Dr. Su Djie To Rante, M.Biomed, Sp.

OT
 Types
1. Specific Infection
– Pyogenic : osteomyelitis, septic arthritis
– Granulomatous : TB osteomyelitis, TB arthritis

2. Non Specific & Idiopathic Inflammatory types of

rheumatic disease
– Rheumatic fever, transient synovitis, rheumatoid arthritis,
ankylosing spondylitis

3. Secondary to a chemical irritant

– Metabolic arthritis : gout

4. Chronic Inflammation by repeated physical injury

– Bursitis, Tenosynovitis Stenosans
• Definition • Pathogenesis & Pathology
Is a rapidly developing blood – small focus + edema & hyperemi in
borne bacterial infection of metaphyseal region of long bone
bone & its marrow in
children
– Early edema  sharp rise in the
intraosseus pressure  severe &
• Incidence constant local pain
– children, boys >> – Pus form  ↑ local pressure 
– Long bones compromise local circulation 
– Metaphyseal region vascular trombosis  necrosis of
• Etiology bone
– Staphylococcus Aureus
(90%)
– Streptococcus,
pneumococcus (infants)
– h. Influenzae
– Portal of entry : skin, URTI,
inflamed gums
Untreated infection
– Local spread to medullary cavity 
spread by several routes compromise local circulation  bone
- Through damage vessel  necrosis
bacteriemia  septicemia
- Local spread : Penetrates
the relatively thin cortex 
involve periosteum 
subperiosteal abcess
- Penetrates periosteum 
cellulitis & soft tissue
abcess
– Metaphyseal region within
a synovial joint  septic
arthritis
– Metaphyseal region is
outside but close to the
joint sterile synovial
effusion
– Area of bone necrosis :
• Sequestrum : separated
fragment of infected dead bone

• involucrum : enveloping bony

tube from extensive new bone
formation from the deep layer
of elevated periosteum
• Clinical Feature & Diagnosis
-Acute, rapidly progressive
history of recent local injury in
50% px.
-Hx recent inf i(URTI,Ear,Skin)
-severe & constant pain near
the joint
-Local tenderness, child is the
unwillingness to use the limb
-Within 24 hours, septicemia :
malaise, anorexia, fever,
acutely ill.

clinical manifestations of
infection in a child  always
justify the clinical diagnosis of
acute hematogenous
osteomyelitis. At least until
there is definite evidence to the
contrary.
First weeks  no concrete
radiographic evidence of bone inf.
After the first week  reveal
destruction of bone in metaphysis &
the first sign of reactive new bone
from the periosteum
WBC & sedimentation rate ↑
Blood culture gives positive
result in half of px
DD :
• > first week :
– Early stage :
ro change of irregular
rheumatic fever
metaphyseal rarefaction &
cellulitis of soft tissues subperiosteal new bone
local trauma to soft tissues formation 
or bone. langerhans cell histiocytosis
ewing’s sarcoma,
osteosarcoma
• Treatment
– Bed rest & analgesic
– Supportive measures
– Local rest for the involved extremity
– Antibacterial Therapy
Parenteral administration of appropriate antibacterial therapy (as
soon as blood sample has been taken for culture)
After first 2 week, AB may be given orally
– if local & systemic manifestations haven’t improved after 24 h of
intensive tx  surgical decompression  continous local
infusion of saline with an appropriate antibiotics + drainage (for
severe infection)
– AB continue for minimal 3-4 weeks. Tx is discontinued when a
sedimentation rate begins approach to normal
• Prognosis
– The time interval between
the onset of infection & 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
Complications
• Early
– Death, from the associated
septicemia
– Abcess formation
– Septic arthritis
• Late
– Chronic Osteomyelitis
– Pathological Fracture
– Joint Contracture
– Local Growth Disturbance
• Inadequate tx of acute phase
 local pathological
process chronic
• Incidence
failure to diagnose an acute
phase within the first few day
Failure to provide effective
antibacterial therapy
Failure to intervene surgically
when indicated
• Pathogenesis &
Pathology
infected dead bone :
bacteria are able to survive
& multiply within it.
Surrounding pond of pus
prevent revascularization 
protects bacteria from
leukocyte & circulating
antibacterial drugs.
Osteoclast cant reach the
sequestrum  persist 
source of recurrent infection
• Eliminating the sequestra
by the natural process of
spontaneus extrusion
through an opening
(cloaca) in the involucrum
& thence through a sinus
track to the exterior or by
surgically removal
(sequestrectomy)

