Bone and Joint Infections

Dr. Sayid omar Mohamed

 Introduction
Trauma is the leading cause of death in young
population
Long bones account most common anatomic parts
fractured
Infection risk varies according to extent of trauma
as well as local and systemic factors
Gustilo-Anderson Classification
Negative Effect of Open fractures
Contamination
Crushing
Stripping
Devascularization
Comminution
 Introduction
Infection:
 is a condition in which pathogenic organisms multiply
and spread within the body tissues
Consequence:
Acute or chronic inflammatory reaction clinically
characterized by classical features of redness,
swelling, heat, pain and loss of function.
Significance:
bone infection differs from soft-tissue infection, since bone
consists of a collection of rigid compartments, it is more
susceptible than soft tissues to vascular damage and cell
death from the build-up of pressure in acute inflammation.
 Predisposing factors
Host response is crucial in determining the course of
the disease. Susceptibility to infection is increased by:
local factors: trauma, poor circulation, diminished
sensibility, chronic bone or joint disease and the
presence of foreign bodies
Systemic factors: malnutrition, general illness,
diabetes, rheumatoid disease, corticosteroid
administration and all forms of immunosuppression,
either acquired or induced.
Bacterial colonization and resistance to antibiotics
 Acute vs Chronic infection
Acute Pyogenic infections are characterized by the
formation of pus which is often localized in an abscess
Chronic infection follow on acute and it usually
involves the formation of granulation tissue leading to
fibrosis.
 Principles of Management
 Provide analgesia and general supportive measures
 Rest the affected part DBR
Antibiotics
Initiate antibiotic treatment
Reduce
 Evacuate pus and remove necrotic tissue Stabilize
Stabilize the bone if it has fractured Cover wound

Maintain soft tissue and skin cover

Osteomyelitis
 Osteomeylitis
Definition: it is a progressive inflammatory process
caused by pathogens, resulting in bone destruction and
sequestrum formation
Route of infection:
Blood stream
Direct invasion: skin puncture, operation or open frx
Outcome of Microorganism invasion:
Pyogenic osteomyelitis
Septic arthritis
Chronic granulamotous reaction
Fungal infection
 Osteomeylitis
Pathogenesis:
Blood stream
Direct invasion: skin puncture, operation or open frx
Outcome of Microorganism invasion:
Pyogenic osteomyelitis
Septic arthritis
Chronic granulamotous reaction
Fungal infection
 Acute Hematogenous Osteomyelitis
Acute Pyogenic infections are characterized by the
formation of pus which is often localized in an abscess
Chronic infection follow on acute and it usually
involves the formation of granulation tissue leading to
fibrosis.
Anatomic Classification
Medullary Osteomyelitis
Superficial Osteomyelitis
Localized Osteomyelitis
Diffuse Osteomyelitis
 Acute Hematogenous Osteomyelitis
Cause: in adults, MCC are trauma, immunodeficiency
and diabetic foot
Pathogens:
Adults: Staphylococcus aureus, sStreptococcus
pyogenes, S. pneumoniae.
Young children: Haemophilus influenzae
Sickle-cell patients are prone to infection by
Salmonella typhi.
Acute Osteomyelitis Pathology
Acute Hematogenous Osteomyelitis
Source of infection:
Skin abrasion
Infected umblical cord
Urethral catheter
Arterial line
Dirty needle or syringe
 Clinical features
Children over the age of 4 years are most commonly
Affected with severe symptoms and toxemia
Infants especially newborn, only constitutional
symptoms are seen
Suspicion should be aroused by a
history of birth difficulties or umbilical artery
catheterization
 Clinical features
None
Pain
Tenderness
Fever
Nausea & vomiting
Erythema
Swelling
Sinus tract
Drainage
Limp
Clinical features in Children
Pain
Fever
Refusal to bear weight
Elevated white cell count
Elevated ESR
Elevated CRP
 Laboratory investigations
WBC, CRP and ESR

