Maksum Pandelima, MD

Soepraoen Army Hospital

Malang
 Musculoskeletal infection remain
a common challenge.
Even though morbidity &
mortality have dropped by using
by antibiotics.
 Orthopaedic infections may be cured
& deformity and disability prevented
with:
- Early diagnosis.
- Appropriate antibiotic
therapy.
- Surgical intervention.
 Pain
Fever
Swelling
Tenderness
 Can be examined from several perspectives:
- Patient age (neonatal, childhood, adult).
- Causative organism (pyogenic or
granulomatous).
- Nature of onset (acute, subacute,
chronic).
- Route of infection (hematogenous, direct,
contiguous spread).
 AHO has decreased over resent
decades.
Prompt diagnosis and treatment
remains unchanged.
 Rheumatic fever.
Septic arthritis.
Cellulitis.
Malignancy (Ewings sarcoma &
leukemia).
Thrombophlebitis.
Sickle-cell crisis.
Gauchers disease.
Toxic synovitis.
(Richard, B.S. 1996)
Neonates : Staphylococcus aureus,
Group B streptococcus,
gram-negative colliform.

Infant & Children : Staphylococcus

aureus.
 Clinical.
Laboratory.
Radiological.
 Fever and unexplained pain.
Refused to move the limb.
Tenderness over the involved bone.
Decreased ROM in adjacent joint.
Swelling, erythema, warmth.
 WBC not reliable indicator.
ESR elevated in over 90%.
C-reactive protein (CRP) over 19mg/l.
Blood cultures are positive 40 50%.
Aspiration of the affected site.
 Plain radiographs.
Bone scan.
CT-Scan.
Magnetic resonance imaging (MRI).
Ultrasound.
 Plain radiographs may show soft
tissue swelling within 3 days, but
bone changes do not appear for 7 to
14 days.
 Bed rest and analgesic.
Supportive therapy (IV fluids).
Local rest for the involved extremity.
Antibacterial therapy.
Surgical decompression (if after 24
hours not improved).
Antibacterial is continued for 4 6
weeks (ESR or CRP normal).
 The time interval between the onset of
infection and the institution of treatment.
The effectiveness of the antibacterial drug
against the specific causative bacteria.
The dosage of the antibacterial drug.
The duration of antibacterial therapy.
 Several anatomic features.
The metaphyseal vessels
communicate with the epiphyseal
vessel.
Septic arthritis and AHO often
together.
 The metaphyses of the hip, proximal
humerus, proximal radius and distal
lateral tibia are intra-articular.
Thrombosis of the vessel may cause
ischemia of epiphyseal growth plate.
 Complete ischemia and lysis of the
physis before ossification of the
femoral head, may result necrosis
and reabsorbtion of femoral head.
 The immune system of neonate is
immature, inflammatory response is
compromised.
 Have only minimal symptoms,
malaise, failure to gain weight.
There may be no fever.
Soft tissue swelling and
pseudoparalysis.
Detection of infection is often
delayed.
Multiple site of infection 40%.
 WBC count and ESR may be normal.
It is important to aspirate and
culture.
Staphyloccocus aureus the most
prevalent microorganism, but
recently group B Strepto-ccocus.
 Osteonecrosis of epiphysis.
Joint dislocation.
Premature physeal arrest.
 SHO is the cause of nearly one third of
primary bone infection.
Insidious onset.
Mild symptoms.
Longer duration.
Inconclusive laboratory data.
Can cross the growth plate.
Rarely causes permanent damage.
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Subacute Acute
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Pain Mild Severe
Fever Few patients Majority of patients
Loss of function Minimal Marked
Prior Antibiotic therapy Often (30 -40%) Occasionally
Elevated WBC count Few Majority of patient
Elevated ESR Majority of patient Majority of patient
Blood cultures Few positive 50% positive
Bone cultures 60% positive 85% positive
Initial radiographs Frequently abnormal Often normal
Site Any location (may cross Usually metaphysis
physis)
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 Ewings sarcoma.
Metastatic neuroblastoma.
Malignant round cell tumor.
Osteoid osteoma.
 Cultures are frequently negative.
Staphylococcus species is the
common microorganism.
A biopsy is usually required to rule
out tumor and provide a definitive
diagnosis.
 Most patient respond to a single
course of antibiotic.
A positive culture or failure to
respond to antibiotic indicates for :
Curettage, draindage of abcesses,
and sequestrectomy.
 Despite adequate drainage of pus and
intensive antibiotic therapy, with acute
osteomyelitis, develop chronic
osteomyelitis.
With cavities, sequestra, and sinusis.
S. aureus are the common micro-organism.
 Plain X-ray and CT.
To identify the number and extent of
infected cavities and location of
sequestra.
 A : Healthy.
Bs : Compromised due to
systemic factors.
Bl : Compromised due to local
factors.
Bls : Compromised due to local
& systemic factors.
C : Treatment worse than the
disease.
 Antibiotic.

Local treatment.

Surgery.
 Septic Arthritis (SA) requires
urgent treatment.
The duration of symptoms prior
to treatment is the most
important prognostic factor for
outcome.
 Trantient synovitis.
Rheumatic fever.
Hemarthrosis.
Juvenile arthritis.
Cellulitis.
Osteomyelitis.
Hemophilia.
Leg-Calve-Perthes disease.
 Insidence:
- More common in boys than in
girl.
- Children younger than 2
years.
- The hip, knee, ankle, elbow,
90% of affected joint.
 High temperature (38 400 C).
Asymetric posturing of the extremity.
Restricted joint motion.
Tenderness.
Joint warmth.
Effusion.
 WBC count is elevated in 30% to
60% with a left shift.
The ESR usually higher (sensitive
test).
C-reactive protein (CRP).
Blood cultures are positive in
40% - 50%.
Needle aspiration.
_______________________________________________
Neonate Group B Streptococcus
species, Stap. aureus,
gram neg. coliform.
Infant 4 years Stap aureus,
pneumococcus, Group A
strep, Haemophilus
influen B.
Over age 4 years Stap. aureus,
gonococcus.
 Plain radiography.
Bone scan (technetium bone scan).
Ultrasound.
 The first priority is aspirate the joint
and examine the fluid.
Plant of treatment:
1. General supportive care.
2. Local rest.
3. Antibiotic.
4. Drainage.
 Children under 4 years: high
incidence of Haemophilus infection
--- Ampicillin or Cephalosporins.
Older children: Flucloxacillin and
Fusidic acid.
 Aspiration.
Small incision --- drainage and
washed out. Advisable in :
1. In very young infant.
2. In the hip joint.
3. Pus is very thick.