BONE, JOINT HAND

INFECTIONS
Nur Adzyan Ruhaizad
1001335975

 Describe the epidemiology of the bone and joint infection.

Describe and differentiate the clinical features of the bone and joint
infection.
Make a diagnosis and a list of differential diagnoses by analysis of
clinical findings in history and physical examination of the patient with
bone and joint infection.
Select appropriate investigation and interpret to confirm the diagnosis,
to evaluate the pathological stages of bone and joint infection.
Plan the provisional management for the bone and joint infection.
Discuss the definitive managements and treatment options depend on
the clinic-pathological stages of bone and joint infections.
Discuss the complications and prevention of bone and joint infection.
Discuss the role of physiotherapy and occupational therapy for
rehabilitation.

OSTEOMYELI
TIS

ACUTE

ACUTE
HAEMATOGENOU
S
POST TRAUMATIC

CHRONIC

ACUTE HAEMATOGENOUS
OSTEOMYELITIS

 Mainly a disease of children

Adults are affected usually because their
resistance is lowered
Causal organism in both adults and children is
usually staphyloccocus aureus (>70%)
Less often one are other Gram-positive cocci :
Group A beta-haemolytic streptococcus (Streptococcus
pyogenes) which is found in chronic skin infections
Group B streptococcus (especially in new-born babies)
Alpha haemolytic diplococcus S. pneumoniae.

Children
infection usually starts in
the vascular metaphysis of
a long bone, most often in
the proximal tibia or in
the distal or proximal
ends of the femur.
In infants, in whom there
are still anastomoses
between metaphyseal and
epiphyseal blood vessels,
infection can also reach
the epiphysis.

Adults

haematogenous infection
accounts for only about 20%
of cases of osteomyelitis,
mostly affecting the
vertebrae.

Staphylococcus aureus is the

commonest organism but
Pseudomonas aeruginosa
often appears in patients
using IVDU.

Adults with diabetes, who are

prone to soft-tissue infections
of the foot, may develop
contiguous bone infection
involving a variety of
organisms

CLINICAL FEATURES IN
CHILDREN
Severe pain, malaise and fever
In neglected cases, toxaemia may be
marked.
The parents will have noticed that he or
she refuses to use one limb or to allow
it to be handled or even touched.
There may be a recent history of
infection: a septic toe, a boil, a sore
throat or a discharge from the ear.

 Typically the child looks ill and feverish; the pulse rate is likely to be over
100 and the temperature is raised.
The limb is held still and there is acute tenderness near one of the larger
joints (e.g. above or below the knee, in the popliteal fossa or in the groin).
Even the gentlest manipulation is painful and joint movement is restricted
(pseudoparalysis).
Local redness, swelling, warmth and oedema are later signs and signify that
pus has escaped from the interior of the bone.
Lymphadenopathy is common but non-specific.
It is important to remember that all these features may be
attenuated if antibiotics have been administered.

CLINICAL FEATURES IN
ADULTS

The commonest site for haematogenous infection is the

thoracolumbar spine.

There may be a history of some urological procedure followed by a

mild fever and backache.

Local tenderness is not very marked

May take weeks before x-ray signs appear; when they do appear
the diagnosis may still need to be confirmed by fine-needle
aspiration and bacteriological culture.

Other bones are occasionally involved, especially if there is a

background of diabetes, malnutrition, drug addiction, leukaemia,
immunosuppressive therapy or debility.

In the very elderly, and in those with immune deficiency, systemic

LAB INVESTIGATIONS
aspirate pus or uid
from the
metaphyseal
subperiosteal
abscess, the
extraosseous soft
tissues or an
adjacent joint.

Even if no pus is found,

a smear of the
aspirate is examined
immediately for
cells and organisms

A sample is also sent

for detailed
microbiological
examination and
tests for sensitivity
to antibiotics.

Tissue aspiration will

give a positive result in
over 60% of cases;
blood cultures are
positive in less than
half the cases of
proven infection

CRP values are usually

elevated within 1224
hours after onset of
symptoms,

ESR within 2448 hours

after the onset of
symptoms.

FBC: The white blood

cell (WBC) count rises
and the haemoglobin
concentration may be
diminished.