• An area of persistent
infection within
cancellous bone may
eventually become walled
off from the surrounding
bone by fibrous tissue 
Brodie’s abcess
• Clinical Features &
Diagnosis
– The child having recovered
from acute phase, has
residual painful lesion
associated with swelling,
tenderness, loss pf
function, draining sinuses

– Radiographic : sequstra +,
combination of local
rarefaction, sclerosis,
periosteal new bone
formation, brodie’s abcess

– Persistent anemia,
elevation of sedimentation
rate
• Treatment
– Sequestrectomy
– Saucerization
– Antibacterial Therapy
• Complications
– Joint contracture
– Pathological fracture
– Amyloid disease
– Epidermoid carcinoma
• Pyogenic bacteria invade a synovial joint  a rapidly
progressive infection
• unless adequate tx  lead to severe destruction of the
joint
• Incidence
– Associated with hematogenous osteomyelitis
– Primarily a disease of childhood
– Methapysis of the bone, entirely intracapsular :Hip, elbow.
– In adult – any joint : unrelated to osteomyelitis
• Etiology
– S.aureus – osteomyelitis
– Streptococcus, pneumococci, salmonella
– Adult :staphylococci, pneumococci, gonococci – from systemic
infection
• In infants, small capillaries cross the epiphyseal growth plate and permit
extension of infection into the epiphysis and joint space .
• metaphysis is intracapsular the infection spreads to the joint space.
• Pathogenesis & pathology
– Hematogenous spread,
– Direct inoculation from trauma or surgery
– Contangious spread from adjacent site of osteomyelitis or cellulitis

purulent exudate  rapidly digest articular cartilage  by enzimatic

digestion of the matrix by lysosomal enzymes from PMN leukocyte &
bacteria.

 collagen fiber lose their support & cartilage disintegrates.

 granulation tissue may creep over the articular

cartilage as a pannus,
blocking its nutrition from synovial fluid 
leading to even further destruction.
Inflamed synovial membrane becomes grossly swollen. Joint
become filed with pus, fibrous capsule soften & strectches 
pathological dislocation may ensue

hip joint  intra articular fluid pressure↑  occludes blood suply 

AVN of femoral head  late sequale : degenerative joint disease,
fibrous ankylosis, bony ankylosis
• Clinical Feature & Diagnosis
• Septic Arthritis in Infants
– Irritability, pseudoparalysis
– Tenderness over the joint, painful restriction of joint motion
– hip joint, typically holds that joint in a position of flexion,
abduction, and external rotation
– Fever, ↑WBC
– Clinical suspicion  urgent indication for immediate needle
aspiration of joint
• Septic Arthritis in older children & adult
– Severe pain (slightest movement) at the involve joint
– Protective muscle spasm, Tenderness
– Febris, ↑ WBC, ↑ sedimentation rate
– Needle aspiration of joint : > 100.000/ml  strongly suggestive
of septic arthritis
– Plain radiography can
reveal subtle signs early
in the disease process
(capsular distention and
joint space widening) and
metaphyseal lucency later
in the course
– Dislocation/subluxation

– Useful tool for guiding

aspiration and confirming
needle location
• Treatment Complications
• Aims of treatment • Early
– Sterilise the joint – Death
– Evacuate the bacterial products – Destruction of joint cartilage
and debris associated with – Pathological dislocation
infection – AVN of the epiphysis
– Relieve pain • Late
– Degenerative joint disease
– Prevent deformity
– Permanent dislocaton with a
– Restore normal joint function false joint
Acute septic arthritis  surgical – Fibrous ankylosis
emergency
– Bony ankylosis
– Antibacterial drugs
– Arthroscopic lavage  effective for
knee joint
– Arthrotomy + remove pus & irrigation
of joint continous local infusion of
saline + antibacterial drug with
drainage
– Residual damage  arthrodesis
 Hematogenous Osteomyelitis Of The
Spine
• Incidence
– Any age, young children >>
– Benign osteitis of the spine – mild systemic manifestation & little
supuration. Spondylarthritis.
– >> lower thoracic & Upper lumbar spine (route of infection may
be via Batson’s plexus of paravertebral vein)
• Etiology
– Staphylococcus Aureus & E. Coli
• Clinical Feature & diagnosis
– First ,poorly localized back pain + physical sign of protective
muscle spasm in the back & local deep tenderness
– Meningeal irritation (painful limittion of neck flexion & straight leg
raising)
– Child is reluctant to sit up or stand & is always reluctant to bend
forward
 – Systemic manifestations : irritability, loss of apetite, mild fever.
– WBC frequently n, ↑ sedimentation rate
– Ro : > 2 weeks : narrowing of the adjacent intervertebral disc
space & osteolysis of vertebra
– Adult : severe back pain is prominent, systemiic reaction more
marked
• DD
– Spinal Tuberculosis. Tuberculin skiin test +
• Treatment
– Local rest for the spine : body cast
– Operative drainage of the vertebra (if non operative fail)
 Pyogenic Infection In The Hand
• Soft tissue of the hand infected by pyogenic
bacteria
• High incidence of monor hand injuries
• 3 groups :
– 1. Involve nail fold (paronychia)
– 2. Involve the potential space in the hand
• pulp space (felon)
• Thenar space
– 3. Involve tendon sheath (pyogenic
tenosynovitis) : most serious
Pyogenic Tenosynovitis
• Etiology
– Laceration & puncture wounds  port d entry
– S.Aureus >>>
• Pathogenesis & Pathology
– Inflamed synovial sheath  edema, hypertrophy, synovial
effusion
– progressively distended by pus underpressure (semiflexed
position of the digit)
– Blood supply to the tendon may be compromised  tendon
necrosis
– Untreated  fibrous adhesion between tendon & sheath
permanent loss of motion
• Clinical Features & Diagnosis
– Severe local pain, local swelling, tenderness, severe pain with
passive movement of the digit
– ↑ sedimentation rate, WBC, Temperature.

