Musculoskeletal

InfectionsOM & SA - - both are emergency

If treated- - totally normal
If not-- lifelong handicap
 distal tibia & Proximal femur high blood
so In adults high chance of osteomyletists infection
☆ have
supply
site & Mets site .

Principles of Bone & Joint Infections

•Osteomyelitis (OM) is an infection of bone and bone marrow. Deposition of granulation tissue
on walls of lacuna (bone marrow)

•Symptom may include pain in a specific bone with overlying

-> isolate it from bloodstream
(chronic)

redness,hotness,swelling, fever, and weakness.

Antibiotic not effective
Needs debridement
In superficial bone
SA: irritation of nerve endings
•Onset may be sudden or gradual.
OM: buildup of pressure (1-2 days)

•The long bones of the arms and legs are most commonly involved in
children
Diabetic foot, direct spread not hematogenous

• while the feet, spine, and hips are most commonly involved in adults.
•The cause is usually a bacterial infection and rarely a fungal infection.
 Most route of infection
1) Hemato genus Route
common
→

fracture 7 Surgery
2) Direct in#tin → open
invitation
3) Direct spread →
Diabetic foot Pressure
,
sore

•Risks for developing osteomyelitis include diabetes, intravenous Any chronic medical
illness increase risk of

drug use, prior removal of the spleen, and trauma to the area.
infection

•Diagnosis is typically suspected based on symptoms. This is then

supported by blood tests, medical imaging, or bone biopsy.
•Treatment often involves both antimicrobials and surgery.
It may occur via spread from the blood or from
surrounding tissue
Routes of infection
◦Hematogenous (most commonly. After a remote
infection) URTI mc
◦Direct inoculation: open fractures, post surgical
Skin

◦Direct spread: diabetic foot, pressure sore

Bone infections:
1-Acute pyogenic infections (staph. Aureus):
-Pus formation mainly as an abscess
-May spread via lymphatics/blood
Chronic
2-Acute non-pyogenic infections (TB):
-formation of cellular granulomas

3-Chronic infection:
-after an acute one, or start as a chronic
-formation of granulation tissue & fibrosis will take place
classifications
Based on the duration and type of symptoms
§ Acute : < 2 weeks
§Chronic : > 2 weeks
Acute Hematogenous Osteomyelitis
Usually is a disease of children Peds distal femur & Proximal tibial metapheses
Adults spine

Causal organisms
◦ Staph. Aureus (M.C. in both adults and children .)
◦ S. pyogenes (found in chronic skin infections)
◦ S. pneumoniae
◦ H. infleunzae
◦ Gram –ve
◦ Anaerobes
◦ Salmonella especially in sickle cell disease
Pathophysiology: Hematogenous
Progression of Disease
Infection (regardless site) leading to inflammation and exudation Throbbing pain
With every systole

increase intra-osseous pressure and decrease in perfusion pressure Distention of compartment

decrease in blood supply leading to ischemia

thrombosis from pus formation that digests the vessels wall in addition to stasis
from its accumulation
bone
on
¢
Elevation of periosteum also will lead to decreased blood supply ]
On X-RAY → acute mono finding
AT the end → bone necrosis Just soft tissue
swelling
.

of chronic osteomylities
chronic -0 bone
findings
üall these changes lead to decrease in blood supply leading to :-
-ischemia and necrosis > sequestrum ( dead bone ) hyper dense collapsed
trabeculae
New bone formation (the body reacts to the elevation of periosteum as if its a
fracture ) 1st x ray findings 2 wks

-The new bone formed is called involucrum ,(perioseal reaction)

- The increased blood flow will lead to hypo dense areas called rarefaction .
No poles
 elevation was by pus
☆In tumors elevation by
tumor cells .

ios6 his ji ¥ .

