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Disorders of the Musculoskeletal System

By Bekele T.(BSc,MSc) 1
Anatomy and physiology overview
Musculoskeletal system includes the bones ,
joints, muscles, tendons, ligaments and bursae
of the body.
Bony structures and connective tissues
accounts for approximately 25% of the body
weight and muscle accounts about 50%.

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Fracture
Fracture is any disruption in the normal continuity of
bone or is a break in the bone
Etiology
Mechanical overload of the bone
A metabolic bone disease /pathological such as
osteoporosis
An endocrine disorder E.g. Hyperparathyroidism
Direct force/ trauma or crushing force
Sudden twisting motion
Powerful muscle contraction pulls against the bone
Bone tumors, which weaken the bone structure

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Classification of fracture
Fracture can be classified based on
I. Anatomical alignment /type

Transverse Impacted/jammed/
Oblique compression
Spiral- angular area Avulsion
Comminuted Pathologic
Greenstick Torus/ridged body/
Depressed segmented
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Cont,..

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Cont.
II.Based on location
Middle fracture-fracture occurs at the middle
of the bone
End fracture/distal- occurs at the distal part of
the bone
Proximal fracture-occurs at the proximal tip of
the bone

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III. Based on communication with the
external environment
An open fracture (compound, or complex,
fracture) is one in which the skin or mucous
membrane wound extends to the fractured bone.
open fractures are graded according to the
following criteria:
Grade I is a clean wound less than 1 cm long.
Grade II is a larger wound without extensive soft
tissue damage.
Grade III is highly contaminated, has extensive
soft tissue damage, and is the most severe.
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Cont.

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Cont.
A closed fracture (simple fracture) is one that
does not cause a break in the skin.
less dangerous than open types of fracture
IV. special types of fracture
Colles fracture-that involves the distal end of the
ulna & radius.
Potts fracture- involves the distal end of the tibia
& fibula.
Articular fracture- involves the joint & the
articular surface.

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Clinical Manifestations
The clinical manifestations of a fracture are:
Pain,
Loss of function,
Deformity,
Shortening of the extremity,
Crepitus,
Local swelling
discoloration.
Not all of these features are present in every
fracture.
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Management of fracture
EMERGENCY MANAGEMENT OF FRACTURES
Immediately after injury, whenever a fracture
is suspected,
It is important to immobilize the body part
before the patient is moved.
Adequate splinting, including joints adjacent
to the fracture, is essential.

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Cont..
With an open fracture, the wound is covered
with a clean (sterile) dressing to prevent
contamination of deeper tissues.
No attempt is made to reduce the fracture,
Even if one of the bone fragments is
protruding through the wound.

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MEDICAL MANAGEMENT OF FRACTURES
The principles of fracture treatment include :
1. Reduction,
2. Immobilization, and
3. Regaining of normal function and strength
through rehabilitation.
Fracture Reduction
Reduction of a fracture (setting the bone) refers
to restoration of the fracture fragments to
anatomic alignment and rotation.

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Cont.
Either closed reduction or open reduction
may be used to reduce a fracture.
The specic method selected depends on the
nature of the fracture.

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cont,
Before fracture reduction and immobilization:
-The patient is prepared for the procedure
-Permission for the procedure is obtained
-Administer analgesics as prescribed
-Anesthesia may be administered.
-The injured extremity must be handled
gently to avoid additional damage.

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Closed reduction
Closed reduction is accomplished by bringing
the bone fragments into apposition (i.e.
placing the ends in contact) through
manipulation and manual traction.
X-rays are obtained to verify that the bone
fragments are correctly aligned.
Traction (skin or skeletal) may be used to
effect fracture reduction and immobilization

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Open Reduction
Through a surgical approach, the fracture
fragments are reduced.
Internal xation devices (metallic pins, wires,
screws, plates, nails, or rods) may be used to
hold the bone fragments in position until solid
bone healing occurs.

