11. Bone & Joint Infections

Bone & Joint Infections
Geleta Abebe, MD
December ,2018
Introduction
• Suppurative infections of bones & joints in
children is important b/s of their potential to
cause permanent disability.
• Frequency of infection is greater in infants &
toddlers than older children.
• Early recognition
• The risk is greatest if the growth plate or
synovium is involved.
A - Osteomyelitis
• Inflammation of bone.
• For clinical purpose- caused by bacteria
Epidemiology
-common in children 3-12yrs
-1/3rd of cases <2yrs, 50% in < 5yrs
-two times common in boys than girls.
-trauma is a common preceding event in upto1/3 rd
of cases.
Etiology
• Staph aureus = 80%
• Group A streptococcus = 5%
• H. influenza = 2%
• Others = 13%
Route of infection
Hematogenous - majority
Local spread of infection as in cellulitis &
other soft tissue infection.
Direct inoculation – penetrating trauma
Pathogenesis
• Affects the metaphysis of long bones
• Factors favoring metaphyseal infection include
-sluggish blood flow in the area.
-decreased/absent of phagocyte cells
• There is bacterial proliferation leading to
obstruction of small vessels by bacterial micro
emboli.
• small areas of necrosis…
Pathogenesis cont…
 Then accumulation of exudate & bacterial
products under pressure which leads to
metaphyseal necrosis.
 Purulent matter spreads laterally through
cortical vascular channels / Haversian system/
& accumulates under the periosteum
 Trauma may result in local areas of necrosis
favoring bacterial growth
• In newborns and young infants, transphyseal
blood vessels connect the metaphysis and
epiphysis, so it is common for pus from the
metaphysis to enter the joint space.
• This extension through the physis has the
potential to result in abnormal growth and
bone or joint deformity.
• During the latter part of the first year of life,
the physis forms, obliterating the transphyseal
blood vessels.
• Once the physis forms joint involvement may
occur in joints where the metaphysis is intra-
articular (e.g., hip, ankle, shoulder, and
elbow) and subperiosteal pus ruptures into the
joint space.
• In chronic Osteomyelitis – the infected

periosteum may calcify in to a shell of new
bone = INVOLCRUM
• SEQUESTRUM
• Brodie’s abscess - metaphyseal abscess
Clinical manifestations
• Depends on age
New borns
-fever ,irritability
-pseudoparalysis
-apparent pain on movement of affected limb
- thin cortex- purulent matter may rupture &
dissect the muscle bands
Clinical manifestations cont..
• Adjacent joint – osteoarthritis
• Redness & swelling of the skin & over laying
soft tissue.
 Older infants & children
- thick cortex & dense periosteum ruptures
rarely
- pain, fever
Clinical manifestations..
• Limping
• More localized tenderness & signs of
infection.
 Sites of involvement
 Commonly the long bones;
tibia,femur,humerus,fibula,radius,ulna,..
 Less commonly the flat bones
Sites of bone involvement by %
Bone % of involvement
tibia 24.3%
femur 23.8%
humerus 13.2%
fibula 5.9%
radius 3.9%
ulna 2.3%
vertebra 2%
Sites of bone involvement by %
Bone %involvement
Foot bones 7.5%
Pelvic bones 6.8%
Hand bones 6.1%
Chest bones 2.9%
Head bones 1.4%
• Diagnosis
 mainly clinical-over diagnosis
Marked tenderness over the site.
 bacteriologic;- culture of periosteal aspirate or
bone itself = 80% diagnostic
- blood culture- 60% diagnostic
 Radiologic –may be normal in the 1 st 10-14 dys
-soft tissue swelling
- periosteal elevation & calcifications
• Radionuclide imagining
Technicium pyrophosphate scan-
exaggerated uptake = early diagnosis.
Others : ESR ,WBC count mainly for follow up
• Differential diagnosis
 Septic arthritis
Cellulitis
Ewings sarcoma
Toxic synovitis
leukemia
• Treatment
 Medical
Antibiotics based on age, culture results &
associated diseases
Staph – iv cloxacillin 200mg/kg
in 4 divided doses
Rx for salmonella in pts with sickle cell disease
.G-ve in contaminated wound
.H.influenzae in younger children
.Response is seen in 24 hrs
Surgical drainage
- if there is sequestrum
-if there is hip joint involvement
- spinal cord compression
- chronic Osteomyelitis
Physical therapy
- keep in extension position
- passive movement after pain
decreases
Prognosis : 10% of case develop
chronic osteomyelitis
• Complications
Chronic Osteomyelitis
Draining sinus
Pathologic fracture
Orthopedic deformities
Amyloidosis
B - Septic arthritis
• Infection of the joints.
• Etiology
- S. aureus – in all age groups
-H. influenzae in 2 mo- 4yrs followed by s.aureus
Others – G-ves, streptococci
-gonococci,meningococcal
- fungi
• Epidemiology
½ of the cases occur by age 2yrs
¾ of the cases occur by age 5yrs
Pathogenesis
• Hematogenous
• The synovial membrane has a rich vascular
supply and lacks a basement membrane,
providing an ideal environment for
hematogenous spread
• Contagenous spread from surrounding
infection
• Spread from osteomyelitis; in young children
• Direct inoculation
• Bacterial endotoxin In the joint space.
• Inflammatory cells – inflammation
• Cartilage damage.
Clinical manifestations
• Usually involves single joint (>90%)

• Sudden onset with fever,chills
• Erythema,warmth,swelling & tenderness
• Decreased range of movement,pseudoparalysis
• Limping
• Palpable effusion.
Joints involved
Joint % involvement
Knee 40%
Hip 22%
Elbow 14%
Ankle 13%
Shoulder 5%
Wrist 4%
Others 3%
• Diagnosis
- clinical
- laboratory – Leukocytosis
- Elevated ESR,
- Arthrocentesis
- blood/joint fluid culture +ve in 85%
- G.stain / acid fast stain
-Antigen detection
- Synovial biopsy
• Synovial fluid analysis profiles at different
joint problems is depicted in the following
table.
condition appeara Mucin WBC Glucose
nce clot Total %PM as % of
N blood glu
Normal Clear, good 0 -200 <10 100%

yellow
Septic A. turbid Curdled 10,000- >90 50-90%
milk 250,000
TB.art. turbid Tight 2,500- >60 40-70%
rope 100,000
JRA/ turbid Small 250- >70 30%
reactive friable 80,000
masses
• Differential diagnosis
 Rheumatic fever
Post infectious arthritis
JRA,SLE,
Toxic synovitis of the hip
Leukemia
• Treatment
- Iv antibiotics – likely organism
- age gm stain result
usually cloxacillin +/- chloroamphenicol
-prompt drainage
- duration of therapy 2-3wks
THANK YOU

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Bone & Joint Infections

• In chronic Osteomyelitis – the infected

• Usually involves single joint (>90%)

Normal Clear, good 0 -200 <10 100%

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