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Bone& Joint sepsis
SepticLimp Tumor
Joint swelling R.F
What antibiotics before culture result?
If negative culture??
What way & how long
Surgery Diversity of organismLocationAssociated conditions
Definition
• Osteomyelitis
• Arthritis
InflammationBone
Joint
BACTERIA But if not?
Peltola&VahanenMorey&Peterson
CriteriaPletola&Vahanen Morey&Peterson
Puss aspiration from bone
+Bone or Blood cultureClassic symptoms
Local pain, Swelling,Warmth&Limited ROM
Roentgenography
DEFINTE:+Cultre from bone or adjacent soft tissue Characteristic histology
Probable:+Blood culture& clinical or X-Ray
Likely:TypicalClinic&X Ray+Response to Antibiotics
Classification
DurationMechanism Host response
AcuteSubacuteChronic
ExogenousHematogenous
PyogenicNonpyogenicChronic:
MedullarySuperficialLocalizedDiffuse
Morey
T>38.3
Pain worse with motion
Swelling
Systematic symptoms
No other pathology
Response to antibiotics
Epidemiology
Childhood 50 Yr.s Childhood Older ages
Late 10s Early 10
M>FLate summer&Early autumn
Race?
Heamophylus Influenza 1-4 Yr.s
KIngella Kingae
Etiology
KOCH
The organism must be identified at the site of the disease
Not found in other disease
Produce the disease in other animals
Be identified in the produced disease
30%-50%
Predilection for MalesLower extremities
Peak age incidence
Most rapidly growing ends
Pathophysiology of Osteomelitis
Cortical bone 2 typesCancellous bone
Less cellular less defense
Thick priostemOutside blood supply
Involecrum
Turbulence
Permeable
Bacteria substrate interacting?
Before ossific nucleus
Nucleus presents
Growth plate presents
Consequent growth alteration
Osteoblasts death
Resorption by Osteoclast 12-18 hr.
Inflammation
Bone resorption
Priosteal reaction
Few days Probability of septic joint
Puss in medullary cavity ?Neglected cases
Immunity deficiency
Pathophysiology of Septic Arthritis
Synovium
Vasclar
No Basement membrane
Serum transudate Avascular Joint cartilage
But with defense
S.aureus
SynovitisFibrinous exudate
Synovial necrosis
EnzymesProteasesPeptidasesCollagenases
Some BacteriaGlycosaminoglycan
Collagen
8hr.
Live o
r n
ot
Septic Arthritis
Pain
Position of rest
Lab.Tests
• CBC
• ESR
• CRP
Not specific48hrs, 3-5 Days, 3 Weeks
6 hrs, 2Days, 1Week
• .
Total leukocyte count &Diff Crystal,glucose&proteins
Culture & Gram staining Viscosity
GrossAppearance
No anticuaguant except a few ml. For cytologic studyto which is added 2mg potassium oxalate per ml.of fluid.
All studies can be performed with only 1-2ml. Of fluid.
Only a few drops may be adequate for Cx &gram stain
Synovial fluid analysis
Imaging
• X-ray
• CT-Scan
• Radionuclide scanning
Sequestrum
Identify the organismSelect the correct antibiotics
Deliver the antibiotics to the organism
Stop the tissue distuction
Age Neonate(1-6 weeks)Streptococcus A&B“ “ . PneumaniaeE.ColiStaphylococcus aureus
CefotaximeCeftriaxone
CefotaximeCeftriaxone
HIB
Kingella kingae
Staphylococcus aureus
Antibiotics
• Penicillinase-resistant syntetic penicillin+3d generation cephalosporin
• Vancomycin or clindamycin+3d generation cephaosporin• Ciprofloxacin+Rifampin in adults & 3d generation
cephalosporin• For Salmonella in adults Fluroquinolon may be added• For post traumatics Nafcillin+ciprofloxacin orVancomycin+3d
g,c&Carbencillin
Cloaxicillin+CefizoximeMethycillin+CefriaxoneVancomycin+CefizoximeCiprofloxacin+Refampin+CefizoximeNafcillin or Ciprofloxacin+Cefriaxon
Deliver the antibiotics to the organism
I.V or Orally
Duration
Penetration
Does kill ?
The course of the disease is resolving
No abcess
Well tolerated orally
Reliable Parents
4-6 weeks
+2-3 additional weeks
Principles of surgery
1-Incision:Only large enough to expose the area of bone envolved.
2-Subperiosteal abcess drainage.3-Bone drilling:It could be enlarged enough to access B.M.
Feel&Appearancedictates NORMALITY
Adequate drainageAntibiotics
Rest the joint in stable position
Large joints:Antibiotics&surgery
Small joints:Antibiotics
Repeated aspiration!!?? Arthroscopy?