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INFECTIONS OF THE BONES & JOINTSINFECTIONS OF THE BONES & JOINTS

DR.S.BRANAVANDR.S.BRANAVAN

CONSULTANT SURGEONCONSULTANT SURGEONTH BATTICALOATH BATTICALOA

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OSTEOMYELITISOSTEOMYELITIS

Suppurative process of the boneSuppurative process of the bone

Can be Acute or ChronicCan be Acute or Chronic

ACUTE OSTEOMYELITISACUTE OSTEOMYELITIS 

Commonly in children

If adults are affected its due to immuno compromization

Usually a haematogenous spreadMostly affects the metaphysis / joint involvement is rare

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Pathogens – Staphylococcus aureas -60-85%Pathogens – Staphylococcus aureas -60-85%

Streptococcus haemolyticusStreptococcus haemolyticus

Salmonella – in Sickle cell disease patientsSalmonella – in Sickle cell disease patients

PseudomonasPseudomonas

ClostridiumClostridium

H.influenza – between 7/12 and 4 years of lifeH.influenza – between 7/12 and 4 years of life

Pathophysiology – abscess forms in metaphysis if no antibioticPathophysiology – abscess forms in metaphysis if no antibiotic

treatment is commencedtreatment is commenced

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CLINICAL FEATURESCLINICAL FEATURESFever, swelling, limitation of movementsmovements

tachycardia, dehydration, extreme tendernesstachycardia, dehydration, extreme tenderness

DD- Septic arthritis, cellulitisDD- Septic arthritis, cellulitis

INVESTIGATIONSINVESTIGATIONSElevated WCCBlood cultures are positive in 60%

X rays – Essentially normal for 10 days

>2/52 shows – Sequestrum- dense dead boneInvolucrum – reactive new bone formationCloacae – holes through which sequestrum

is released

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Bone scan ( Tc99, GA 67) – Confirms diagnosis early as 24-48 hrs.Bone scan ( Tc99, GA 67) – Confirms diagnosis early as 24-48 hrs.But it cannot differentiate infection from tumourBut it cannot differentiate infection from tumour

TREATMENTTREATMENT

Rest / elevation of the limb

IV fluidsIV antibiotics – initially cloxacillin & fuscidic acid

Children <4 yrs cephalosporins preferred as

Gram negative infections are common

Then change according to ABST

IV until patient clinically improves/ CRP improves(usually 1-2 wks)Then continue oral antibiotics for a total period of 4-6 weeks

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Surgery – If the child doesn’t settle by 48 hrs or obviousSurgery – If the child doesn’t settle by 48 hrs or obvious

abscess formsabscess forms

ComplicationsComp

lications

SepticemiaSeptic arthritis -rare

Chronic osteomyelitis

Pathological fractures

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CHRONIC OSTEOMYELITISCHRONIC OSTEOMYELITIS

Om lasting for > 3/52Om lasting for > 3/52

CausesCausesSequalae of acute OMOpen #Bone surgeriesChronic from the beginning eg.TBFungal

CLINICAL FEATURESSymptoms are few; acute exacerbations produce symptomsOf acute inflammation

Signs – Irregular thickening / sausage fingerSinusesShortening / lengthening on limbsPathological fractures

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PATHOLOGY OF CHRONIC OSTEOMYELITISPATHOLOGY OF CHRONIC OSTEOMYELITIS

Sequestrum

Involucrum

Clocae

Brodies abscess – localized abscess on metaphysis

INVESTIGATION

X rays

Sinogram

Tc99-HDP scan

CT/MRI

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TREATMENTTREATMENT

Antibiotics – which should penetrate the sclerotic boneAntibiotics – which should penetrate the sclerotic bone

Fuscidic acid , Clindamycin, CephalosporinsFuscidic acid , Clindamycin, Cephalosporins

Surgery – SequestrectomySurgery – Sequestrectomy

AmputationsAmputations

ComplicationsComplications

Acute exacerbationsAcute exacerbations

Growth retardationGrowth retardation

Pathological #Pathological #DeformitiesDeformities

Amyloidosis – Which type? ReadAmyloidosis – Which type? Read

Squamus cell carcinoma of the chronic sinus tractSquamus cell carcinoma of the chronic sinus tract

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TB OSTEOMYELITISTB OSTEOMYELITIS

Skeletal TB is always secondary – primary is from lung,GIT,Skeletal TB is always secondary – primary is from lung,GIT,

LNLN

Spine is the commonest bone (Pott’s Disease)Spine is the commonest bone (Pott’s Disease)

Dorsal > Lumbar > CervicalDorsal > Lumbar > Cervical

CLINICAL FEATURESCLINICAL FEATURES

Mono articular pain / backpainMono articular pain / backpain

Constitutional symptomsConstitutional symptoms

Pathological # / KyphosisPathological # / Kyphosis

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INVESTIGATIONSINVESTIGATIONS

General InvestigationsGeneral Investigations

X rays – Disc & adjacent two bodies (Common blood supply)X rays – Disc & adjacent two bodies (Common blood supply)

CTCT

MRIMRI

BiopsyBiopsy

TREATMENTTREATMENT

Anti TB drugs for 9/12Anti TB drugs for 9/12Surgery for pathological #, Cord compressionSurgery for pathological #, Cord compression

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INFECTIVE ARTHRITISINFECTIVE ARTHRITIS

Pyogenic – Septic arthritisPyogenic – Septic arthritis Gonococcal arthritisGonococcal arthritis Syphylitic arthritisSyphylitic arthritis

SEPTIC ARTHRITISSEPTIC ARTHRITIS

Acute Bacterial Infections of jointsAcute Bacterial Infections of joints

90% are mono articular90% are mono articular

Causes – S.aureas 50%Causes – S.aureas 50%

Streptococcus 20%Streptococcus 20%

PneumococcusPneumococcus

Routes of Entry – Haematogenous from GI,RSRoutes of Entry – Haematogenous from GI,RS

Pyogenic OMPyogenic OM

Penetrating woundsPenetrating wounds

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PATHOLOGYPATHOLOGY

Exudation into joints – serous/ purulentExudation into joints – serous/ purulent

Destruction of articular cartilage & ligamentsDestruction of articular cartilage & ligaments

CLINICAL FEATURESCLINICAL FEATURES

Pain – usually mono articularFever – in 50% , unwell

Local inflammatory signs

INVESTIGATIONS

General blood investigations

Joint aspirate for Gram stain, cultureX rays – soft tissue swelling only

later develop cartilage destruction and loss of joint space

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TreatmentTreatmentSurgical Emergency – Arthrotomy and drainage

Immobilize

Antibiotics – 4/52