Musculoskeletal Infection

Punto Dewo
Dept. of Orthopaedics & Traumatology
Bone and Joint Infection
Osteomyelitis
Septic arthritis
How do infecting organisms enter
bones or joints
Hematogenous spread
Inoculation through wounds
Extension from adjacent infected
structures
Inoculation
through
traumatic
wounds,
operations
Extension
from adjacent
infected
structures
Hematogenous spread
Bacteremia
Sluggish circulation in metaphysis
(in children)
Foci spread subperiosteal
abscess () draining sinus
(infants) foci spread through
growth plate

Involucrum : new bone formation
encircling cortical shaft
Sequestrum : dead bone surrounded by pus
or scar tissue
Acute hematogenous osteomyelitis
Male : female = 2 : 1
> 90% monostotic
> 90% lower extremity
The child limp or refuse to walk or
refuse to use the extremity involved
Early acute : w/in 24-48 hrs, only pain
and fever
Late acute : 4-5 days after onset,
subperiosteal abscess needs
surgical drainage
Neonates
Older children
Premature infants
Evaluation of Acute Osteomyelitis
CBC, ESR, CRP
Blood culture : ident. causative
organism in 50%
Bone aspiration : for subperiost
abscess, ident. 70%
X-Ray : could be normal
Bone scan Tc 99m
MRI scan
Treatment of Acute Osteomyelitis
I.V Antibiotic started promptly
S. aureus most common infecting
agent
Gram ()ve organism in vertebrae
and immunocomp pts
Surgery for late acute (draining
abscess)
Complications
Recurrent osteomyelitis : to minimize
AB coverage for 6 weeks
Distant seeding
Septic arthritis
Pathologic fracture due to
osteonecrosis
Growth arrest due to damaged gr. pl.
Subacute Hematogenous
Oeteomyelitis
Less virulent org + effective immune
response
Less clear onset, older children ( 2-
16 y.o), equiv sex ratio
No or mild fever, mild tenderness
Lab findings inconclusive
AB for 6 weeks



Chronic Hematogenous
Osteomyelitis
Sx several weeks-months
Developed vs developing countries
Child : neglected cases
Adult : secondary
Sequestra, involucrum, draining
sinus
Needs culture from bone/deep tissue

Treatment of Chronic Osteomyelitis
Aggressive debridement
Bone grafting
Antibiotic beads (local)
Soft tissue coverage
Systemic antibiotic for 6-12 weeks

Trisna Rahardja, M, 46 yo,
Chronic osteomyelitic of the distal third
of the left tibia and fibula post ORIF
on 2008
Didik R, M, 20 yo
Chronic osteomyelitis of the right tibia fibula with bone
defect post nailing
Septic Arthritis
More common in children < 5 y.o
S. aureus, > 95% monoarticular,
hematogenous or extension from
adjecent structures
41% knee, 23% hip, 14% ankle, 12%
elbow, 4% wrist, 4% shoulder
Cartilage eroded
Clinical feature
Pain and swelling in affected joint
Malaise, fever, limp, refuse to walk,
refuse to move extremity
(pseudoparalysis)
Joints held in comfy positions
CBC, ESR, X-Ray, joint aspiration
Synovial fluid analysis :
-Turbid
-Yellow to creamy pus
-WBC > 50.000/mm3
-Glucose decreased
Treatment of Septic Arthritis
i.v antibiotic promptly
Surgical irrigation and drainage
Open or arthroscopic
complications
Joint destruction
Bony ankylosis
Soft tissue ankylosis (Tuberculosis)

Clinical Feature
X-ray of the Left lower leg
Cellulitis
Subcutaneous
Less distinctive margins
Local signs + lymhadenopathy
Th/ Systemic + Local
Erysipelas
Similar to cellulitis BUT more
superficial
Well demarcated and painful plaque
Th/ Systemic + Local

Necrotizing Fasciitis
Muscle fascia
Aggressive and life threatening
Etiology : Streptococcus Group A
Requires emergent and extensive
surgical debridement
Gas Gangrene
Muscle

In grossly contaminated
traumatic wounds

Etiology :
Clostridium Perfringens
and Clostridium Welchii

Need surgical debridement
and fasciotomy

Hyperbaric chamber
therapy