MUSKULOSKELETAL

INFECTION
dr. Henry Pebruanto, SpOT
CURICULUM VITAE
 
EDUCATION UNDER-POST GRADUATE TRAININGS
⦿ Medical Faculty of Udayana University, Denpasar – Bali; 2005
⦿ Orthopaedic Training (Airlangga Univ., Sby/ Udayana Univ., Dps); Jan 12
⦿ Overseas Observership Programme (Hip and Knee Arthroplasty): Perth – WA; Nov 10
⦿ ASEAN Cadaveric Knee Course: Chiang Mai Univ. – Thailand; Apr 12.
⦿ Australian Educational Program (Knee &Shoulder): Sydney – NSW; Jun 12
⦿ ASEAN Cadaveric Knee Course: Bangkok – Thailand; May 14.
⦿ ASEAN EASE (Express Arthroplasty and Arthroscopy Skills Education) Knee Course :
Bangalore – India; May 15.

COURSES
⦿ Advanced Trauma Life Support (Denpasar – Bali); Jan 06
⦿ Basic Orthopedic Skill Course (Surabaya – East Java); Aug 07
⦿ Basic Surgical Skills Course (Surabaya – East Java); Jan 08
⦿ Ultrasonography for Abdominal and Chest Trauma Course (Jakarta); Apr 08
⦿ Total Nutritional Treatment Course (Tanah Lot – Bali); Dec 08
⦿ Basic AO Trauma Course (Nusa Dua – Bali); May 09
⦿ Bali Hand Course (Denpasar – Bali); Jul 09
⦿ Post Graduate Course : Musculoskeletal Trauma (Jakarta); Nov 09
⦿ 8th Annual Meeting of Indonesian Spine Society & 1st International Society for Minimal
Intervention in Spinal Surgery (Denpasar – Bali); Jun 10
COURSES
⦿ Workshop Hemiarthroplasty and Bone Substitute (Malang – East Java); Jun 10
⦿ Ponsetti Course (Denpasar – Bali); Dec 10
⦿ 4th Arthroplasty Workshop : Jump Start on Total Knee Replacement (Jakarta); Apr 11
⦿ 3rd Arthroplasty Workshop : Jump Start on Total Hip Replacement (Jakarta); Apr 11
⦿ AO Spine Principles Course (Jakarta); Jun 11
⦿ Current Diagnosis and Comprehensive Treatment of Brachial Plexus Injury (Surabaya –

East Java); Oct 11

⦿ 3rd Pelvic and Acetabular Course and Workshop (Surabaya – East Java); Oct 11
⦿ Lower Extremity Trauma Course (Denpasar – Bali); Jan 12
 OSTEOMYELITIS
Clinical features
• Occurs more often in children because of their rich
metaphyseal blood supply and thick periosteum.
• More common in boys

 OSTEOMYELITIS
Pathology:
• Most common organism : Staphylococcus aureus
• With the advent of the Haemophilus influenzae vaccination, H.
influenzae ~ less commonly found in musculoskeletal sepsis.
• Kingella kingae infection ~ becoming common in younger age
groups.
• potential cause of culture negative infections—difficult to
isolate;

• need blood culture medium.

• History of trauma common in children with osteomyelitis.
 OSTEOMYELITIS
Pathology:
• Osteomyelitis in children usually begins with hematogenous seeding of a bony metaphysis.

• Small arterioles just beyond the physis

• Blood flow becomes sluggish and phagocytosis is poor.

• Bone abscess (Figure 3-12).

• Pus lifts the thick periosteum —> pressure on the cortex, causing coagulation.

• Chronic bone abscesses ~ surrounded by thick fibrous tissue and sclerotic bone
(Brodie abscess).

• Manifests with a tender, warm, sometimes swollen area over a long-bone metaphysis

• Fever may or may not be present.

• Methicillin-resistant S. aureus (MRSA)

• associated with deep venous thrombosis and septic emboli.

OSTEOMYELITIS
 OSTEOMYELITIS
Diagnosis
• Laboratory tests(blood cultures, WBC count, ESR, CRP).
• Imaging studies
• Radiographs :

• soft tissue edema early, metaphyseal rarefaction late.

• Periosteal new bone appears at 5 to 7 days.