• Treatment
– Early operative tx : incision along one side of the digit
– Continuous drainage & instillation of antibacterial drugs
 Necrotizing Fasciitis

• A potentially lethal soft tissue infection

• Caused by virulent strain of group A β hemolytic
streptococcus
• Involving the deep fascia & subcutaneous fat
• Cause extensive necrosis & gangrene, associated with
toxic shock & end organ failure
• Lay term : flesh eating disease
• Antibiotic + radical surgical debridement
• Amputation of an involved limb along with tx of shock 
life saving
• Mortality rate > 30%
 TB Osteomyelitis
• Usually begins during early
• Always secondary to a childhood
TB lesions elsewhere in • >> Lower thoracic & upper lumbar
the body vertebra  probably secondary to
Urinary tract TB, hematogenous
• Its a blood borne infection route via Batson’s plexus of
& usually afflicted paravertebral veins
children
• Most frequently in
vertebral bodies (TB
Spondylitis)
• May also develop in the
epiphysis of long bone &
spread into the joint to
produce TB arthritis
TB Osteomyelitis Of The Spine / TB Spondylitis
/ Pott’s Disease
• Pathogenesis & Pathology
– Slowly progressive bone
destruction (local osteolysis) in
the anterior part of vertebral
body & is accompanied by
regional osteoporosis
– Spreading caseation prevents
reactive new bone formation &
at the same time renders
segment of bone avascular,
producing tuberculous
sequestra (>> thoraxic region)
– TB granulation tissue
penetrates the thin cortex of
the vertebral body to produce
paravertebral abcess
– The infection spreads up and
down the spine under the
anterior & posterior
longitudinal ligaments
– The intervertebral disc being
avascular, relative resistant to
TB infection
– Initially the adjacent disc
become narrowedfrom
dehydration, & may be
partially destroyed by
granulation tissue
– Progressive destruction 
anterior collapsed of vertebral
bodies  kyphosis
• Clinical Features & Diagnosis
– Back pain, reluctant to sit up, stand up, or bend forward
– Local deep tenderness, protective muscle spasm
– Systemic manifestation : chronic ill, pulmonary or urinary tract
TB
– ↑ sedimentation rate, tuberculin skin test +
– Ro : early stage : osteolytic lesion in anterior part of vertebral
body, regional osteoporosis, narrowing intervertebral disc.
Advanced stage : extensive anterior destruction, paravertebral
abcess
– Aspiration of paravertebral pus
• Treatment
– Antituberculous drugs, general rest, nourishing diet
– Local rest on a turning frame or in a plaster bed
– After 1 mo, most effective tx by bold, direct open operation to
evacuate the tuberculous pus, to remove sequestra, to fuse the
involved segment (anterior interbody fusion using autogenous
bone graft)