Golden standard to confirm the diagnosis is culture

(to aspirate pus from the subperiosteal abscess or the
adjacent joint)
 Radiologic findings
X-rays usually negative in the early stage (first
10days)
Radiologic changes first detected on x-ray after 10-
21days
MRI shows pathological changes before x-rays and
can help to distinguish between bone and soft-tissue
infection
 Treatment
If osteomyelitis is suspected on clinical grounds,
blood and fluid samples should be taken for laboratory
investigation and then treatment started immediately
without waiting for final confirmation of the diagnosis
4 main aspect in management
1. Supportive treatment for pain and dehydration.
2. Splintage of the affected part.
3. Appropriate antimicrobial therapy.
4. Surgical drainage.
 Treatment
Antibiotics:
empiric antibiotics should be started immediately
until culture results are out
Start with IV for 2-4weeks then oral for 3-6weeks
Monitor response on CRP levels
Drugs should NOT be discontinued untill WBC, ESR
and CRP return to normal levels
 Treatment
Supportive treatment:
Continuous bed rest is important.
the affected limb is splinted and
Adequate analgesics must be given.
 Treatment
Drainage:
if the clinical features do not improve within 36
hours of starting treatment, or even earlier if there
are signs of deep pus (swelling, oedema, fluctuation),
and most certainly if pus is aspirated, the abscess
should be drained by open operation under general
anaesthesia.
 Treatment
Follow-up:
Once the infection has subsided, movements are
encouraged; however, the patient may have to
use crutches for another few weeks.
Outpatient follow-up is important, to ensure that
there is no recurrence of infection.
 Complications
Pathological fracture
Growth disturbance
Metastatic infection

Chronic Osteomyelitis
Septic Arthritis
 Septic Arthritis
is the most rapid and destructive joint disease, and is
associated with significant morbidity and a mortality of
10%
The incidence is:
2–10 per 100 000 in the general population, and
30–70 per 100 000 in those with pre-existing joint
disease or joint replacement
 Risk factors
Increasing age
Pre­existing joint disease (principally RA)
Diabetes mellitus
Immunosuppression (by drugs or disease) and
Intravenous drug misuse
Prosthetic joints
 Pathogens
Cause: S. aureus;
in Children between 1 and 4 years old, H. influenzae
is an important pathogen unless they have been
vaccinated against this organism
In adults, the most likely organism is Staphylococcus
aureus, particularly in patients with RA and diabetes.
In young, sexually active adults, Neiseria gonorrhea
 Clinical Features
Clinical Finding: typical features are
acute pain and swelling in a single large joint
commonly the hip in children and the knee in adults
The joint usually swollen, hot and red, with pain at
rest and on movement
Fever
The patient becomes ill, with a rapid pulse and
swinging fever.
 Clinical Features
There is superficial warmth, diffuse tenderness
All movements are grossly restricted and often
completely abolished by pain and spasm
(pseudoparesis).
 Clinical Features
Infants:
The emphasis is on Septicemia rather than joint pain.
The baby is irritable and refuses to feed;
Rapid pulse and fever
The umbilical cord should be examined for a source
of infection.
An inflamed intravenous infusion site should always
lead to high suspicion.
 Clinical Features
Adults:
a superficial joint (knee, wrist, finger, ankle or toe)
that is painful, swollen and inflamed.
Warmth and marked local tenderness, and movements
are restricted.
The patient should be questioned and examined for
evidence of gonococcal infection or drug abuse.
 Investigations
Laboratory Investigations:
WBC, CRP and ESR
Blood cultures may be positive
Golden standard of diagnosis is joint aspiration
(Synovial fluid analysis) and immediate microbiologic
examination
 Synovial Fluid Analysis
Leukocyte count more than 50,000/mcl predominantly
neutrophils
Gram stain: gram +ve (staphylococcal) or gram –ve inf.
Culture: +ve in up to 90% (staphylococcus aureus is
the most common organism)
 Investigations
Imaging:
Ultrasound is the most reliable method for revealing
a joint effusion in early cases.
X-ray examination are usually normal in early stages
and MRI are helpful occasionaly
 Differential diagnosis of Septic Arthritis

Acute osteomyelitis
Transient synovitis
Gout and pseudogout
Other infections: psoas abscess
Sickle cell disease
Rheumatoid arthritis (Juvenile))
 Treatment
The first priority is to aspirate the joint and
examine the fluid.
Treatment is then started without further delay
4 main aspect in management
1. Appropriate antimicrobial therapy
2. Supportive treatment for pain and dehydration.
3. Surgical drainage & wash out of the joint
4. Splintage of the affected part.
 Treatment (Step by Step)
Hospital admission
Perform urgent investigations
Start Broad spectrum IV antibiotics
Relieve pain
Joint aspiration or Surgical drainage
Splint & Elevation
Physiotherapy (early passive then active ROM)
 Prognosis
Poor outcomes are associated with delayed
treatment, comorbities and staph aureus
Less than 10% of patients may die for Sepsis

The affected joint may end up with destruction and

bone ankylosis