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Pyogenic Bone and Joint Infection

Pyogenic Bone and Joint Infection. Abdulaziz Al-Ahaideb FRCSC. According to the host response, infections of the bone are divided into: Pyogenic and granulomatous Pyogenic infections Acute and chronic osteomyelitis Septic arthritis

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Pyogenic Bone and Joint Infection

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  1. Pyogenic Bone and Joint Infection Abdulaziz Al-Ahaideb FRCSC

  2. According to the host response, infections of the bone are divided into: Pyogenic and granulomatous • Pyogenic infections • Acute and chronic osteomyelitis • Septic arthritis • Granulomatous infections (e.g. TB, syphilis ) will be covered in the other lecture

  3. Acute osteomyelitis • Classification • Duration: • Acute • Subacute • Chronic • Route of Infection: • Hematogenous • Exogenous

  4. Acute osteomyelitis • Definition: • Osteomyelitis is an inflammation of bone caused by an infecting organism. • It may remain: • Localized • Spread to: • Marrow • Cortex • Periosteum • Soft tissue

  5. Acute osteomyelitis • Organism: • Neonates: Staph aureus, Strep, E coli • Children: Staph aureus, E coli, Serratia, Pseudomona ( Hem. Infl < 4 yrs) • Sicklers: Staph aureus, Salmonella (most unique) • Drug addicts: Staph aureus, Pseudomonas (most unique)

  6. Acute osteomyelitis • Organism: the commonest is staph. Aureus • Source of infection: Hematogenous, direct extension, direct from outside • Incidence: • Age: more in children • Sex: Boys> Girls • Site of infection: metaphysis • Bones: commonest are tibia and femur

  7. Pathology • Hematogenous colonisation of the bones by bacteria • Stage of inflammation • Spread of infection with pus formation • Formation of subperiosteal abscess • Pus tracks towards skin to form a sinus • Bone infarction (Sequestrum) • Subperiosteal new bone formation (Involucrum)

  8. Involucrum is seen in the distal fibula

  9. Involucrum is seen in the distal fibula

  10. This lateral radiograph of the humerus was done four months after the onset of osteomyelitis. Reactive bone beneath the periosteum forms the involucrum about the central abscess in the medullary canal.

  11. This x-rays show sequestra

  12. Pathology and age variation • Neonates: • Extensive bone necrosis • Increased ability to absorb large sequestrum • Increased ability to remodel • Epiphysio-metaphyseal vascular connection • Secondary septic arthritis

  13. Pathology and age variation • Adults: No subperiosteal abscess Adherent periosteum Soft tissue abscess Vascular connection with the joint Secondary septic arthritis

  14. Clinical Picture • History: Skin lesion Sore throat Trauma

  15. Clinical Picture • Symptoms: • Pain • Fever • Restlessness • Vomiting • The limb is held still • Malaise

  16. Clinical Picture • General signs: • Looks ill • Fever • Tachycardia • Local signs: • Look, feel and move

  17. Laboratory tests • CBC • ESR • C-reactive protein (most sensitive) • Blood cultures (positive up to 50 %) • Aspiration (send for Gram stain and C&S)

  18. Radiography • Plain x-rays (Normal in the first ten days, after that resorption of affected bone and sub-periosteal new bone formation) • Bone scan (very sensitive but not specific) • Gallium scan • Ultrasound • MRI

  19. Acute osteomyelitis An AP radiograph shows the radiolucency of acute osteomyelitis

  20. Differential Diagnosis • Acute septic arthritis • Cellulitis • Ewing’s Sarcoma • Sickle cell bone crisis • Acute rheumatoid arthritis

  21. Treatment • General: • Admission • Hydration • Correction of electrolyte imbalance • Analgeics • Immobilization

  22. Treatment • Antibiotics: • Type ? • Route ? • When to start ? • When to stop ? • Monitoring ?

  23. Surgical treatment • Drainage: • Indications ? • Drilling ? • Skin closure ? • Second look ?

  24. Chronic osteomyelitis

  25. Chronic osteomyelitis Draining sinus from a sequestrum

  26. Septic Arthritis • May affect any age and any joint • The hip and knee are the most affected • Pathology: hematogenous or from the bone • In neonates: transphyseal vessels • In joints where the metaphysis is intracapsular (Hip, shoulder, proximal radius and distal fibula)

  27. Septic Arthritis • Symptoms : like AO • Signs: hot swollen joint which is painful to any motion, inability to bear weight

  28. Investigations: CBC,ESR and CRP • Organisms: similar to AO • Rx: Arthrotomy and washout + Antibiotics (similar to AO) • Main DDx: transient synovitis of the hip

  29. The End

  30. Scenarios • 2 year-old boy presented to the ER with painful swollen Right knee for 2 days

  31. 3 year-old girl, brought to the ER because she is unable to weight bear on the Lt lower extremity

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