Musculoskeletal Block

Stage 4
1-Septic arthritis; Acute suppurative arthritis
2-Osteomeylitis
3- Diabetic foot

Surgery Block

By
Prof.Dr.Omer A.R.Barawi
F.I.C.M.S. Orthopedics-M.D.O.A.the Netherlands
 Septic Arthritis
Definition: is a condition of infection of a joint by pus
forming microorganism, the joint can become infected by :
• Direct invasion through a penetrating wound ,intra
articular injection or arthroscopy .
• Direct spread from adjacent bone abscess ,especially in
very young infant in whom the growth plate is not an
impenetrable barrier .
• When metaphysis is intracapsular as in upper femur and
upper humerus so osteomyelitis of those sites easily
associate with septic arthritis .
• From metastatic infection , when there is blood spread
from distant sites.
 The causal organisms is usually :
• Staphylococcus aureus
• Haemophilus influenzae in children between 1-4 years of
age .
• Streptococcus
• Escherichia coli
• Proteus .
Predisposing conditions are :
• Rheumatoid arthritis
• Chronic disorders
• I . V. drug abuse
• Immunosuppressive drug therapy
• AID disease
Pathology
Clinical features :
Differ according to the age of the patient :
New born infant , the emphasis on septicemia
rather than arthralgia.
Irritable
Refuse to feed
Increased pulse rate
Fever
The joint is warmth , tender and resist to move
The umbilical cord should be examined
The I.V. site
In children :
Arthralgia
Commonest sites ,hip , knee , shoulder .
Pseudo paresis
Increased pulse rate
Fever
Joint swelling
The joint is held in position of ease
Warmth
Tender
• In adult :
More common in superficial joints like knee ,
wrist , fingers ,ankle
Resisted movement
Ask for gonococcal infection
Drug abuse
 Investigations :
• Ultrasonography
• Plain radiograph
• W.B.C.
• E.S.R.
• C . Reactive Protein
• Joint fluid aspiration
• Blood culture
Differential Diagnosis

• Acute osteomyelitis
• Trauma causing synovitis , haemarthrosis
• Psoas abscess
• Local infection of the pelvis
• Irritable hip
• Hemophilic bleeding
• Juvenile rheumatoid arthritis
• Gout and Pseudogout
Treatment :

• Antibiotics ,Flucloxacillin , third generation

Cephalosporin, Fucidic acid
• Analgesics
• I . V. fluid
• Drainage
• Splintage
Complications :

• Osteomyelitis
• Subluxation or dislocation
• Damage to the epiphyseal plate , causing
deformity or limb length discrepancy .
• Bony ankylosis.
• Septicemia ,if the patient untreated , it is a
lethal complication .
• Anemia .
Osteomeylitis
Is infection of bone marrow by pus forming
microorganism, pyogenic microorganism ,which
may be in acute or chronic form .

How does micro organisms reach the

Musculoskeletal tissues?
• Direct
• Direct spread from a contiguous focus of
infection
• Indirect spread via the bloodstream
 FACTORS PREDISPOSING TO BONE INFECTION
• Malnutrition and general debility
• Diabetes mellitus
• Corticosteroid administration
• Immune deficiency
• Immunosuppressive drugs
• Venous stasis in the limb
• Peripheral vascular disease
• Loss of sensibility
• Iatrogenic invasive measures
• Trauma
ACUTE HAEMATOGENOUS OSTEOMYELITIS

• Occurs mainly in children

• Adults with lowered immunity
• Trauma may determine the site of infection
 Causal microorganisms
• Staphylococcus aureus (>70%)
• Streptococcus pyogenes (chronic skin infection
• Group B streptococcus (newborns)
• Alphahaemolytic diplococcus S. pneumonia
• Gram-negative Haemophilus influenza(in 1-4 years old
children)
• Kingella kingae (mainly following URT infection in young
children)
• Salmonella typhi in sickle cell disease.
• Gram-negative organisms (e.g. Escherichia coli,
Pseudomonas aeruginosa, Proteus mirabilis and the
anaerobic Bacteroides fragilis)
• In adults, the source of infection might be
a urethral catheterization or a
contaminated needle or syringe.
• In new borns, an infected umbilical cord
could be the source.

Pathology:
the infection usually starts in the vascular
metaphysis of a long bone, attributed to the
peculiar arrangement of the blood vessels in
that area: the non-anastomosing terminal
branches of the nutrient artery twist back in
hairpin loops before entering the large
network of sinusoidal veins, the relative
vascular stasis and consequent lowered
oxygen tension are believed to favor
bacterial colonization.
 Acute haematogenous osteomyelitis shows a
characteristic progression:
• inflammation
• Suppuration
• Bone necrosis
• Reactive new bone formation
• Resolution and healing or intractable chronicity.

the pathological picture varies considerably,

depending on the patient’s age, the site of infection,
the virulence of the organism and the host response.
 ACUTE OSTEOMYELITIS IN CHILDREN
• 2 to 6 years.
• Acute inflammatory reaction and vascular congestion of
the metaphysis> exudation of fluid > infiltration by
plymorphonuclear leucocytes. > intense pain>
obstruction and intravascular thrombosis.
• Even at an early stage the bone is threatened by
ischemia and resorption due to phagocytic activity and
cytokines, prostaglandin growth factors and bacterial
enzymes ac.
• By the 2nd to 3rd days , pus forms and through the
Volkmann canals becomes subperiosteal abcess.
• The developing physis acts as a barrier to
direct spread toward the epiphysis ,but
where the metaphysis is partly
intracapsular (e.g. at the hip,shoulder or
the elbow).pus may discharge through
the periosteum into the joint.
 Clinical features
• Pain
• Fever (increased PR)
• Refusal to bear weight (or restricted movement)
• Elevated white blood cell count
• Elevated ESR
• Elevated CRP

• In new borns (failure to thrive, hx of umbilical infection or

difficult labour)
• In children discharge , boils or toxemia in neglected cases
my be noticed.
• In adults , extreme age , low immunity and hx of
catheterization or trauma should raise the concern.
 Diagnosis
• Plain Xray
• Ultrasonography
• CT scan
• Radionuclide scanning
• Single photon emission computed tomography/CT
• MRI

• CBC,ESR,CRP
• blood culture , pus for culture and sensitivity (aspirated from the
periosteal abscess )
• Anti streptococcal antibody titers for confirmation
• IL-6 and alpha-defensin immunoassay are under evaluation, but
their role is yet to be established.
 Differential diagnoses
• Cellulitis
• Acute suppurative arthritis
• Streptococcal necrotizing myositis
• Acute rheumatism
• Sickle cell crisis
• Gausher disease
• Ewing sarcoma
• Osteosarcoma
• Scurvy
 Treatment
• appropriate antimicrobial therapy (first
empirical-don’t wait for C&S results, then
specific)
• surgical drainage if required
• splintage and rest of the affected part
• supportive treatment for pain and
dehydration.
 Complications
• Epiphyseal damage and altered bone growth
• Suppurative arthritis
• Metastatic infection
• Pathological fracture
• Chronic osteomyelitis
• Anemia,toxemia and death