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The Diagnosis of Acute Osteomyelitis of the Pelvis Alan Morgan, Alan K

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The Diagnosis of Acute Osteomyelitis of the Pelvis Alan Morgan, Alan K 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 PELVIS 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- bone involved and does not include other graphy, probably because of its relative bones 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 ilium 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 ischium 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- pubis 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) Hip 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 knee. 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 acetabulum. 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 abdomen. 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 iliac fossa. 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.
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