Transcript Bone& Joint sepsis Relatively common in the peditric population

Bone& Joint sepsis
Septic
Limp
Joint swelling
R.F
Tumor
What antibiotics before culture result?
If negative culture??
What way & how long
Surgery
Diversity of organism
Location
Associated conditions
Definition
• Osteomyelitis
Bone
Inflammation
• Arthritis
Joint
BACTERIA
Peltola&Vahanen
Morey&Peterson
But if not?
Criteria
Pletola&Vahanen
Puss aspiration from bone
+Bone or Blood culture
Classic symptoms
Morey&Peterson
DEFINTE:+Cultre from bone or adjacent soft tissue
Characteristic histology
Probable:+Blood culture& clinical or X-Ray
Likely:TypicalClinic&X Ray+Response to Antibiotics
Local pain, Swelling,Warmth&Limited ROM
Roentgenography
Classification
Duration
Mechanism
Acute
Subacute
Chronic
Chronic:
Medullary
Superficial
Localized
Diffuse
Host response
Exogenous
Pyogenic
Hematogenous Nonpyogenic
Morey
T>38.3
Pain worse with motion
Swelling
Systematic symptoms
No other pathology
Response to antibiotics
Epidemiology
Childhood
Childhood
50 Yr.s
Early 10
Late 10s
Late summer&Early autumn
Older ages
M>F
Race?
KIngellaInfluenza
Kingae
Heamophylus
1-4 Yr.s
Etiology
The organism must be identified at the site of the disease
KOCH
Be identified in the produced disease
Not found in other disease
Produce the disease in other animals
30%-50%
Predilection for
Males
Lower extremities
Peak age incidence
Most rapidly growing ends
Pathophysiology of Osteomelitis
Bacteria substrate interacting?
Cortical bone 2 types
Cancellous bone
Turbulence
Permeable
Less cellular less defense
Thick priostem
Outside blood supply
Involecrum
Before ossific nucleus
Consequent growth alteration
Nucleus presents
Growth plate presents
Osteoblasts death
Resorption by Osteoclast
12-18 hr.
Inflammation
Bone resorption
Few days
Probability of septic joint
Priosteal reaction
Puss in medullary cavity ?
Neglected cases
Immunity deficiency
Pathophysiology of Septic Arthritis
Vasclar
Serum transudate
Synovium
Avascular Joint
cartilage
No Basement membrane
But with defense
S.aureus
Glycosaminoglycan
Some Bacteria
Proteases
Peptidases Enzymes
Collagenases
Collagen
Live or not
8hr.
Synovitis
Fibrinous exudate
Synovial necrosis
Septic Arthritis
Pain
Position of rest
Lab.Tests
• CBC
• ESR
Not specific
48hrs, 3-5 Days, 3 Weeks
• CRP
6 hrs, 2Days, 1Week
• .
Synovial fluid analysis
All studies can be performed with only 1-2ml. Of fluid.
Only a few drops may be adequate for Cx &gram stain
Total leukocyte count &Diff
Crystal,glucose&proteins
Culture & Gram staining
Viscosity
GrossAppearance
No anticuaguant except a few ml. For cytologic study
to which is added 2mg potassium oxalate per ml.of fluid.
Imaging
• X-ray
• CT-Scan
• Radionuclide scanning
Sequestrum
Identify the organism
Select the correct antibiotics
Deliver the antibiotics to the organism
Stop the tissue distuction
Age
Neonate(1-6 weeks)
Streptococcus A&B
“ “ . Pneumaniae
E.Coli
Staphylococcus aureus
Cefotaxime
Ceftriaxone
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
Nafcillin or Ciprofloxacin+Cefriaxon
• For post traumatics Nafcillin+ciprofloxacin orVancomycin+3d
g,c&Carbencillin
Cloaxicillin+Cefizoxime
Ciprofloxacin+Refampin+Cefizoxime
Vancomycin+Cefizoxime
Methycillin+Cefriaxone
Deliver the antibiotics to the organism
The course of the disease is resolving
I.V or Orally
Duration
No abcess
Well tolerated orally
Reliable Parents
Penetration
Does kill ?
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&Appearance
dictates NORMALITY
Adequate drainage
Antibiotics
Rest the joint in
stable position
Large joints:Antibiotics&surgery
Small joints:Antibiotics
Repeated aspiration!!??
Arthroscopy?