infeksi tulang dan persendian

8/11/2019 infeksi tulang dan persendian

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Musculoskeletal Infection

Punto DewoDept. of Orthopaedics & Traumatology


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Bone and Joint Infection

Osteomyelitis

Septic arthritis


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How do infecting organisms enter

bones or joints

Hematogenous spread

Inoculation through wounds

Extension from adjacent infected

structures


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Inoculation

through

traumatic

wounds,

operations


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Extension

from adjacent

infected

structures


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Hematogenous spread

Bacteremia

Sluggish circulationin metaphysis

(in children)

Foci spread subperiosteal

abscess () draining sinus

(infants) foci spread through

growth plate


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Involucrum : new bone formationencircling cortical shaft

Sequestrum : dead bone surrounded by pusor scar tissue


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Acute hematogenous osteomyelitis

Male : female = 2 : 1

> 90% monostotic

> 90% lower extremity

The child limpor refuse to walkor

refuse to use the extremityinvolved


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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


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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


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Treatment of Acute Osteomyelitis

I.V Antibiotic started promptly

S. aureusmost common infecting

agent

Gram ()ve organism in vertebrae

and immunocomp pts

Surgery for late acute (draining

abscess)


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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.


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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


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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


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Treatment of Chronic Osteomyelitis

Aggressive debridement

Bone grafting

Antibiotic beads (local)

Soft tissue coverage

Systemic antibiotic for 6-12 weeks


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Trisna Rahardja, M, 46 yo,

Chronic osteomyelitic of the distal third

of the left tibia and fibula post ORIF

on 2008

Didik R M 20 yo


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Didik R, M, 20 yo

Chronic osteomyelitis of the right tibia fibula with bone

defect post nailing


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Septic Arthritis

More common in children < 5 y.o

S. aureus, > 95% monoarticular,

hematogenous or extension fromadjecent structures

41% knee, 23% hip, 14% ankle, 12%

elbow, 4% wrist, 4% shoulder Cartilage eroded


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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


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Synovial fluid analysis:

-Turbid

-Yellow to creamy pus

-WBC > 50.000/mm3

-Glucose decreased


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Treatment of Septic Arthritis

i.v antibiotic promptly

Surgical irrigation and drainage

Open or arthroscopic


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complications

Joint destruction

Bony ankylosis

Soft tissue ankylosis (Tuberculosis)


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Clinical Feature


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X-ray of the Left lower leg


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Cellulitis

Subcutaneous

Less distinctive margins

Local signs + lymhadenopathy

Th/ Systemic + Local


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Erysipelas

Similar to cellulitis BUT more

superficial

Well demarcated and painful plaque Th/ Systemic + Local


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Necrotizing Fasciitis

Muscle fascia

Aggressive and life threatening

Etiology : Streptococcus Group A

Requires emergent and extensive

surgical debridement

Gas Gangrene


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Gas Gangrene Muscle

In grossly contaminatedtraumatic wounds

Etiology :

Clostridium Perfringens

and Clostridium Welchii

Need surgical debridement

and fasciotomy

Hyperbaric chamber

therapy


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