• Complications
– Pott’s paraplegia
– Early : from extradural pressure or direct involvement by
granulation tissue
– Late : gradual development of bony ridge that impinges on the
spinal canal or from granulation tissue.
 TB Arthritis
• >> direct extension of infection into the joint from an area
of TB osteomyelitis in the epiphysis
• >> hip & knee
• Pathogenesis & Pathology
– Synovial membrane : villous hypertrophy & effusion 
distension of joint capsule.
– Small grayish tubercles on the inflamed synovial surface
– TB pannus crreep across joint surface  cartilage necrosis
– TB granulation tissue erodes subchondral bone  local area of
Tb osteomyelitis  collapsed the bone
– Cause sequestrate of cartilage
– Cartilage necrosis + destruction of underlying bone 
irreparable joint damage
• Clinical Features & Diagnos joints
– Chronically irritable joint. @lower limb : limp
– Painful limitation of joint motion, protective muscle spasm,
muscle atrophy
– ↑ sedimentation rate, tuberculin skin test +
– Ro : early stage : regional osteoporosis, soft tissue swelling .
Later stage : osteolytic lesion in epiphysis become apparent.
Loss of cartilage space.
– Opening surgical biopsy
• Treatment
– Antituberculous drugs
– General rest
– Nourishing diet
– Early : synovectomy
– arthrodesis
 Adult Rheumatoid Arthritis
• Characterized by exacerbations & remissions of joint
pain & swelling that frequently lead to progressive
deformities & may lead to permanent disability
• Symmetric polyarticular inflammatory disease
• Incidence
– Relatively common, 1,5% of adult population
– Women>, peak period : 20-40 yo
– The peripheral joint, >>hand, symmetrical
• Etiology
– Unknown
– Theory : Bacterial infection, vitamin deficiency, hormonal
imbalance
– Genetic predispotition : Exaggeration of normal immune
mechanism / hypersensitivity
• Pathogenesis & Pathology
– Primary target : synovial membrane & tendon sheath
– Synovial membrane  congestion, edem, fibrin exudation,
proliferation, villous formation
– Synovial fluid  pmn>>. Synovial membrane  mn>>
– Pmn engulf immune complexes, extrude hydrolytic enzimes –
degrading proteoglycan & collagen  destruction of the joint
– Inflammatory granulation tissue infiltrate the subsynovial
connective tissue  swollen & boggy. Fibrous capsule & joint
ligament  subluxated/dislocated. Replace by scar formation 
joint contracture & deformity
– Pannus  cartilage necrosis
– Erodes subchondral bone  osteolysis  regional osteoporosis
– Fibrous adhesion fibrous ankylosis  bony ankylosis
• Clinical Features & Diagnosis
– Usually insidious, but can be episiodic or acute
– Polyarthritis, monoarthritis
– Hands, wrists, knees, elbows, feets, shoulders, hips
– Periarticular soft tissue swelling, symmetrical
– Systemic : malaise, fatigbility, weight loss
– Local : pain, morning stiffness, swelling, heat, loss of function
– Deformity : musle spasm, muscle atrophy, muscle contracture,
subluxation & dislocation, capsular & ligament contracture,
tendon’s rupture
– Ro :periarticular soft tissue swelling, joint effusion, regional
osreoporosis, narrowing of cartilage space
– Laboratory : anemia, elevated WBC, elevated ESR, rheumatoid
factor +
– Synovioanalysisleucocytes > 2000/mm,less viscous, low glucose
Rheumatoid nodule:
1. Histology: central necrotic zone surrounded by palisading histiocytes;
these are surrounded by a layer of granulation tissue.
2. The nodules characteristically occur over the elbows but can occur in
the synovium, on tendons, in the sclera and in the viscera.
• Prognosis
• Treatment
Aims of treatment
– To help the patients understand the nature of disease
– To provide psychological support
– To alleviate pain
– To supress inflammatory reaction
– To encourage the patient to remain as physically active as
possible in order to maintain joint motion & prevent deformity
– To correct existing deformity
– To improve function
– To strnghten weak muscle
– To rehabilitate the individual patient
• Psychological Consideration
– Sympathetic understanding & free discussion of the nature of
disease
• Therapeutic Drugs
– Short or fast acting NSAID
– SAARDs
– Corticosteroid
– Immunosupressive agents
• Orthopaedic appliances
– Local rest by removable splint
– Remedial shoes, canes or crutches
• Physical Therapy
• Orthopaedic Surgical Operations
– Arthrodesis
– Arthroplasty
– synovectomy
Juvenile Rheumatoid Arthritis / Juvenil Chronic
Arthritis
• Different from adult rheumatoid
arthritis
• Clinical Varieties
• Pauarticular (Oligoarticular)
Juvenile Arthritis
– < 5 joints. >> girls
– Knee, ankle, elbow, finger,
toe
– Young children : may
develop iridocyclitis of the
eye
– Older children : ankylosing
spondylitis
• Polyarticular Juvenile Arthritis
– ≥ 5 joint. > girls
– Knees, ankles, feet, wrists,
hands, neck
– Complication : general
retardation of skeletal growth
• Systemic Juvenile arthritis
– < 5 yo. Involve multiple body
systems = Still’s Disease
– High fever, erythematous rash,
anemia, generalized
lymphadenopathy,
hepatosplenomegali,
pericarditis
• Laboratory :
– ↑ ESR, ↑ CRP , Ana +