é
#

chronic
chronic
Clinical Presentation

History (usually a child )

◦ Pain ( Gradual ), malaise, fever. Acute
◦ History of a preceding URTI/ UTI, skin lesion. Surgery, trauma, open fracture
P/E
◦ Very tender limb
◦ Redness, warmth and edema
◦ Limited Range of motion ( due to pain ) SA no range of motion

Clinical presentation in
◦ Infants (failure to thrive,irritable,tender,refuse feeding ,decrease range of motion)
◦ Adults ( back pain mainly )
Imaging
ØX-ray
For the first 10 days X-ray is normal : no bone findings ( bone edema can be
detected early via MRI , there is only soft tissue edema
ØPeriosteal reaction on X-ray which is the earliest sign of CHRONIC O.M.
ØThe sequestrum appears a bit whiter than normal bone on x-ray; because of
the loss of normal bone structure
ØMRI (bone vs soft tisuue infection ) 100% Sensitive (-ve MRI can rule out O.M)
but not specific
ØFNA : To confirm Dx (not performed if MRI is done)
ØU/S: presence of an abscess
" " ""
"" "ʳᵗ"" bone collapse/ destruction .

.gg
-subperiosteal abscess

-This represented early Staphylococcus

osteomyelitis
 very
MRI sensitive 1001 ,
but not specific
.

water )
Investigations
C detect
if it is doesn't show water means no infection

1. CBC: leukocytosis
2. CRP, ESR: elevated 99% sensitive
*

3. Blood culture ( +ve 30% of cases ) Before giving AB

-

4. Aspiration Biopsy (Good, only 10-15% false negative) painful, preferably do an

MRI before
5. Bone Biopsy for Culture (Definitive diagnosis of osteomyelitis)
6. Anti-staphaylococcus antibodies
Differntial Diagnosis
Cellulitis : mcc is streptococcus pyogen
Septic arthritis
Streptococcal necrotizing myositis
Acute suppurative arthritis
Acute rheumatism 1st attack
Sickle cell crisis
Gaucher’s disease
Treatment
(no role of oral antibiotics)
for ACA
✓
•Systemic IV Antibiotic → Augmentin for 6 weeks, covers most of the
bacteria (two thirds ) that causes acute osteomyelitis, the other ⅓
needs surgical debridement. ← for chronic
• Oral antibiotic have no role in bone infections Bone bioavailability less than soft tissue

•In ER → Cannula : Blood culture (+ve in 30% of cases) , IV fluids then

IV ANTIBIOTICS
Surgical Indications: CAP time to form a new one
1- Controllable drainage
{
No painreleave, fever, CRP remains high, abscess formation

1-
BE Failure to respond to antibiotics within 48 to 72 hrs, the
patient comes with: Persistence of symptoms, Patient is still
febrile, CRP is still elevated.
2- Chronic osteomyelitis.
%
Complications
Chronic osteomyelitis
Septic arthritis
Growth disturbance
Septicemia
DVT
Pulmonary embolism
Subacute Hematogenous
Osteomyelitis
Relatively mild (less virulent organism or patient resistant)
staph
Common sites:
◦ Distal femur
◦ Proximal and distal tibia/ fibula
◦ Distal radius

Clinical picture …child ..dull aching pain for several weeks(>3 months)
,localized pain , near a large joint often nocturnal , alleviated by aspirin
 Brodie’s abscess

◦ A subacute OM, may persist for years before converting to a frank

osteomyelitis (may present after conversion of a draining abscess extending
from the tibia out through the shin ) distal tibia Proximal femur most
. ← common site

◦ Occasionally acute osteomyelitis may be contained to a localized area and

walled off by fibrous and granulation tissue
Brodie’s abscess
◦ Circumscribed, round or oval cavity 1-2 cm in diameter
◦ Most often seen on the tibial or femoral metaphysis
◦ Confused with Osteod osteoma(less than 1 cm)
◦ Treatment :- mainly surgery
◦ Imaging: CT
Brodie’s Abscess
 brodie 's & Osteomytetis by MRI
Diffrenciate between
investigations
WBCs: generally normal.
ESR : elevated in only 50% of patients.
Blood culture: usually negative.
Plain radiographs and bone scans: positive
Chronic Osteomyelitis (>3wks) Fibrin deposition

• Follows acute infection

• Chronic from the start rst
Attack
M.C. Organism: Staph. Aureus Mixed

Sequestra are usually present (pathognomonic of chronic

osteomyelitis)