IMAGING INVESTIGATION
PLAIN X-RAY
During the first week after the onset of
symptoms the plain x-ray shows no abnormality
of the bone.
By the second week there may be a faint extracortical outline due to periosteal new bone
formation; this is the classic x-ray sign of
early pyogenic osteomyelitis, but treatment
should not be delayed while waiting for it to
appear.

ULTRASONOGRAPHY
May detect a subperiosteal collection of uid in the early
stages of osteomyelitis, but it cannot distinguish between a
haematoma and pus.
RADIONUCLIDE SCANNING
May show increased uptake, by the bone in the metaphysis.
This is positive before the changes appear on an X-ray.
This is a highly sensitive investigation, even in the
very early stages, but it has relatively low specicity
and other inammatory lesions can show similar changes.
MAGNETIC RESONANCE IMAGING
Helpful in cases of doubtful diagnosis, and particularly in
suspected infection of the axial skeleton.
It is also the best method of demonstrating bone marrow
inammation. It is extremely sensitive, even in the early
phase of bone infection, and can therefore assist in
differentiating between soft-tissue infection and

DIFFERENTIAL DIAGNOSIS

Cellulitis
Acute suppurative arthritis
Streptococcal necrotizing myositis
Acute rheumatic arthritis
Acute septic arthritis
Sickle cell crisis
Gauchers disease

TREATMENT
PRINCIPLE OF TREATMENT
1)to provide analgesia and general supportive measures
2)to rest the affected part
3)to identify the infecting organism and administer effective antibiotic
treatment or chemotherapy
4)to release pus as soon as it is detected
5) to stabilize the bone if it has fractured
6)to eradicate avascular and necrotic tissue
7)to restore continuity if there is a gap in the bone
8)to maintain soft-tissue and skin cover.
Acute infections, if treated early with effective antibiotics, can usually be
cured. Once there is pus and bone necrosis, operative drainage will be
needed.

TREATMENT
Early, adequate treatment of acute
osteomyelitis is the key to success.
The child is admitted and investigated.
Treatment depends upon the duration of
illness after which the child is brought.
Cases can be arbitrarily divided into two groups:
Brought within 48hours of onset of symptoms
Brought after 48hours of onset of symptoms

Brought within 48hours of

onset
It is supposed that pus has not yet formed and the
inammatory process can be halted by systemic antibiotics.
REST : The limb is put to rest in a splint or by traction.
ANTIBIOTIC:
started after taking blood for C&S
choice depends on age of child and choice of doctors.
<4 months old, ceftriaxone + vancomycin
the antibiotic is changed to a specific one depending upon C&S
report.

GENERAL : The child is adequately rehydrated with

intravenous uids.

 The response to the above treatment is evaluated by frequent assessment of

the patient.
A four-hourly temperature chart and pulse record is maintained.
It is a good idea to outline the area of local tenderness precisely with the help of
the back of a match-stick over regular intervals.
If the patient responds favourably, fever will start declining and local
inammatory signs will diminish.
As the child improves, the limb can be put to use.
After 2 weeks, antibiotics can be administered by the oral route for 6 weeks.
If the patient does not respond favourably within 48 hours of starting the
treatment, surgical intervention is required.

Brought after 48 hours of

onset
It is taken for granted that there is already a
collection of pus within or outside the bone.
The detection of pus is often difficult by clinical
examination because it may lie deep to the
periosteum.
An USG examination of affected part may help
in early detection of deep collection of pus.
Surgical exploration and drainage is the
mainstay of treatment at this stage.

 A drill hole is made in the bone in the region of

the metaphysis. If pus wells up from the drill hole,
the hole is enlarged until free drainage is obtained.
A swab is taken for culture and sensitivity.
The wound is closed over a sterile suction drain.
Rest, antibiotics and hydration are continued postoperatively.
Gradually, the inammation is controlled and the
limb is put to use.
Antibiotics are continued for 6 weeks.

