Punto Dewo

Dept. of Orthopaedics & Traumatology

Musculoskeletal Infection
Osteomyelitis
Septic arthritis
How do infecting organisms enter bones or
joints

 Inoculation through wounds

 Extension from adjacent infected structures
 Hematogenous spread
Inoculation
through
traumatic
wounds,
operations
Extension
from adjacent
infected
structures
Hematogenous spread
 Bacteremia
 Sluggish circulation in
metaphysis (in children)
 Foci  spread  subperiosteal abscess () draining sinus

(infants) foci  spread through growth

plate
• Involucrum : new bone formation
encircling cortical shaft

• Sequestrum : dead bone surrounded by pus

or scar tissue
Acute hematogenous osteomyelitis
 Male : female = 2 : 1
 > 90% monostotic
 > 90% lower extremity
 The child limps or refuse to walk or refuse to use the
extremity involved
 Early acute : w/in 24-48 hrs, only pain and fever
 Late acute : 4-5 days after onset, subperiosteal
abscess needs surgical drainage
 Neonates
 Older children
 Premature infants
Evaluation of Acute Osteomyelitis
 CBC, ESR, CRP
 Blood culture : ident. causative
organism in 50%
 Bone aspiration : for subperiost abscess, ident. 70%
 X-Ray : could be normal
 Bone scan Tc 99m
 MRI scan
Treatment of Acute Osteomyelitis
 I.V Antibiotic started promptly
 S. aureus most common infecting agent
 Gram (–)ve organism in vertebrae and immunocomp
pts
 Surgery for late acute (draining abscess)
Complications
 Recurrent osteomyelitis : to minimize  AB coverage
for 6 weeks
 Distant seeding
 Septic arthritis
 Pathologic fracture due to osteonecrosis
 Growth arrest due to damaged gr. pl.
Subacute Hematogenous Oeteomyelitis
 Less virulent org + effective immune response
 Less clear onset, older children ( 2-16 y.o), equiv sex
ratio
 No or mild fever, mild tenderness
 Lab findings inconclusive
 AB for 6 weeks
Chronic Hematogenous Osteomyelitis
 Sx several weeks-months
 Developed vs developing countries
 Child : neglected cases
 Adult : secondary
 Sequestra, involucrum, draining sinus
 Needs culture from bone/deep tissue
Treatment of Chronic Osteomyelitis
 Aggressive debridement
 Bone grafting
 Antibiotic beads (local)
 Soft tissue coverage
 Systemic antibiotic for 6-12 weeks
Septic Arthritis
 More common in children < 5 y.o
 S. aureus, > 95% monoarticular, hematogenous or
extension from adjecent structures
 41% knee, 23% hip, 14% ankle, 12% elbow, 4% wrist,
4% shoulder
 Cartilage eroded
Clinical feature
 Pain and swelling in affected joint
 Malaise, fever, limp, refuse to walk, refuse to move
extremity (pseudoparalysis)
 Joints held in comfy positions
 CBC, ESR, X-Ray, joint aspiration
Synovial fluid analysis :
-Turbid
-Yellow to creamy pus
-WBC > 50.000/mm3
-Glucose decreased
Treatment of Septic Arthritis
 i.v antibiotic promptly
 Surgical irrigation and drainage Open or arthroscopic
complications
 Joint destruction
 Bony ankylosis
 Soft tissue ankylosis (Tuberculosis)