Caused by:
Ø Acute osteomyelitis
Ø Open fracture
Ø Operation
 Chronic Osteomyelitis
Organisms
-Most common: mixed ( non healthy bone can attract different bacteria ) à 50%
S. Aureus after surgery
- Staph epidermis à metal or screw implant with chronic presentation
less than Tizcdenovoinf )
← .

not
after
3. month -Post op acutely à Staph S. Aureus S pyogens and shigella disentery
More vurelent
surgery a year laterà Staph epidermis Endolent
2 days to cause infection

Less vurelent microorganism

Chronicde novo
3 months - 2 yrs
 < 14 week d- infection don't remove

{
we

# the metal at
surgery
>4 weeks of infection we remove the

Chronic Osteomyelitis metal at

surgery

Clinical Presentation:

ØRecurrent bouts of pain, redness and tenderness.

ØHealed and discharging sinuses.
ØX-ray Bone rarefaction (↓ density) surrounded by dense sclerosis and cortical
thickening.
Ø Sequestrum. ←on X-RAY /most definitive diagnose found for osteomyelitis
-

ØBone scan : reveal hidden foci with inflammatory activity .

Chronic Osteomyelitis
Treatment

Depends on the frequency of relapsing flare-ups.

Surgical
◦ Sequestrectomy
◦ Muscle flap transfer
◦ Ilizarov method (external fixation)
Antibiotics following surgery, not before to avoid altered cultures
 disease
Posttraumatic Osteomyelitis
sickle cell more

Suseptable to Salmonella
Open fractures
bacteria
Staph. Aureus m.c.o ↓envi#ment
saline ✗
Prophylaxis glucose
◦ Irrigation with normal saline or derivatives (3litres in GA I, 6 litres in GAII, 9 litres in GAIII) Ringer lactate ✗
◦ Sterile dressing
Tap water Relativespeakinan.no
Ringer Lactate War conditions
◦ Analgesia (narcotics) 3 carbon atom, bacteria can feeds from it
more sterile

◦ Splint compared to skin

◦ Antibiotics (Augmentin till GA type II add gentamycin ☆A&idini

Or cefiroxim toxic to
ATS- anaphylaxis osteocytes
So don't
TT use it
granulosa
.

E. coli , Sannes
neonatal sepsis -0
. -

most organism
,

below Hear at age

-0

scrums strep pyogen H influenza type B

2-34
.

. ,
→ ,

>3 -0 S . aureus
☆ Give anti tetanus vaccine
-

,
toxic for unvaccinated people

Postoperative Osteomyelitis - Amoxicillin-1 Clarino

acid .

-
Vancomycin -0 S awes
.
with resistance .

ØS. epidemidis is common High affenity to metal

Biofilm 4 before start of infection
Predisposing factors:
◦ Debility
◦ Chronic disease
◦ Previous infection
◦ Steroid therapy
◦ Difficult or long operations
◦ Hematoma formation
◦ Wound tension
◦ Tight dressings or plasters
◦ Use of foreign material.
Treatment (Removal of implants, Abx ttt, revision for arthroscopy)
 Pus inside the bone digesting the ☒ arti /age

Acute Suppurative Arthritis (Septic arthritis) Top emergency

&
pain due
to in orthopedics
Microbiology
nerve

Peds hip
irritation
◦ Staph. aureus Adults knee & Pressure inside the
bone
◦ H. infleunzae (Common in children <4yrs) .

Clinical presentaion
◦ Acute pain and swelling in a single large joint

Local signs:
◦ Superficial joints (tenderness, erythema, swelling)
◦ Pseudoparesis (restricted movement due to pain and spasm)
◦ Picture of septicemia in infants.
 soft tissue infection .