• Osteolysis—30% to 50% loss of bone mineral—day 10 to 14.

• MRI : evaluate for abscess (intraosseous vs. subperiosteal).

• Definitive diagnosis : aspiration or positive clinical picture with

convincing MRI.
 OSTEOMYELITIS
Treatment
• IV antibiotics ~ best initial treatment.
• If no subperiosteal abscess or abscess within the bone
• Broad-spectrum antibiotics followed by antibiotics specific ~ organism cultured
from percutaneous aspiration/biopsy.
• CRP : to monitor the therapeutic response to antibiotics.
• Failure to decline within 48 to 72 hours warrants alteration in treatment.
• necessitates operative drainage and débridement.
• Drilling the metaphysis ~ draining some of the infection.
• Specimens ~ histologic study and culture.
• Antibiotics : until the ESR (or CRP level) normal (4 to 6 weeks).
 SEPTIC ARTHRITIS
Clinical features 


• Can develop from osteomyelitis

• Especially in neonates

• transphyseal vessels allow proximal spread into the joint in joints with
an intraarticular metaphysis (hip, elbow, shoulder, ankle)

• as a result of hematogenous spread of infection.

• Because pus is chondrolytic, septic arthritis in children is an acute

surgical emergency.

• Most frequently occurs in children < 2 years.

SEPTIC ARTHRITIS
 SEPTIC ARTHRITIS
Clinical features 


• Infecting organisms vary with age.

• Septic arthritis manifests as a much more acute process

than osteomyelitis.

• Decreased ROM and severe pain with passive motion may

be accompanied by systemic symptoms of infection.
SEPTIC ARTHRITIS
 SEPTIC ARTHRITIS
Diagnosis and Radiographic findings:

• Radiographs : widened joint space or even dislocation.

• Joint fluid aspirate :

• high WBC count (>50,000/mm3);

• glucose level may be 50 mg/dL lower than in serum;

• lactic acid level : high.

 SEPTIC ARTHRITIS
Clinical Features 


• DD septic arthritis of the hip VS transient synovitis

• 3 of 4 of the following criteria are present, the diagnosis of septic

arthritis is made in > 90% of cases:
• WBC count higher than 12,000 cells/mL,

• ESR higher than 40,

• inability to bear weight,
• temperature higher than 101.5° F (38.6° C) (Kocher criteria).

• • Ultrasonography : effusion.
 SEPTIC ARTHRITIS
Clinical Features 


• Lumbar puncture : when sepsis is caused by H. influenzae.

• Prognosis is usually good except in patients with a delayed diagnosis.

• N. gonorrhoeae septic arthritis :

• migratory polyarthralgia,

• small red papules, and

• multiple joint involvement.

• WBC response (<50,000 cells/mL).

• usually does not necessitate surgical drainage.

• Treatment : Large doses of penicillin.

 SEPTIC ARTHRITIS
Treatment
• aspiration + irrigation + débridement in major joints
(especially in the hip)
• culture of synovium.
PYOGENIC TENOSYNOVITIS
• Infection of flexor tendon sheath
• May occur in delayed fashion after penetrating trauma
• S. aureus is most common pathogen

• Kanavel signs (four):

• Flexed resting posture of digit

• Fusiform swelling of digit

• Tenderness of flexor tendon sheath

• Pain with passive digit extension

PYOGENIC TENOSYNOVITIS
• Patient should be admitted and treated with splinting, IV
antibiotics, and close observation
• If signs improve within first 24 hours, surgery may be
avoided.
• Otherwise, the treatment of choice is incision and drainage
of flexor tendon sheath.

• full open exposure using long midaxial or Bruner incision or

with two small incisions placed distally (open A5 pulley) and
proximally (open A1 pulley) using an angiocatheter (Figure
7-70)
PYOGENIC TENOSYNOVITIS
• Index and thumb FTS ~ can spread to deep thenar space.
• Long, ring, and small finger FTS ~ can spread to the midpalmar space.
• Small finger FTS ~ can spread to the ulnar bursa.

• Classical “horseshoe abscess” ~ based on proximal communication

between the thumb and small finger flexor tendon sheaths in the
Parona space, a potential space between the pronator quadratus
and FDP tendons.

• Aggressive postoperative hand therapy.

THANK YOU