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Poorly defined
Direct inoculation
Hematogenous spread
Local invasion
Pathophysiology
Infection
Starts in Metaphysis
• Arteriole Loop / Venous Lakes
Spread via Volkman’s canal / Haversian system
Endothelium Leaks
Pathophysiology
Few phagocytes in Zone of
Hypertrophy
Rabbit experiment
IV injection of bacteria
With # start in hematoma
Pathophysiology
Role of growth plate
Over 18/12
Impermeable to spread
Under 18/12 infection crosses growth plate
Pathophysiology
Pathophysiology
1st osteoblasts die
Lymphocytes release osteoclast activating
factor
Hole in bone
Diagnosis
Pain
Neonate peudoparalysis
NWB
Failure to use limb
Fever
Lethargy
Anorexia
CBC Diff
ESR
CRP
Blood Culture
Pathophysiology
WBC increased 30-40%
+ 30-60%
Decreased with antibiotic
Multiple cultures no significant increase in
yield
48 hours to get most organisms
Diagnosis
Pus aspiration
70% bone + cultures
Septic arthritis
• Gram stain
• Lymphocyte count
• % polymorphs
> 80 000 = Septic arthritis
> 50 000 in some series
80 000 also in JRA
Diagnosis
Do blood and joint cultures
Indium
I131 leucocytes
24hrs to prepare
Monoclonal antibodies
Not proven to be better
Radiology
MRI
Sensitivity 83-100%
Specificity 75-100%
PPV = Tc99
Timing !!
Early antibiotic before necrosis / pus then sx
less likely to be needed
Treatment
Antibiotic treatment
Parenteral / oral combinations
Often empirical
Serum level more important than route
Newer studies
Follow CRP
Shorter period of tx needed
IV 5d / total 23 d tx
Cephalosporin 150mg/kd/day
Treatment
Neonates
No studies, little evidence
CRP / ESR not reliable
Oral absorption not reliable
Therefore IV neonates
Cloxacillin
Treatment
Longer treatment required
Pelvis
Vertebrae
Diskitis
Calcaneus
Treatment
Surgical intervention
Controversial indications
Hole in bone not always Sx
If purulent aspirate Sx necessary
Subperiosteal Abscess
Soft Tissue abscess
Bone Abscess
Failure of clinical response to antibiotic
Associated septic arthritis
Complications
Infection Complications
Recurrence
Chronic osteo
Pathologic fracture
Growth plate injury
Antibiotic Complications
Diarrhea
N+V
Rash
Thrombocytopenia
Neutropenia