COMPLICATIONS
Epiphyseal damage and altered
bone growth
Suppurative arthritis
Metastatic infection
Pathological fracture
Chronic osteomyelitis

POST TRAUMATIC
OSTEOMYELITIS

 This is the most common cause of osteomyelitis

in adults.
Open fractures are always contaminated and are
therefore prone to infection.
Tissue injury, vascular damage, oedema,
haematoma, dead bone fragments and an open
pathway to the atmosphere must invite bacterial
invasion even if the wound is not contaminated
with particulate dirt.

 Staphylococcus aureus is the usual

pathogen, but other organisms such as E.
coli, Proteus mirabilis and Pseudomonas
aeruginosa are sometimes involved.
Occasionally, anaerobic organisms
(clostridia, anaerobic streptococci or
Bacteroides) appear in contaminated
wounds.

CLINICAL FEATURES
Feverish and develops pain and
swelling over the fracture site
Wound is inamed
May be a seropurulent discharge

INVESTIGATIONS
Blood test : Increased CRP levels, leucocytosis, ESR
X-ray : may be more difficult than usual to interpret
because of bone fragmentation
MRI : helpful in differentiating between bone and
soft tissue infection. Less reliable in distinguishing
longstanding infection and bone destruction due to
trauma
Wound swab : Cultured for organisms

TREATMENT
The essence of treatment is
prophylaxis :
through cleansing and debridement of
open fractures
Provision by drainage by leaving the
wound open
Immobilization of the fracture and
antibiotics

Regular wound dressing and

 Traditionally it was recommended that stable implants

(fixation plates and medullary nails) should be left in place
until the fracture had united, and this advice is still
respected in recognition of the adage that even worse than
an infected fracture is an infected unstable fracture.
External fixation techniques have meant that almost all
fractures can, if necessary, be securely fixed by that
method, with the added advantage that the wound remains
accessible for dressings and supercial debridement.
If these measures fail, the management is essentially that
of chronic osteomyelitis.

CHRONIC OSTEOMYELITIS

CHRONIC OSTEOMYELITIS
Used to be the dreaded sequel to acute haematogenous
osteomyelitis; nowadays it more frequently follows an open
fracture or operation.
The usual organisms (and with time there is always a mixed
infection) are :
Staphylococcus aureus
Escherichia coli
Streptococcus pyogenes
Proteus mirabilis
Pseudomonas aeruginosa

In the presence of foreign implants Staphylococcus epidermidis,

which is normally non-pathogenic, is the commonest of all

PREDISPOSING FACTORS
Acute haematogenous osteomyelitis, if left untreated , and
provided the patient does not succumb to septicaemia will
subside into a chronic bone infection
The host defences are inevitably compromised by the presence of
scar formation, dead and dying bone around the focus of infection,
poor penetration of new blood vessels and non-collapsing cavities
in which microbes can thrive.
These processes are evident in patients who have been
inadequately treated (perhaps too little too late)
The commonest of all predisposing factors is local trauma,
such as an open fracture or a prolonged bone operation, especially
if this involves the use of a foreign implant.

PATHOLOGY
When the infection persists, the host bone responds by
generating more and more sub-periosteal new bone.
This results in a thickening of the bone.
The subperiosteal bone is deposited in a very irregular fashion
so that the osteomyelitic bone has an irregular surface.
The continuous discharge of pus results in the formation of a
sinus.
With time, the wall of the sinus gets fibrosed and the sinus
becomes fixed to the bone.

 Sequestrum is a piece of dead bone, surrounded by

infected granulation tissue trying to 'eat' the
sequestrum away.
It appears pale, and has a smooth inner and rough outer
surface, because the latter is being constantly eroded by the
surrounding granulation tissue.

Involucrum is the dense sclerotic bone overlying a

sequestrum.
There may be some holes in the involucrum for pus to drain
out.
These holes are called cloacae
The bony cavities are lined by infected granulation tissue.

CLINICAL FEATURES
Pain, pyrexia, redness and tenderness(a are)
Discharging sinus
In longstanding cases the tissues are thickened and often
puckered or folded inwards where a scar or sinus adheres to the
underlying bone.
There may be a seropurulent discharge and excoriation of the
surrounding skin.
In post-traumatic osteomyelitis the bone may be deformed or
ununited.

