MUSCULOSKELETA

L INFECTION)

Ismail Bastomi
Div Orthopaedi & Traumatology
Faculty of Medicine, Universitas Sriwijaya
Dr. Moh. Hoesin Hospital - Palembang
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

Infection of the skeletal still present

challenges, since these illnesses are
often difficult to manage medically
and surgically

In spite of our best effort, a substantial

portion of those treated are left with
dispelling sequelae
J.D. Nelson MD
 RECENT ADVANCEMENT AND BASIC TREATMENT
PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

 200.000 deaths/years  US

 1/5000 children < decade I – ostemyelitis

 Poor outcome 27% (40% septic arthritis

of hip)
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

 Infection process  changing overtime

 Incidence sepsis >> (gram +)
 Overuse A.B.  resistant bacterial strain
 AB better  mortality < 1%
 Haemophilus influenza type B
Vaccination   incidence of septic
Arthritis (0%)
 Techniques for diagnosis  quickly
- Polymerase chain reaction
- detection of bacterial pathogen
- Ultrasound
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

OSTEOMYELITIS
Classification
1. Age (neonatal, children, young adult)
2. Organism (pyogenic, granulomatous)
3. Onset (acute, subacute, chronic)
4. Route (haematogenous, direct inoculation)
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

INFANT :
1. Reversible destruction of an epiphysis
2. Epiphysitis  recovery to normal may occur
3. Coxa Magna  sequel to epiphysitis
4. Coxa Vara  destruction of a growth plate
5. Secondary pyoarthrosis  common
6. Septic arthritis  dislocation
7. Failure of development of femoral head
8. Fusion of the joint  not occur
9. Large involucrum  complete remodeling
of diaphysis (typical feature)
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

CHILD :
1. Sequester  common
2. Epiphysis  not affected
3. Secondary septic arthritis  not occur
(except metaphysis intra articular)
4. Chronic osteomyelitis  late affect
5. Aseptic necrosis of capital epiphysis
(hip)  occur
6. Occur of septic arthritis  fibrous
ankylosis  deformity
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

ADULT :
1. Rapid spread to marrow cavity
2. Sub periosteal abscess – large sequestra  not
typical
3. Involucrum  limited
4. Ability to repair diaphysis  reduce
5. Septic arthritis bony ankylosis  deformity ↑
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

ETIOLOGY
 Neonates :
- Sprepto Coccus group B >> staphilococcus

 Infants / children :
- Staphilococcus aureus (90%)
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

DIFFERENTIAL DIAGNOSIS

 Cellulitis
 Thrombophlebitis
 Ewing’s Sarcoma – Leukemia
 Rheumatic fever
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

PATHOGENESIS :
Infection begins in metaphysial

 Vascular (HABO 1921, Trueta 1957)

Vascular loop therapy
 Imatur fagositosis (Rang 1960)
Undeveloped phagocyte theory /
Immune system deficiency
 Injury theory (Morrisy & Hagnes 1989)
Trauma theory  Regional ischemia
 TRUETA 1968 :
 Pathology : 3 clinical stages
Stage I : “In the bone (deep)”
Tenderness (+)
Ask the child to point to the side
of pain
Stage II : “Pus on medulla and subperiosteal”
Malaise, Fever, Pain, Headache
Stage III : “Pus in soft tissue”
Calor, Dolor, Rubor, Tumor and
Functio laesa
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

DIAGNOSIS
BY CLINICAL :
- Child with fever and unexplained bone pain =
osteomyelitis until proved otherwise
- Refuse to move the limb
- Tenderness over the involved bone
LATER :
- Swelling – Erythema – Warmth – ROM
LAB :
- WBC count – not always elevated
- ESR ↑ (90%)
- C-reactive protein ↑ (98%)
- Blood culture – (+) 40%
- X-ray  soft tissue swelling (3 days infection)
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

Gram Stained
Aspirate
Culture
“With bone marrow needle biopsy No.11”

Bone Scan :
 Tc 99  Hot spot
- Useful  - difficult site : pelvis – spine
- multiple site
- Rarely used to establish the diagnosis
- False negative
 Gallium scan more sensitive :
- indicated : take 24 – 48 hours
 Indium
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

CT : - Not been useful establishing the diagnosis

- Useful for identifying extra osseous collection
of pus
- Help in differentiating chondroblastoma and
osteoid osteoma

MRI : - Sensitive but not specific

differentiated between acute and chronic form

Ultrasound :
- Localizing a sub periosteal abscess
- Show the early changes in soft tissue
- 24 hours infection / 2mm periosteum lifted
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

Ultrasound :
1. Thickening of the periosteum
2. Elevation periosteum
3. Swelling muscle and subcutaneous
tissue
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

TREATMENT
Principles :
 Identification of the micro organism
 Correct antibiotic
 Delivery antibiotic
 Concentration antibiotic
 Duration
 Arrest tissue destruction
TREATMENT

Antibiotic :
 Culture
 Broad spectrum (gram stain)
empirical therapy
 Duration of intravenous - debatable
 Monitoring : * Clinical examination
- Temperature
- E.S.R.
- C-reactive protein
 SURGERY :

- The presence of an abscess

Th/ - Opening periosteum
- Drill the cortex
Principles of Treatment :
1. AB  effective before pus has formed
2. AB  cannot sterilize avascular tissue and pus
3. Surgery  should not pus at further risk the
ischaemic bone
4. AB  should continued after surgery
5. AB  can prevent pus
 Suspicion of osteomyelitis
(clinical / serologic evidence)

Radiographic evaluation

Negative Positive

Bone scan
Antibiotic Consider
therapy aspiration
Negative Positive

No clinical Negative Positive

improvement
MR imaging, CT, Antibiotic in 48 hr
or ultrasound for therapy
abscess/sequestrum

