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Bone& Joint sepsis

Bone& Joint sepsis. Relatively common in the peditric population. Defficulties in diagnosis :. Protean manifestations. Joint swelling R.F. Septic. Limp. Tumor. ??????????!!!!!!!!!!!. What antibiotics before culture result? . Diversity of organism Location Associated conditions.

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Bone& Joint sepsis

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  1. Bone& Joint sepsis Relatively common in the peditric population Defficulties in diagnosis : Protean manifestations Joint swelling R.F Septic Limp Tumor ??????????!!!!!!!!!!! What antibiotics before culture result? Diversity of organism Location Associated conditions Surgery If negative culture?? What way & how long

  2. Definition • Osteomyelitis • Arthritis Bone Inflammation Joint BACTERIA But if not? Peltola&Vahanen Morey&Peterson 2 from 4 Criteria Definite Probable Likely

  3. Criteria Pletola&Vahanen Morey&Peterson Puss aspiration from bone DEFINTE:+Cultre from bone or adjacent soft tissue Characteristic histology +Bone or Bloodculture Probable:+Blood culture& clinical or X-Ray Classic symptoms Likely:TypicalClinic&XRay+Response to Antibiotics Local pain, Swelling,Warmth&Limited ROM Roentgenography 2/4

  4. Classification Duration Host response Mechanism Acute Subacute Chronic Exogenous Hematogenous Pyogenic Nonpyogenic Chronic: Medullary Superficial Localized Diffuse Immune system

  5. Septic arthritis 5/6 Morey T>38.3 Pain worse with motion If negative culture Swelling Systematic symptoms No other pathology Response to antibiotics

  6. Epidemiology Osteomyelitis Septic arthritis Childhood Childhood 50 Yr.s Older ages 1/2 Early 10 Late 10s M>F Late summer&Early autumn Changing Race? KIngella Kingae Heamophylus Influenza 1-4 Yr.s Subacute Acute

  7. Etiology The organism must be identified at the site of the disease KOCH Be identified in the produced disease Not found in other disease Produce the disease in other animals Bacteriapathogenicity Necrosis Failoure Trauma Host resistance 30%-50%

  8. Predilection forMales Lower extremities Most rapidly growing ends Peak age incidence !?

  9. Pathophysiology of Osteomelitis Bone Bacteria substrate interacting? No scar Cortical bone 2 types Cancellous bone Regidiy Turbulence Permeable Less cellular less defense Thick priostem Outside blood supply Involecrum

  10. Before ossific nucleus Consequent growth alteration Nucleus presents Growth plate presents

  11. Osteoblasts death Resorption by Osteoclast 12-18 hr. Inflammation Bone resorption Few days Probability of septic joint Priosteal reaction Neglected cases Puss in medullary cavity ? Immunity deficiency

  12. Pathophysiology of Septic Arthritis Vasclar Avascular Joint cartilage Synovium Serum transudate No Basement membrane Culture tube But with defense Amount of bacteria Type of bacteria S.aureus ? 8hr. Live or not Some Bacteria Glycosaminoglycan Hours Proteases Peptidases Collagenases Synovitis Fibrinous exudate Enzymes Cartilage Synovial necrosis Collagen

  13. Septic Arthritis Acutely swollen&painful joint Urgent Diagnosis Hip !!!

  14. Diagnosis History Examination Labratory Pain Imaging Aspiration Position of rest

  15. Lab.Tests • CBC • ESR • CRP Aspiration Not specific 48hrs, 3-5 Days, 3 Weeks 6 hrs, 2Days, 1Week Staph surface Ag.&ab

  16. . Synovial fluid analysis • All studies can be performed with only 1-2ml. Of fluid. • Only a few drops may be adequate for Cx &gram stain Total leukocyte count &Diff Crystal,glucose&proteins Culture & Gram staining Viscosity GrossAppearance No anticuaguant except a few ml. For cytologic study to which is added 2mg potassium oxalate per ml.of fluid.

  17. Imaging • X-ray • CT-Scan • Radionuclide scanning 10-21 Days&30-50% 48 hrs.

  18. Sequestrum

  19. Treatment Identify the organism Infection Select the correct antibiotics Deliver the antibiotics to the organism Stop the tissue distuction Before culture report Age Neonate(1-6 weeks) Streptococcus A&B “ “ . Pneumaniae E.Coli Staphylococcus aureus Culture & antibiogram Cefotaxime Ceftriaxone HIB <4 Yr. Cephtriaxone Kingella kingae septic arthritis Epiphysis Peditrician Oxacillin Cephalosporin Staphylococcus aureus >5 Yr

  20. Antibiotics • Penicillinase-resistant syntetic penicillin+3d generation cephalosporin • Vancomycin or clindamycin+3d generation cephaosporin • Ciprofloxacin+Rifampin in adults & 3d generation cephalosporin • For Salmonella in adults Fluroquinolon may be added • For post traumatics Nafcillin+ciprofloxacin orVancomycin+3d g,c&Carbencillin Cloaxicillin+Cefizoxime Methycillin+Cefriaxone Vancomycin+Cefizoxime Ciprofloxacin+Refampin+Cefizoxime Nafcillin or Ciprofloxacin+Cefriaxon

  21. Deliver the antibiotics to the organism Reaches &kills The course of the disease is resolving No abcess I.V or Orally Well tolerated orally Duration Reliable Parents Penetration Does kill ? 4-6 weeks Osteomyelitis At least 5 days +2-3 additional weeks Septic joint

  22. Principles of surgery • 1-Incision:Only large enough to expose the area of bone envolved. • 2-Subperiosteal abcess drainage. • 3-Bone drilling:It could be enlarged enough to access B.M. Feel&Appearance dictates NORMALITY

  23. Rest the joint in stable position Treatment Antibiotics Adequate drainage Nade

  24. Treatment Large joints:Antibiotics&surgery Small joints:Antibiotics Repeated aspiration!!?? Arthroscopy?

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