• Treatment
– NSAID
– Corticosteroid intraarticular
– Surgical
 Ankylosing Spondylitis
(Marie Strumpell Disease, Bechterew’s Disease, Pelvospondylitis ossificans,
rheumatoid spondylitis)

• Chronic seronegative
spondyloarthritis • Clinical Featureas& Diagnosis
• Progressive involvement of the – Gradual onset of vague low
back pain.
sacroiliac & spinal joint with bony
ankylosis. – Night pain
– Morning stiffness
• Incidence
– Local deep tenderness over
– Onset : late teens, seldom > 30 yo
sacroiliac joint
• Etiology
– Related to HLA –B27
• Pathogenesis & Pathology
– Attack the site of tendons insertion,
ligament, fascia, fibrous joint capsule
= enthess
– Progressive fibrosis & ossification in
periarticular soft tissues =
enthesopathy
• Treatment
– Psychological
Consideration
– Therapeutic Drugs
– Radiation Therapy
– Orthopaedic appliances
– Physical Therapy
– Orthopaedic surgical
operation
 Transient Synovitis Of The Hip Joint In
Children
• Non bacterial inflammatory • Ro : effusion in hip joint
disorder of uncertain origin.
• DD : legg Perthes’ disease, septic
• Boys 3-10 yo arthritis, rheumatic fever, TB
• Hip pain, occasionally pain in the arthritis
knee, antalgic limp, restriction of • Tx : bed rest, maintain hig in
hip joint motion position of flexion, abduction &
external rotation
• Synovial effusion  child prefer
lying down with hip in flexion,
abduction & external rotation
• Systemic manifestation are
minimal
 Gout & Gouty Arthritis
• Familial inborn error of purine
metabolism
• Characterized by
hyperuricemia, recurrent attack
of acute gouty arthritis in
peripheral joint, & chronic
gouty arthritis associated with
tophi of urate salts
• Incidence
– Male >>, > 40 yo
– Peripheral joint of the feet
& hands. > MTP of great
toe
• Etiology
– hyperuricemia caused by
excessive production or
deficient urinary excretion
of uric acid
– Attack of acute gouty
inf,alcohol, diet,
emotional, injury, cold
– Secondary from leukemia,
polycythemia, renal
disease
• Pathogenesis & Pathology
– Sudden deposition of • Acute Gouty Arthritis
sodium monourate crystal
in synovial membrane 
acute attack
– Tophi : nodular deposit of
crystal urate, surrounded
by chronic inflammatory
tissue.
– Tophi develop in synovial
membrane, articular
cartilage, subchondral
bone, bursae, tendon
sheath, cartilage of the
external ear
• Chronic Tophaceous Gout
• Clinical Feature
– monoarticular
– >> MTP joint of the great toe
(podagra)
– Warning symptom: mood
chage, constipation, diuresis
– Attack : intense pain, local
tenderness, swollen, &
inflamed. Fever< lekocytosis
– Between attacks, px free of
symptoms
– Early, urate crystal are usually
absorbed after each attack &
joint return to normal
– Several years later, nodular
deposit or tophi develop
– Usually painless. May ulcerate
through the skin
• Chronic Gouty Arthritis • Treatment
– Articular & subchondral • Acute
tophi  degenerative – Colchicine
arthritis. – Indomethacin
– Acute attack may • Chronic
superimposed – Uricosuric agent : probenecid,
sulphinpyrazone
• Laboratory – Allopurinol : uric acid lowering
agent
– Hyperuricemia during &
between attack
– Normal serum : 6mg/100ml
for adult men, 5.5
mg/100ml for adult women
PSEUDOGOUT • Pyrophosphate arthropaty :
- Crystal (CPPD : Calcium destructive degenerative
pyrophosphate dyhidrate) arthritis
induce arthritis • Tx :
- Recurrent painful attackof - phenylbutazone &
acute arthritis. indomethacin for acute attack
- May triggered by trauma or - intraarticular inj. Of steroid to
illness reduce synovitis
- >> hand, wrist, knee, hip
- Ro :
- Calcium deposit within the
hyaline cartilage &
fibrocartilage of menisci
(chondrocalcinosis)

- Calcification of
periarticular soft tissue