Bone& Joint sepsis Septic Limp Tumor Joint swelling R.F What antibiotics before culture result? If negative culture?? What way & how long Surgery Diversity of organism Location Associated conditions

Definition Osteomyelitis Arthritis Inflammation Bone Joint BACTERIA But if not? Peltola&Vahanen Morey&Peterson

Criteria Pletola&VahanenMorey&Peterson Puss aspiration from bone + Bone or Blood culture Classic 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 Duration Mechanism Host response Acute Subacute Chronic Exogenous Hematogenous Pyogenic Nonpyogenic Chronic: Medullary Superficial Localized Diffuse

Morey T>38.3 Pain worse with motion Swelling Systematic symptoms No other pathology Response to antibiotics

Epidemiology Childhood 50 Yr.s Childhood Older ages Late 10s Early 10 M>F Late 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 Males Lower extremities Peak age incidence Most rapidly growing ends

Pathophysiology of Osteomelitis Cortical bone 2 types Cancellous bone Less cellular less defense Thick priostem Outside blood supply Involecrum Turbulence Permeable Bacteria substrate interacting?

Before ossific nucleus Nucleus presents Growth plate presents Consequent growth alteration

Osteoblasts death Resorption by Osteoclast hr. Inflammation Bone resorption Priosteal reaction Few daysProbability of septic joint Puss in medullary cavity ? Neglected cases Immunity deficiency

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

Septic Arthritis

Pain Position of rest

Lab.Tests CBC ESR CRP Not specific 48hrs, 3-5 Days, 3 Weeks 6 hrs, 2Days, 1Week

. Total leukocyte count &DiffCrystal,glucose&proteins Culture & Gram stainingViscosity GrossAppearance No anticuaguant except a few ml. For cytologic study to 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 organism Select the correct antibiotics Deliver the antibiotics to the organism Stop the tissue distuction Age Neonate(1-6 weeks) Streptococcus A&B “ “. Pneumaniae E.Coli Staphylococcus aureus Cefotaxime Ceftriaxone 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+Cefizoxime Methycillin+Cefriaxone Vancomycin+Cefizoxime Ciprofloxacin+Refampin+Cefizoxime Nafcillin 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&Appearance dictates NORMALITY

Adequate drainage Antibiotics Rest the joint in stable position

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