chir., 80, 504. AVILA, LEON JR. (1941): Primary Pyogenic Infection WELD, P. W. (1960): Osteomyelitis of the Ilium of the Sacro-Iliac Articulation, J. Bone Jt Surg., masquerading as Acute Appendicitis, J. Amer. med. 23, 922. Ass., 173, 634. BEARSE, C. (1923): Osteomyelitis of the Ilium in YOUNG, F. (1934): Acute Osteomyelitis of the Ilium, Children, J. Amer. med. Ass., 80, 991. Surg. Gynec. Obstet., 58, 986.