infections of the bones & joints
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8/6/2019 Infections of the Bones & Joints
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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