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Immobilization
After the fracture has been reduced, the bone
fragments must be immobilized, or held in
correct position and alignment, until union
occurs.
Immobilization may be accomplished by
external or internal xation.
Methods of external xation include
Bandages,
Casts,
Splints,
Continuous traction, and
External xators.
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Inflatable splints- control bleeding and swelling.

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Traction splints are metal devices that immobilize and
pull on contracted muscles.

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Immobilizers are commercial splints made from cloth
and foam and held in place by adjustable Velcro straps.

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Molded splints- Used for chronic injuries or
diseases.

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Cervical collar- used to treat athletic neck injuries and
other trauma that results in a neck sprain or strain.

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A sling - is a cloth device used to elevate, cradle, and
support parts of the body.

Sling

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Braces designed to support weakened structures.

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Patients with open fractures
In an open fracture, there is risk of osteomyelitis,
tetanus, and gas gangrene.
The objectives of management are:
- to prevent infection of the wound, soft
tissue, and bone and
-to promote healing of soft tissue and
bone.
The nurse administers tetanus prophylaxis if
indicated.
Serial irrigation and dbridement are used to
remove anaerobic organisms.
Intravenous antibiotics are prescribed to prevent
or treat infection.
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Stages of fracture healing
There are six stages of fracture healing
1. Hematoma formation( inflammatory phase)
2. Organization (granulation tissue formation)
. Capillary loop formation
3.Provisional callus( callus formation)
. Formation of cartilage, ca++,fibrous tissue,
bone
.Soft tissue callus formation( uncalcified
tissue)
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Cont,
4. Definitive/fully grown/ callus( clinical union)
. The cartilage under goes
endochondorial ossification.
. Formation of bony callus
5. Ossification phase
1st formation of bone
6.Remodeling
. The normal contour/shape of the bone
is reconstituted by the process of remodeling
due to osteoblast
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Complications of fracture
Early complications
SHOCK
Hypovolemic or traumatic shock resulting from
hemorrhage
FAT EMBOLISM SYNDROME
After fracture of long bones or pelvis, multiple
fractures, or crush injuries, fat emboli may develop.

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COMPARTMENT SYNDROME
Compartment syndrome is a complication that
develops when tissue perfusion in the muscles
is less than that required for tissue viability.
The patient complains of pain characterized by:
Deep,
Throbbing,
Unrelenting pain; w/c is unresponsive to opoids

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OTHER EARLY COMPLICATIONS
Deep vein thrombosis (DVT),
thromboembolism, and pulmonary embolus
(PE) are associated with reduced skeletal
muscle contractions and bed rest.
Pulmonary emboli may cause death several
days to weeks after injury
DIC - includes a group of bleeding disorders
with diverse causes, including massive tissue
trauma.
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Delayed complications
Delayed union occurs when healing does not
occur at a normal rate for the location and
type of fracture.
Nonunion
results from failure of the ends of a fractured
bone to unite.
Avascular necrosis occurs when the bone loses
its blood supply and dies

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Managing Care of the Patient in a Cast
A cast is a rigid external immobilizing device
that is molded to the contours of the body.
purposes :
- to immobilize a body part in a specic
position
-to apply uniform pressure on encased soft
tissue
The joints proximal and distal to the area to
be immobilized are included in the cast.
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CASTING MATERIALS
Nonplaster
Generally referred to as berglass casts
nonplaster casts are porous ; no skin problems
They do not soften when wet, which allows
for hydrotherapy when appropriate.
They are used for nondisplaced fractures with
minimal swelling and for long-term wear.

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Plaster(pop)
The traditional cast is made of plaster.
The plaster cast requires 24 to 72 hours to dry
completely, depending on its thickness and
the environmental drying conditions.
A freshly applied cast should be exposed to
circulating air to dry and should not be
covered with clothing or bed linens.

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A cylinder cast encircles an arm or leg and leaves the
toes or fingers exposed.

