Bone& Joint sepsis

SepticLimp Tumor

Joint swelling R.F

What antibiotics before culture result?

If negative culture??

What way & how long

Surgery Diversity of organismLocationAssociated conditions

Definition• Osteomyelitis

• ArthritisInflammation

Bone

Joint

BACTERIA But if not?

Peltola&VahanenMorey&Peterson

CriteriaPletola&Vahanen Morey&Peterson

Puss aspiration from bone

+Bone or Blood cultureClassic symptoms

Local pain, Swelling,Warmth&Limited ROM

Roentgenography

DEFINTE:+Cultre from bone or adjacent soft tissue Characteristic histology

Probable:+Blood culture& clinical or X-Ray

Likely:TypicalClinic&X Ray+Response to Antibiotics

Classification

DurationMechanism Host response

AcuteSubacuteChronic

ExogenousHematogenous

PyogenicNonpyogenicChronic:

MedullarySuperficialLocalizedDiffuse

MoreyT>38.3Pain worse with motion

SwellingSystematic symptomsNo other pathology

Response to antibiotics

Epidemiology

Childhood 50 Yr.s Childhood Older ages

Late 10s Early 10

M>FLate summer&Early autumn

Race?

Heamophylus Influenza 1-4 Yr.s

KIngella Kingae

Etiology

KOCH

The organism must be identified at the site of the disease

Not found in other disease

Produce the disease in other animals

Be identified in the produced disease

30%-50%

Predilection for MalesLower extremities

Peak age incidence

Most rapidly growing ends

Pathophysiology of Osteomelitis

Cortical bone 2 typesCancellous bone

Less cellular less defense

Thick priostemOutside blood supply

Involecrum

Turbulence

Permeable

Bacteria substrate interacting?

Before ossific nucleus

Nucleus presents

Growth plate presents

Consequent growth alteration

Osteoblasts death

Resorption by Osteoclast 12-18 hr.

Inflammation

Bone resorption

Priosteal reactionFew days Probability of septic joint

Puss in medullary cavity ?Neglected cases

Immunity deficiency

Pathophysiology of Septic Arthritis

SynoviumVasclar

No Basement membrane

Serum transudate Avascular Joint cartilage

But with defense

S.aureus

SynovitisFibrinous exudate

Synovial necrosis

EnzymesProteasesPeptidasesCollagenases

Some BacteriaGlycosaminoglycan

Collagen

8hr.

Live or not

Septic Arthritis

Pain

Position of rest

Lab.Tests

• CBC• ESR

• CRP

Not specific48hrs, 3-5 Days, 3 Weeks

6 hrs, 2Days, 1Week

• .

Total leukocyte count &Diff Crystal,glucose&proteins

Culture & Gram staining Viscosity

GrossAppearance

No anticuaguant except a few ml. For cytologic studyto which is added 2mg potassium oxalate per ml.of fluid.

All studies can be performed with only 1-2ml. Of fluid.

Only a few drops may be adequate for Cx &gram stain

Synovial fluid analysis

Imaging

• X-ray

• CT-Scan

• Radionuclide scanning

Sequestrum

Identify the organismSelect the correct antibiotics

Deliver the antibiotics to the organismStop the tissue distuction

Age Neonate(1-6 weeks)Streptococcus A&B“ “ . PneumaniaeE.ColiStaphylococcus aureus

CefotaximeCeftriaxone

HIB

Kingella kingae

Staphylococcus aureus

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+CefizoximeMethycillin+CefriaxoneVancomycin+CefizoximeCiprofloxacin+Refampin+CefizoximeNafcillin or Ciprofloxacin+Cefriaxon

Deliver the antibiotics to the organism

I.V or Orally

Duration

Penetration

Does kill ?

The course of the disease is resolving

No abcess

Well tolerated orally

Reliable Parents

4-6 weeks

+2-3 additional weeks

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&Appearancedictates NORMALITY

Adequate drainage Antibiotics

Rest the joint in stable position

Large joints:Antibiotics&surgery

Small joints:Antibiotics

Repeated aspiration!!?? Arthroscopy?