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Bone and Joint Infection

Bone and Joint Infection. Prof. Mamoun Kremli AlMaarefa College. Objectives. Understand the Pathogenesis, clinical picture, and principles of management of Acute osteomyelitis Chronic osteomyelitis Chronic specific osteomyelitis – TB Acute septic arthritis. Infection in Bone.

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Bone and Joint Infection

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  1. Bone and Joint Infection Prof. Mamoun Kremli AlMaarefa College

  2. Objectives Understand the • Pathogenesis, • clinical picture, and • principles of management of • Acute osteomyelitis • Chronic osteomyelitis • Chronic specific osteomyelitis – TB • Acute septic arthritis

  3. Infection in Bone • Osteomyelitis (Bone and marrow infection): • Osteo = bone • myel = bone marrow • itis = inflammation • Acute • Sub-acute • Chronic • Specific (e,g. TB, Brucellosis, Fungal) • Non specific (most common)

  4. Route of Infection Micro-organisms may reach the musculoskeletal tissues by: • Indirect spread via blood stream from a distant site • The commonest • Prick, injection, boil, distant wound infection • Nose, mouth, respiratory tract, bowel, genitourinary tract • Direct spread from a contiguous focus of infection • Direct implantation from trauma or surgery Slide Atlas of Orthop Radiology, A Greenspan. Gower Med Publ.

  5. Factors and Types • Factors affecting type and severity: • Type of invader • Site of infection • Host response • Types • Pyogenicosteomyelitis • Septic arthritis • Chronicgranulomatous reaction • Tuberculosisof bone or joint • Indolent response to unusual organism • Fungal infection

  6. Pathology • Infection: Multiplication and spread of pathogenic organisms within the body tissues • Inflammatory reaction: Acute / Subacute / Chronic • Redness, heat, swelling, pain, loss of function http://sphweb.bumc.bu.edu/

  7. Pathology • Bone infection is different from soft-tissue infection: • Bone consists of rigid compartments • Pressure is increased in acute inflammation • More vascular damage and cell death because of the tight compartments • If not rapidly suppressed, will lead to necrosis

  8. Principles of Treatment • Analgesia, rest, general supportive measures • Identify organism, use effective antibiotics or chemotherapy • Release pus as soon as it is detected, and remove avascular and necrotic tissue • Stabilize the bone if fractured

  9. Acute pyogenic bone infection • Pathology: • Formation of pus • a concentrate of defunct leucocytes, dead and dying bacteria and tissue debris • Localized in an abscess. Pressure builds up (tight space) • Local spread • Through the cortex • Along adjacent tissue planes • Nearby joint • Distant spread • via lymphatics • causing lymphangitis & lymphadenopathy • via the blood stream (bacteremia & septicemia) Apley,s System of Orthop & Fractures

  10. Principles of Treatment • Acute infections, if treated early with effective antibiotics, can usually be cured • Operative drainage needed once there is pus and bone necrosis

  11. Acute haematogenous OM • Mostly children • Boys> girls • History of trauma often present • ? Micro-hematoma, ? insignificant

  12. Acute OM - source of infection Hematological (the commonest) • Infants: • infected umbilical cord • Children: • Boils, tonsillitis, skin abrasions, pricks, … • Adults: • UTI, urinary catheter, indwelling arterial line, septic tooth, dirty needle…

  13. Acute OM - organisms • Gram +ve • Staphylococcus aureus(70%) • Streptococcus pyogenes • Streptococcus pneumoniae • Gram –ve • Haemophilusinfluenzae (50% < 4 y) • Escherichiacoli • Pseudomonas aeruginosa • Proteus mirabilis • Salmonella species in patients with sickle cell disease (why?) http://pedemmorsels.com http://pedemmorsels.com

  14. Acute OM - children • Metaphysis of long bones • Upper tibia, proximal or distal femur • ?Trauma • Peculiar arrangement of blood vessels • Terminal arteries twist back in hairpin loops • Vascular stasis • Lowered oxygen tension www.heightquest.com http://cnx.org

  15. Acute OM - children • Metaphysis of long bones • In infants, infection may reach Epiphysis • anastomoses between metaphyseal and epiphyseal blood vessels www.heightquest.com

  16. Acute OM - pathology • Inflammation: • Intra-osseous pressure rises • Sever pain & obstruction of blood flow • Suppuration • Pus from day 2 • Sub-periosteal pus collection • Re-enters bone • To soft tissue • To joint • In infants • In joints where metaphysis is partly intra-capsular • Hip, shoulder, elbow www0.sun.ac.za

  17. Acute OM - pathology • May spread to the joint causing Septic Arthritis • In infants • In joints where metaphysis is partly intra-capsular • Hip, shoulder, elbow Essentials of Orthop Surgery, S Weisel, J Delahay. Saunders

  18. Acute OM - pathology • Necrosis (7 days) • Blood supply compromised by raised pressure, stasis, thrombosis, periosteal stripping • Sequestrum formation (dead bone) • New bone formation • Sub-periosteal • Involucrum formation • Resolution • If infection controlled, & pressure released

  19. Clinical Features - Children • Severe pain • Malaise • Fever • Reluctant to move • Toxemia • History of previous source of infection • Sore throat, skin infection, prick, injury

  20. Clinical Features - Children • Localized pinpoint tenderness • Hotness • Local redness, swelling, edema (late signs) • Reduced range of motion http://quizlet.com

  21. Clinical Features - Infants • Constitutional symptoms may be mild • Failure to thrive, drowsy, irritable • Metaphyseal tenderness • Decreased ROM • Commonest around the knee • History of other infections (umbilical)

  22. Clinical Features - Adults • Commonly thoracolumbar spine • Fever • Backache • History of UTI or urological procedure • Old ,diabetic, immune-compromised,

  23. Diagnosis • History and clinical examination • WBC, ESR, CRP • X-ray (normal in the first (10-14) days • Ultrasound • Bone Scan Tc 99, Gallium 67 • MRI • Aspiration

  24. Acute OM - x-rays • First sign (10-14 days) • Metaphyseal rarefaction • Periosteal reaction (new bone formation) Apley,s System of Orthop & Fractures

  25. Acute OM - x-rays • First sign (10-14 days) • Metaphyseal rarefaction • Periosteal reaction (new bone formation) • Later • Increasing ragged appearance (mottling) • Sclerosis, rarefaction • Cavitation • Sequestrum • Involucrum: new bone formation

  26. Acute OM - ultrasound • Detects sub-periosteal pus collection Osteomyelitis. Mauricio Baptista

  27. Acute OM - Bone scan • Increased activity – early Osteomyelitis. Mauricio Baptista

  28. Acute OM – MRI • Distinguish bet. bone & soft tissue infection • Perfect to detect early signs of infection – replacing bone scan Osteomyelitis. Mauricio Baptista

  29. Acute OM – other tests • WBC: leukocytosis, neutrophils • C-reactive protein: rises very early • ESR: raises several days • Blood culture • Aspiration from sub-periosteal collection or joint • Good, even if no pus • Smear for cells and bacteria • Culture / sensitivity

  30. Differential Diagnosis • Cellulitis • Acute septic arthritis • Acute rheumatism • Sickle cell crisis

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