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A body cast is a larger form of a cylinder cast and encircles
the trunk of the body instead of an extremity

BODY CAST
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A bivalved cast on an extremity is created when Swelling
compresses tissue and interferes with

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A Spica cast encircles one or both arms or legs and the
chest or trunk.

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Managing the Patient in Traction
Traction is the application of a pulling force to
a part of the body.
Purposes:
To minimize muscle spasms
To reduce, align, and immobilize fractures
To reduce deformity
To increase space b/n opposing surfaces
As muscle and soft tissues relax, the amount
of weight used may be changed to obtain the
desired effect.
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Types of Traction
The three basic types of traction are
Manual
Skin
Skeletal.
The categories reflect the manner in which
traction is applied.

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PRINCIPLES OF EFFECTIVE TRACTION

Whenever traction is applied, counter traction


must be used to achieve effective traction.
Counter traction is the force acting in the
opposite direction.
Usually, the patients body weight and bed
position adjustments supply the needed
counter traction.

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Contd
Traction may be applied to the skin (skin
traction) or directly to the bony skeleton
(skeletal traction).
The mode of application is determined by the
purpose of the traction.
Traction can be applied with the hands
(manual traction).

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SKIN TRACTION
Skin traction is used to control muscle spasms
and to immobilize an area before surgery.
Skin traction is accomplished by using a
weight to pull on traction tape or on a foam
boot attached to the skin.
The amount of weight applied must not
exceed the tolerance of the skin.
No more than 2 to 3.5 kg of traction can be
used on an extremity. Pelvic traction is usually
4.5 to 9 kg, depending on the weight of the
patient.
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Cont.

FIGURE: Bucks extension


traction.

Lower extremity in
unilateral Bucks
extension traction is
aligned in a foam boot
and traction applied by
the free-hanging
weight.
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SKELETAL TRACTION
Skeletal traction is applied directly to the
bone.
This method of traction is used occasionally to
treat fractures of the femur, the tibia, and the
cervical spine.
The traction is applied directly to the bone by
use of a metal pin or wire inserted through
the bone distal to the fracture.
Avoid nerves, blood vessels, muscles,
tendons, and joints during application.

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Contd
Skeletal traction frequently uses 7 to 12 kg to
achieve the therapeutic effect.
The weights applied initially must overcome
the shortening spasms of the affected
muscles.
As the muscles relax, the traction weight is
reduced to prevent fracture, dislocation and
to promote healing.

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Bone healing abnormalities
1- Delayed Union
- Failure of a fracture to heal in the expected time period.
2- Non union
- Total failure of the fracture to heal with formation of a
false joint between the fractured ends (pseudoarthrosis)
3- Malunion
- Healing occurs with deformity
4- Avascular necrosis
- Necrosis of part of the fractured bone occurs due to
disruption of its vascular supply.

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Pressure Ulcers
Pressure of a cast or an inappropriately
applied brace on soft tissues may cause
tissue anoxia and pressure ulcers.

Disuse Syndrome
Immobilization can cause muscle atrophy
and loss of strength, known as disuse
syndrome.
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Joint complications
Joint stiffness
Secondary Hemarthrosis
osteoarthritis
Systemic complications
Usually follow polytrauma and major long
bone fracture
Include ARDS/acute respiratory distress
syndrome and fat embolism syndrome
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Amputation
Amputation- is the removal of a body part, usually
an extremity.
Amputation is used:
- To relieve symptoms
-To improve function
-to save or improve the patients quality of
life
Indications of amputation
.progressive peripheral vascular disease. E.g.DM
.fulminating gas gangrene
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Cont
Trauma /accident
Congenital deformity
Malignant tumor
Chronic uncontrollable infections - chronic
osteomyelitis , osteoarthritis

