2. Bone & Joint Infections Dr. Mohamed M. Zamzam Associate Professor & Consultant Pediatric Orthopedic Surgeon

3. Osteomyelitis The term osteomyelitis does not specify the causative organism or the disease process

4. Osteomyelitis Classification: Duration Acute, Subacute or Chronic Route of infection Hematogenous or Exogenous Host response Pyogenic or Granulomatous

5. Acute Pyogenic Osteomyelitis Definition: AO is an infection of bone involving the periosteum, cortical bone and the medullary cavity.

6. Acute Pyogenic Osteomyelitis Incidence: Age more in children Sex boys > girls Bone affected all bones Site of infection metaphysis

7. Acute Pyogenic Osteomyelitis Organism: Neonates: Staph aureus, Strept, E coli Children: Staph aureus, E coli, Serriata, Pseudomonas, H inf Sickle-cell anemia: Staph aureus, Salmonella

8. Acute Pyogenic Osteomyelitis Source of Infection: Hematogenous Direct spread Exogenous

10. Acute Pyogenic Osteomyelitis Pathology: Primary focus and stage of inflammation Spread of infection with pus formation Formation of subperiosteal abscess Pus tracks toward skin to form a sinus Bone infarction (Sequestrum) New bone formation (involucrum)

13. Acute Pyogenic Osteomyelitis Age variation Neonates: Extensive bone necrosis Increased ability to absorb large sequestrum Increased ability to remodel Epiphysio-metaphyseal vascular connection leading to secondary septic arthritis

14. Acute Pyogenic Osteomyelitis Age variation Adults: No subperiosteal abscess due to adherent periosteum Soft tissue abscess Vascular connection with the joint leading to secondary septic arthritis

15. Acute Pyogenic Osteomyelitis Clinical Pictures History: Skin lesion Sore throat Trauma

16. Acute Pyogenic Osteomyelitis Clinical Pictures Symptoms: Pain, restless Malaise and fever The limb is held still (pseudo paralysis) Sometimes mild or absent (neonates)

17. Acute Pyogenic Osteomyelitis Clinical Pictures Signs: General and Local Laboratory Tests: –CBC –ESR+CRP –Blood culture (+ve in 50-70%) –Aspiration (Gram stain + culture and sensitivity)

18. Acute Pyogenic Osteomyelitis Radiography Plain X-ray Ultrasound Bone & gallium scan (Sensitive but not specific) CT scan MRI

23. Acute Pyogenic Osteomyelitis Differential Diagnosis Acute Septic Arthritis Acute monoarticular rheumatoid arthritis Sickle cell crisis Cellulitis Ewing’s Sarcoma

24. Acute Pyogenic Osteomyelitis Treatment General: Hospitalization Hydration Electrolyte replacement Analgesia Immobilization

25. Acute Pyogenic Osteomyelitis Treatment Antibiotics: Type? Route? When to start? When to stop Monitoring?

26. Acute Pyogenic Osteomyelitis Treatment Surgical Drainage: Indications? Procedure? Drilling?

27. Acute Pyogenic Osteomyelitis Prognosis Factors affecting prognosis: Organisms Infected Bone Age of the Patient Treatment

28. Acute Pyogenic Osteomyelitis Complications Septicemia & metastatic abscesses Septic arthritis Growth disturbance (children) Pathological fracture Chronic osteomyelitis

34. Subacute Osteomyelitis Longer history and less virulent organism Insidious onset, Mild symptoms Pain is the most consistent symptom Usually no constitutional symptoms

35. Subacute Osteomyelitis Abnormal initial radiographs Inconclusive laboratory data Negative cultures/ biopsy Difficult to distinguish from bone tumors e.g. Ewing’s, osteosarcoma

41. Chronic Osteomyelitis Factors responsible for chronicity Local factors: Cavity, Sequestrum, Sinus, Foreign body, Degree of bone necrosis General: Nutritional status of the involved tissues, vascular disease, DM, low immunity Organism: Virulence Treatment: Appropriateness and compliance Risk factors: Penetrating trauma, prosthesis, Animal bite

42. Chronic Osteomyelitis Types A complication of acute Osteomyelitis Post traumatic Post operative

47. Chronic Osteomyelitis Clinical picture Continuous or intermittent suppuration and sinus formation with acute exacerbations. Pain, fever, redness, and tenderness during acute exacerbations. Discharging sinus with +ve/-ve culture. Pathological fracture.

49. Chronic Osteomyelitis Investigation Lab tests/ culture Plain X-ray: Bone rarefaction surrounded by the dense sclerosis, sequestration and cavity formation Sinogram Bone scan & gallium scan To detect chronic multifocal osteomyelitis CT Scan & MRI Biopsy

55. Chronic Osteomyelitis Treatment Antibiotics Surgical treatment Preoperative assessment & preparation Derbridement Sequestrectomy Local antibiotics Stability Treatment of bone cavity

58. Chronic Osteomyelitis Complications Recurrence & Recurrence & Recurrence Pathological fractures Growth disturbance Amyloid disease Epidermoid carcinoma of the fistula

66. Septic Arthritis Septic arthritis is an infection of the joint usually bacterial, as viral arthritis is usually self limiting and treatment is supportive. 50% of cases in children <3 years The hip joint is the common site in <3years, whereas the knee joint is more common in older children.

67. Septic Arthritis Acute Septic Arthritis Organism? Route of infection? Pathology: Serous or acute synovitis Serofibrinous Suppurative (purulent) arthritis

68. Septic Arthritis Acute Septic Arthritis Clinical Pictures General manifestations: constitutional symptoms and signs of acute infection Local manifestation: Swelling, hotness and redness Deformity with muscle spasm Restriction of all movements of the joint The joint is fixed in the position of ease

69. Septic Arthritis Acute Septic Arthritis Investigations Lab tests/ cultures Plain X-ray Bone scan & Gallium scan Ultrasound Aspiration: if WBC >50,000with >90% PMNLs suspect septic arthritis even if culture is negative.

70. Septic Arthritis Acute Septic Arthritis Differential Diagnosis Acute osteomyelitis Transient synovitis of the hip (<10) Acute rheumatic fever Haemoarthrosis Haemophilic arthritis

71. Septic Arthritis Acute Septic Arthritis Treatment Aspiration Antibiotics Splintage Surgical drainage Treatment of complications

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