Septic arthritis (acute /

synovitis

most common site in paediatrics is the hip

in adults, theHematogenous
knee. Diabetic foot more than knee

It's a TOP MEDICAL EMERGENCY! Needs to be operated within 8 hours

Route of infection:
oHematogenous
oDissemination from acute osteomyelitis focus
oDissemination from acute soft tissue infection
openetrating injury.
oiatrogenic
Septic arthritis
Imaging
◦ X-ray
◦ Soft tissue swelling, widened joint space, periarticular osteoporosis
◦ Narrowed joint space. Lysis of articular cartilage
◦ Bone destruction Pus 1 wk-- whole epiphysis loss

◦ MRI
◦ Bone scan

Investigations
◦ Joint aspiration (confirmatory)
◦ Blood culture (+ve in 50%) more sensitive than osteomyelitis
◦ CBC, ESR, CRP (not diagnostic)
Septic arthritis Acute infective synovitis

Treatment & Complications

IV antibiotic → oral has no role

Treatment
◦ Drainage
◦ Antibiotics
◦ Augmentin
◦ 3rd generation cephalosporin

Complications :
◦ Dislocation (due to tense effusion)
◦ Epiphyseal destruction (Tom Smith’s dislocation )
◦ Growth disturbance
◦ Ankylosis (late)
 Kocher Criteria to differentiate between
septic arthritis and reactive arthritis
Hip in
← Groin pain with
non Medical Parvovirus 5th disease
1- inability to bear weight (most important )
-

term . RA like pic in pediatric age group

2-T > 37.8

3-ESR > 40 or CRP > 20
4- White Blood Cell Count > 11.8
If all ….. More than 90 % septic arthritis
If nil ….. Less than 10% septic arthritis
If in doubt ….. Deal as septic
Joint aspiration criteria for infection Adults only

White cell count > 50 000 diagnostic of infection >25000 sugesstive

Neutrophils > 90% diagnostic >80% suggestive

Bacteria on gram stain diagnostic
Other causes >50000
Positive culture is pathognomonic Gout ( needle shaped orange - ve birefrenges)
Leukemic infiltrate
Foreign body rxn
we do images & take sample when patient under General
anaesthesia we can do spinal anaesthesia

local (spinal cellulitis

spinal anaesthesia in .

don't do
we
 Tuberculosis brucella ( non caseating granuloma)
-
in causing
Same as
septic

Bones and joints are affected in 5% of TB patients. TB meningitis and military TB

Most common Prevented by vaccine

site
← Vertebral bodies & large synovial joints mainly affected
_

Pathology Kyphosis Compressed vertebra

,

◦ Caseating granuloma
◦ Cold abscess
Vertebral TB
◦ Anterior part of vertebral body
◦ Gibbus On single vertebrae
Joint TB
◦ Chronic monarthritis of a large joint.
◦ Ankylosis
Tuberculosis
Clinical Features
◦ Joint TB Chronic de novo
◦ Pain & swelling
◦ Muscle wasting Knee vastus medialis
Shoulder ifraspinus fossa
◦ Synovial thickening
◦ Movement limitation

◦ Spine TB Ant: groin abcsess, lat: motor and sensory deficit of a nerve root, post: transsection of spinal cord-Potts paraplesis& incontenence
◦ Localized kyphosis
◦ Weakness/ sensory deficit (when pus opens in the spinal canal)
◦ Pott’s paraplegia (if ttt is delayed)
Tuberculosis
X-Rays

◦ Tuberculous arthritis

◦ Soft tissue swelling

◦ Rarefaction of the bone

◦ Narrowed, irregular joint space

◦ Bone erosion.

◦ Cystic lesions
 Tuberculosis
X-Rays
◦ Tuberculous spondylitis:

◦ Localized bone erosion

◦ Collapse in an intervertebral disc

◦ Soft-tissue trace of paravertebral abscesses.

Tuberculosis
Treatment

Antituberculosis chemotherapy
Optic neuritis

◦ Rifampicin, Isoniazid & ethamutol (or pyrazinamide)

◦ for 2 months
Peripheral neuropathy & hepatotoxicity

◦ Rifampicin & isoniazid

◦ for 4 months

Local measures:
◦ Rest, traction, and occasionally operation
 fk
'
Infective bursitis → H
S aureus
Drainage of pus
jig 1
systemic Antibiotic

Thank You