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Musculoskeletal infections
Osteomyelitis
It is an infection of the bone that results in
inflammation, necrosis & formation of new
bones
The mechanism of infection can be through:
1. Hematogenous spread
2. Direct extension
3. Direct bone contamination
4. During surgical intervention
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Acute osteomyelitis
Acute osteomyelitis is an acute bacterial infection
of the bone and its medullary cavity.
It commonly affects children, boys more than
girls.
Etiology
Staphylococcus aureus is the agent in 80% of
cases
Gram negative rods and Staphylococcus in
neonates
H. Influenza is seen in children under 5 years of
age
History of trauma may predispose children to
osteomyelitis
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Pathology
Bacteria reach the bone mostly via the
hematogenous route.
Infection begins in the metaphysis of a long
bone and spreads through the cortex and
medullary cavity causing thrombosis to vessels
and bone infarction.
Pus collects under the periosteum peeling it
off the cortex

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Diagnosis
History -pain, which is gradually increasing in
severity
Fever, Toxicity - Failure to use the involved limb
Physical Examination
localized bony tenderness (most important)
Adjacent joint may have effusion
Lab. Investigations -Leucocytosis and raised ESR
-positive blood culture
X-ray changes of bone:
-late to develop within 10-15 days
-not helpful for Dx of acute osteomyelitis
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Treatment
Antibiotics -IV antibiotic should be started
empirically after taking blood sample for culture
Choice of antibiotics depends on the age:
1. Neonates:- Penicillinase resistant penicillins +
Aminoglycosides E.g. Cloxacillin + Gentamycine
2. Children under 5 years:- Penicillinase resistant
penicillins + Anti H.influenzae E.g. Cloxacillin +
Chloramphenicol
3. Patients above 5 years:- Penicllinase resistant
penicillin E.g. Cloxacillin
The duration of antibiotic treatment is 6 weeks.
IV route is changed to oral after fever and
leucocytosis have disappeared (about 7-14 days).
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Cont
Surgery:
Surgery to drain abscess is recommended if
fever and pain fail to subside after 48 hours of
IV antibiotic treatment or if there is evidence
of pus collection.
Analgesics and splinting:
Analgesics and splinting of the limb in
functional position using POP casts or skin
traction reduces pain in the acute phase.

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CHRONIC OSTEOMYELITIS
Results from delayed or inappropriate
treatment of acute osteomyelitis.
It may also follow direct infection of bone in
compound fracture.
Pathology:
The dead bone (sequester) lies in an abscess
cavity surrounded by a newly formed bone
(Involucrum) under the elevated periosteum.

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Cont..
Diagnosis:
The usual presentation is periods of quiescence
and acute exacerbation of persistently
discharging sinus.
There may be skin hyper pigmentation around
the sinus and palpable bone thickening.
X-ray may show sequester, abscess cavity,
involucrum or diffuse sclerosis.
Treatment
Antibiotics: Used for acute exacerbation and
perioperate for about six weeks.

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Cont..
Surgery can be done:
-To remove a dead bone (sequesterectomy)
-To eliminate an abscess cavity (saucerization)
Amputation may be considered for:
-extensive bone involvement
-heavy discharge or frequent flare-ups
/recurrences/which incapacitate the patient

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Metabolic bone diseases
A) Osteoporosis
Is a metabolic diseases in which bone
demineralization results in decreased density
(reduction in bone mass ) and subsequent
fracture.
Is often referred to as a silent diseases b/c the
first indication of osteoporosis in most people
follows some kind of fracture.
The wrist, hip, and vertebral column are most
often affected.
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Etiology
The exact cause of primary osteoporosis is
unknown, the following are the possible
causes:
Decreased estrogen level : in post
menopausal women
Dietary factors: diet deficient in calcium and
vitamin D.

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Cont---
Protein deficiency may contribute to the
incidence of bone demineralization.
Mal absorption caused by diseases
Alcohol consumption and cigarette smoking
/exact mechanism is unknown
Excessive exercise
Genetic factors

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Diagnosis

X-ray
Serum and urine calcium
Serum protein
Thyroid function test.

