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ISM - Musculosceletal Infection
ISM - Musculosceletal Infection
L INFECTION
Ismail Bastomi
Div Orthopaedi & Traumatology
Faculty of Medicine, Universitas Sriwijaya
Dr. Moh. Hoesin Hospital - Palembang
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
200.000 deaths/years US
OSTEOMYELITIS
Classification
1. Age (neonatal, children, young adult)
2. Organism (pyogenic, granulomatous)
3. Onset (acute, subacute, chronic)
4. Route (haematogenous, direct inoculation)
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
INFANT :
1. Reversible destruction of an epiphysis
2. Epiphysitis recovery to normal may occur
3. Coxa Magna sequel to epiphysitis
4. Coxa Vara destruction of a growth plate
5. Secondary pyoarthrosis common
6. Septic arthritis dislocation
7. Failure of development of femoral head
8. Fusion of the joint not occur
9. Large involucrum complete remodeling
of diaphysis (typical feature)
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
CHILD :
1. Sequester common
2. Epiphysis not affected
3. Secondary septic arthritis not occur
(except metaphysis intra articular)
4. Chronic osteomyelitis late affect
5. Aseptic necrosis of capital epiphysis
(hip) occur
6. Occur of septic arthritis fibrous
ankylosis deformity
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
ADULT :
1. Rapid spread to marrow cavity
2. Sub periosteal abscess – large
sequestra not typical
3. Involucrum limited
4. Ability to repair diaphysis reduce
5. Septic arthritis bony ankylosis
deformity ↑
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
ETIOLOGY
Neonates :
- Sprepto Coccus group B >> staphilococcus
Infants / children :
- Staphilococcus aureus (90%)
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
DIFFERENTIAL DIAGNOSIS
Cellulitis
Thrombophlebitis
Ewing’s Sarcoma – Leukemia
Rheumatic fever
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
PATHOGENESIS :
Infection begins in metaphysial
TRUETA 1968 :
Pathology : 3 clinical stages
Stage I : “In the bone (deep)”
Tenderness (+)
Ask the child to point to the side
of pain
Stage II : “Pus on medulla and subperiosteal”
Malaise, Fever, Pain, Headache
Stage III : “Pus in soft tissue”
Calor, Dolor, Rubor, Tumor and
Functio laesa
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
DIAGNOSIS
BY CLINICAL :
- Child with fever and unexplained bone pain =
osteomyelitis until proved otherwise
- Refuse to move the limb
- Tenderness over the involved bone
LATER :
- Swelling – Erythema – Warmth – ROM
LAB :
- WBC count – not always elevated
- ESR ↑ (90%)
- C-reactive protein ↑ (98%)
- Blood culture – (+) 40%
- X-ray soft tissue swelling (3 days infection)
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Gram Stained
Aspirate
Culture
“With bone marrow needle biopsy No.11”
Bone Scan :
Tc 99 Hot spot
- Useful - difficult site : pelvis – spine
- multiple site
- Rarely used to establish the diagnosis
- False negative
Gallium scan more sensitive :
- indicated : take 24 – 48 hours
Indium
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Ultrasound :
- Localizing a sub periosteal abscess
- Show the early changes in soft tissue
- 24 hours infection / 2mm periosteum lifted
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Ultrasound :
1. Thickening of the periosteum
2. Elevation periosteum
3. Swelling muscle and subcutaneous
tissue
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
TREATMENT
Principles :
Identification of the micro organism
Correct antibiotic
Delivery antibiotic
Concentration antibiotic
Duration
Arrest tissue destruction
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
TREATMENT
Antibiotic :
Culture
Broad spectrum (gram stain)
empirical therapy
Duration of intravenous - debatable
Monitoring : * Clinical examination
- Temperature
- E.S.R.
- C-reactive protein
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
SURGERY :
- The presence of an abscess
Th/ - Opening periosteum
- Drill the cortex
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Principles of Treatment :
1. AB effective before pus has formed
2. AB cannot sterilize avascular tissue
and pus
3. Surgery should not pus at further risk
the ischaemic bone
4. AB should continued after surgery
5. AB can prevent pus
Suspicion of osteomyelitis
(clinical / serologic evidence)
Radiographic evaluation
Negative Positive
Bone scan
Antibiotic Consider
therapy aspiration
Negative Positive
MR imaging,
CT, or ultrasound;
Positive Negative reassess diagnosis
TYPE
I. Brodies abscess
II. Methaphyseal with loss of cortical
III. Diaphyseal lesion
IV. Onion skining
V. Epiphyseal (primary epiphysial
osteomyelitis)
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Etiology
- Staphylococcus
- Streptococcus
Sign
- Temperature, ESR, WBC (n)
- Pain (+)
- DD/ neoplasm
Treatment
- Biopsy + 6 weeks AB
- Culture all biopsies
- Debridement
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Staging is on classification
of Cierny - Mader
Location and extent Physiologic status
of infection A B C
1 1A 1B 1C
2 2A 2B 2C
3 3A 3B 3C
4 4A 4B 4C
Chronic Osteomyelitis
Principle of Treatment
1. Debridement
2. Treat the dead space
3. Stabilization
4. Antibiotic therapy
5. Soft tissue recover completely
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Chronic Osteomyelitis
Assessment of osteomyelitis recovery
is base on :
1. Clinical condition
2. Laboratory finding
3. X-ray without long term
complication :
a. Deformity
b. Functional deficit
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Septic Arthritis :
Delay in Dx and Th poor result
Associated with osteomyelitis worse
Neonates have a perior prognosis than
older children
Hip Poor result than other joint
Hip Common in neonate and young infant
Hip Cause secondary to osteomyelitis
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
EPIDEMIOLOGY
Hip : 20 %
Knee : 53 %
Ankle :8%
Wrist :9%
Shoulder : 11 %
Elbow : 17 %
Monoarticular : 90%
Polyarticular : 10%
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
PHATOGENESIS
Bacteremia
1. Synovial infection inflammation
inflammatory fluid
Pathogenesis
I. Hematogenous Route
1. Synovial Infection
2. Osteomyelitis secondary arthritis
a/. Proximal femoral metaphysis
b/. Femoral Head
c/. Acetabulum
II. Destruction of the Joint
1. Released proteolytic enzymes
2. Released proteases from chondrocytes
& synoviocytes : interleukin
III. Impairment of Intravascular Supply
1. Elevated Intracapsular pressure
2. Thrombosis
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
DIAGNOSIS
History – rapid onset fever – malaise – pain
Orthopaedic Examination
- Joint swelling
- R.O.M. : - limited and painful
- Anorexia, irritability & lethargy
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
LABORATORY DATA :
WBC ↑ ESR ↑
HB ↓ CRP ↑
PMN : 40 – 60 %
Blood culture (+) 30 – 50%
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
Joint Aspiration :
Confirm the diagnosis
Imaging Evaluation
I. Radiography
1. Capsular distention
2. Joint space widening
3. Methaphyseal lucency
II. Nuclear scan
1. Te99 Cold : early
Hot : hyperemic
2. Gallium Atypical cases
3. Indium Acute evaluation
III. Ultrasound
1. Detects effusion 100%
2. Capsule to bone distance > 2mm than
other side
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)
TREATMENT
I. Constitutional support
a/. Hydration
b/. Antibiotic
1. Prematurity
3. Delay in treatment
SUMMARY :
1. Early diagnosis and treatment important
factor in prognosis
2. Permanent damage to the joint greater
in neonate
3. Method for cleaning the joint still
controversial