MR imaging,
CT, or ultrasound;
Positive Negative reassess diagnosis

Biopsy, surgical Antibiotic Biopsy, surgical

debridement therapy debridement
 Sub acute hematogenous osteomyelitis (SHO)

 Milder pain
 Few have fever
 30 – 40% have had AB
 Location is not always in metaphysis
 X-ray  commonly abnormal
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

TYPE
I. Brodies abscess
II. Methaphyseal with loss of cortical
III. Diaphyseal lesion
IV. Onion skining
V. Epiphyseal (primary epiphysial osteomyelitis)
Comparison sub acute osteomyelitis to acute OST

Sub acute Acute

WBC (n) 
ESR  
Blood culture rearly (+) 50% (+)
Bone culture 60% (+) 90% (+)
Location Epiphysis, metaphysis Metaphysis
diaphysis
Pain Mild Severe
Systemic illness (-) Fever – malaise
Loss of function (-) (+)
X-ray Abnormal Normal
Etiology
- Staphylococcus
- Streptococcus
Sign
- Temperature, ESR, WBC (n)
- Pain (+)
- DD/ neoplasm
Treatment
- Biopsy + 6 weeks AB
- Culture all biopsies
- Debridement
Management of the chronic
osteomyelitis is the challenges of
Indonesian Surgeon
Osteomyelitis patients often come to hospital in
neglected condition due to :
 High cost of treatment
 The preference for traditional
methods of treatment
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

Staging is on classification
of Cierny - Mader
Location and extent Physiologic status
of infection A B C
1 1A 1B 1C
2 2A 2B 2C
3 3A 3B 3C
4 4A 4B 4C

Location and extent of infection : type 1, superficial; type 2,

medullary; type 3, localized; type 4, diffuse
Physiologic status : group A, normal, group B, compromised;
group C, treatment worse than disease
 Chronic Osteomyelitis

Principle of Treatment
1. Debridement
2. Treat the dead space
3. Stabilization
4. Antibiotic therapy
5. Soft tissue recover completely
 Chronic Osteomyelitis
Assessment of osteomyelitis recovery
is base on :
1. Clinical condition
2. Laboratory finding
3. X-ray without long term
complication :
a. Deformity
b. Functional deficit
 Bone tumors simulating osteomyelitis

1. Confused  Ewing Sarcoma

2. Leukemia
- >> young children
- Back pain & vertebral collaps
- Fever, leukocyte , anemia, lethargy
- Pathological fracture
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

Bone tumors simulating osteomyelitis

3. Eosinophilic Granuloma
- AKA Langerhans cell
histiocytosis (A.C.H)
- Children < 10 years
- Vertebra plana (+)
- Collaps vertebra  pain, torticollis, kyphosis
- L.C.H.  self limiting process (Langerhans Cell
Histiocytosis)
Septic Arthritis :
 Delay in Dx and Th  poor result
 Associated with osteomyelitis  worse
 Neonates have a perior prognosis than
older children
 Hip  Poor result than other joint
 Hip  Common in neonate and young infant
 Hip  Cause secondary to osteomyelitis
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

EPIDEMIOLOGY
Hip : 20 %
Knee : 53 %
Ankle :8%
Wrist :9%
Shoulder : 11 %
Elbow : 17 %
Monoarticular : 90%
Polyarticular : 10%
 PHATOGENESIS

Bacteremia

1. Synovial infection  inflammation 

inflammatory fluid

2. Osteomyelitis  secondary arthritis

 Pathogenesis

I. Hematogenous Route
1. Synovial Infection
2. Osteomyelitis  secondary arthritis
a/. Proximal femoral metaphysis
b/. Femoral Head
c/. Acetabulum
II. Destruction of the Joint
1. Released proteolytic enzymes
2. Released proteases from chondrocytes
& synoviocytes : interleukin
III. Impairment of Intravascular Supply
1. Elevated Intracapsular pressure
2. Thrombosis
DIAGNOSIS
History – rapid onset fever – malaise – pain
Orthopaedic Examination
- Joint swelling
- R.O.M. : - limited and painful
- Anorexia, irritability & lethargy
RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

LABORATORY DATA :
WBC ↑ ESR ↑
HB ↓ CRP ↑

 PMN : 40 – 60 %
 Blood culture (+) 30 – 50%
 RECENT ADVANCEMENT AND BASIC TREATMENT PRINCIPLE
(PAEDIATRIC MUSCULOSKELETAL INFECTION)

Joint Aspiration :
Confirm the diagnosis

 WBC : 50.000  200.000

 Diff. : 90% Poly
 Mucin poor
 Sugar 50% less than blood
 Gram stain usually positive
 Culture positive 70 – 80%
 Protein < serum protein level
 Glucose < serum level
Imaging Evaluation
I. Radiography
1. Capsular distention
2. Joint space widening
3. Methaphyseal lucency
II. Nuclear scan
1. Te99 Cold : early
Hot : hyperemic
2. Gallium  Atypical cases
3. Indium  Acute evaluation
III. Ultrasound
1. Detects effusion 100%
2. Capsule to bone distance > 2mm than
other side
 TREATMENT

I. Constitutional support
a/. Hydration
b/. Antibiotic

II. Drainage and irrigation

TREATMENT : (Drainage & irrigation)

1. Arthrocentesis and irrigation individually

2. Arthrotomy and irrigation for hip
and shoulder
3. Repeated aspiration and irrigation
4. Arthroscopic lavage
Factor Contributing to Poor Result

1. Prematurity

2. < 6 months of age

3. Delay in treatment

4. Con current osteomyelitis

SUMMARY :
1. Early diagnosis and treatment  important
factor in prognosis
2. Permanent damage to the joint greater
in neonate
3. Method for cleaning the joint  still
controversial