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Mgt

Oral calcium supplement (11.5 g/d of


elemental calcium in divided doses),
vitamin D (400800 IU qid.
Bisphosphonates 70 mg PO weekly;
Risedronate, 35 mg PO weekly augment bone
density and decrease fracture rates.

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Cont---
Hormone replacement (parathyroid hormone
to stimulate new bone formation) , Cacitonin /
inhibits osteocalstic activity/ reduce bone loss
Pain mgt
exercise, and smoking cessation should be
initiated in all patients with osteoporosis
Fall prevention

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B) Osteomalacia
Osteomalacia is a metabolic bone disease
characterized by inadequate mineralization of
bone.
As a result of faulty mineralization, there is
softening and weakening of the skeleton,
Causes pain, tenderness to touch, bowing of
the bones, and pathologic fractures.
w/n osteomalacia is combines with
osteoporosis the incidence of fracture is high.

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Cont---
On P/E, skeletal deformities (spinal kyphosis
and bowed legs) give patients an unusual
appearance and a waddling/walking side to
side or limping gait.
As a result of calcium deficiency, muscle
weakness, and unsteadiness, there is an
increased risk for falls and fractures.

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Pathophysiology

The primary defect in osteomalacia is a


deficiency of activated vitamin D (calcifriol),
which promotes calcium absorption from the
gastrointestinal tract and facilitates
mineralization of bone.
Without adequate vitamin D, calcium and
phosphate are not moved to calcification sites
in bones

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Cont---
Osteomalacia may result from failed calcium
absorption (e.g., mal absorption syndrome) or
from excessive loss of calcium from the body.
E.G. Gastrointestinal disorders
Liver and kidney diseases can produce a lack
of vitamin D because these are the organs that
convert vitamin D to its active form.

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Cont---
Severe renal insufficiency results in acidosis.
Hyperparathyroidism leads to skeletal
decalcification and thus to osteomalacia by
increasing phosphate excretion in the urine.

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Cont---
Prolonged use of antiseizure medication (eg,
phenytoin, phenobarbital) poses a risk for
osteomalacia.
Malnutrition

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Assessment and Diagnostic Findings
On x-ray, generalized demineralization of bone
is evident.
Studies of the vertebrae may show a
compression fracture with indistinct vertebral
end-plates.
Laboratory studies show low serum calcium
and phosphorus levels.
Urine excretion of calcium and creatinine is
low.
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Medical Management
The underlying cause of osteomalacia is
corrected if possible.
If osteomalacia is caused by malabsorption,
increased doses of vitamin D, along with
supplemental calcium, are usually prescribed.
Exposure to sunlight for ultraviolet radiation
to transform a cholesterol substance present
in the skin into vitamin D may be
recommended.

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SEPTIC ARTHRITIS
Defn: It is an acute bacterial infection of joints.
Etiology: -It varies in different age groups
-is similar to that of acute osteomyelitis
-N.gonorrhea in sexually active age groups
Pathology
The hip and knee joints are the commonly affected
joints.
Bacteria may reach the joint via the blood, local
extension of osteomyelitis or directly in
penetrating wounds of the joint.
The pus formed in the joint is chondrolytic and
destroys the joint cartilage if not evacuated.
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Cont
Diagnosis:
History: joint pain, swelling and fever.
P/E: swollen joint with effusion, tender and
warm.
The range of active and passive movement
also gets severely limited.
Lab: Joint fluid analysis reveals opaque yellow
to green fluid with high cell count
(mostly>100,000/mm
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Cont
Treatment
Start with IV antibiotics.
Do joint aspiration repeatedly under aseptic condition.
If frank pus is found, drain it by making arthrotomy.
Immobilize the affected joint in functional position
until inflammation subsides
physiotherapy to prevent joint stiffness.
Complications
Early: destruction of articular cartilage
dislocation
epiphyseal necrosis.
Late: secondary osteomyelitis
joint stiffness and ankylosis/immobility/
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