INVESTIGATIONS
Radiological examination
The following are some of the salient radiological features seen
in chronic osteomyelitis:
Thickening and irregularity of the cortices.
Patchy sclerosis
Bone cavity: This is seen as an area of rarefaction surrounded by
sclerosis.
Sequestrum: This appears denser than the surrounding normal bone
because the decalcification which occurs in normal bone does not
occur here. The granulation tissue surrounding the sequestrum gives
rise to a radiolucent zone around it. A sequestrum may be visible in
soft-tissues.
Involucrum and cloacae may be visible.

Sinogram
May help to localize the site of infection
Radioopaque dye is inserted into sinus and Xray taken.
CT scan and MRI
Show the extent of bone destruction and reactive oedema,
hidden abscesses and sequestra
Blood
ESR, CSR, and WBC levels may be increased ; not diagnostic
Helpful in assessing the progress of bone infection
Pus Culture
Organisms cultured from discharging sinuses
useful for control of the acute stage, or may help in selecting
the pre-operative antibiotics as and when operation is
performed.

STAGING
Helps in risk-benefit assessment and has some
predictive value concerning the outcome of
treatment.

 The least serious, and most likely to benefit, are patients classified
as Stage 1 or 2, Type A, i.e. those with localized infection and
free of compromising disorders.
Type B patients are somewhat compromised by a few local or
systemic factors, but if the infection is localized and the bone
still in continuity and stable (Stage 13) they have a reasonable
chance of recovery.
Type C patients are so severely compromised that the prognosis
is considered to be poor.
If the lesion is also classified as Stage 4 (e.g. intractable diffuse
infection in an un-united fracture), operative treatment may be
contraindicated and the best option may be long-term palliative
treatment. Occasionally one may have to advise amputation.

TREATMENT
1. Antibiotics
. To suppress the infection and prevent its spread to
healthy bone
. To control acute ares
. Antibiotics are administered for 46 weeks (starting
from the beginning of treatment or the last
debridement) before considering operative treatment.
2. Local treatments
. Sinus need dressing to protect the clothing
. Acute abscess may need urgent incision and drainage

3. Operation indicated if :
Chronic haematogenous infections
Post traumatic infections
Postoperative infection
Presence of foreign implants

OPERATIVE PROCEDURES
a) Sequestrectomy:
This means the removal of
sequestrum.
If it lies within the medullary cavity,
a window is made in the overlying
involucrum and the sequestrum
removed.
One must wait for adequate
involucrum formation before
performing sequestrectomy.

b) Saucerization:
A bone-cavity is a 'non-collapsing cavity'
so that there is always some pent-up pus
inside it.
This is responsible for the persistence of
an infection. In saucerization, the cavity is
converted into a 'saucer' by removing its
wall.
This allows free drainage of the infected
material.

c) Curettage:
The wall of the cavity, lined by infected granulation tissue, is
curetted until the underlying normal-looking bone is seen.
The cavity is sometimes obliterated by filling with gentamycin
impregnated beads or local muscle ap.
d) Excision of an infected bone:
In a case where the affected bone can be excised en-bloc
without compromising the functions of the limb, it is a good
method e.g., osteomyelitis of a part of the fibula.
With the availability of Ilizarov's technique, an aggressive
approach, i.e., excising the infected bone segment and
building up the gap by transporting a segment of the bone
from adjacent part has shown good results

e) Amputation:
It may, very rarely, be preferred in a case with a longstanding discharging sinus, especially if sinus undergoes
malignant changes.
In most cases, a combination of these procedures is
required.
After surgery the wound is closed over a continuous suction
irrigation system
This system has an inlet tube going to the medullary cavity,
and an outlet tube bringing the irrigation uid out.
A slow-suction is applied to the outlet tube.
The irrigation uid consists of antibiotics and a detergent.
The medullary canal is irrigated in this way for 4 to 7 days.

COMPLICATIONS
1. An acute exacerbation or 'are up' of the
infection
2. Growth abnormalities:
Shortening, when the growth plate is damaged.
Lengthening because of the increased vascularity of the
growth plate due to the nearby osteomyelitis.
Deformities may appear if a part of the growth plate is
damaged and the remaining keeps growing.

3.
4.
5.
6.

A pathological fracture
Joint-stiffness
Sinus-tract malignancy
Amyloidosis