Bone and Jont, tumours and Infection

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Bone and Jont, tumours and Infection

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Bone and Jont, tumours and Infection

  1. 1. Infection in Bone and Joint
  2. 2. Infection in bone <ul><li>Osteomyelitis </li></ul><ul><ul><li>acute (subacute) </li></ul></ul><ul><ul><li>chronic </li></ul></ul><ul><ul><li>specific (eg TB) </li></ul></ul><ul><ul><li>non specific(most common) </li></ul></ul>
  3. 3. Acute haematogenous OM <ul><li>mostly children </li></ul><ul><li>boys> girls </li></ul><ul><li>history of trauma </li></ul>
  4. 4. Acute Osteomyelitis Source Of Infection <ul><li>infected umbilical cord in infants </li></ul><ul><li>boils, tonsilitis, skin abrasions </li></ul><ul><li>in adults UTI, in dwelling arterial line </li></ul>
  5. 5. Acute Osteomyelitis Organism <ul><li>Gram +ve </li></ul><ul><ul><ul><li>staphylococus aureus </li></ul></ul></ul><ul><ul><ul><li>strep pyogen </li></ul></ul></ul><ul><ul><ul><li>strep pneumonie </li></ul></ul></ul><ul><li>Gram -ve </li></ul><ul><ul><ul><li>haemophilus influnzae (50% < 4 y) </li></ul></ul></ul><ul><ul><ul><li>e .coli </li></ul></ul></ul><ul><ul><ul><li>pseudomonas auroginosa, </li></ul></ul></ul><ul><ul><ul><li>proteus mirabilis </li></ul></ul></ul>
  6. 6. Acute Osteomyelitis Pathology <ul><li>starts at metaphysis </li></ul><ul><li>?trauma </li></ul><ul><li>vascular stasis </li></ul><ul><li>acute inflammation </li></ul><ul><li>suppuration </li></ul><ul><li>necrosis </li></ul><ul><li>new bone formation </li></ul><ul><li>resolution </li></ul>
  7. 7. Acute Osteomyelitis
  8. 8. Acute Osteomyelitis
  9. 9. Acute Osteomyelitis Clinical Features <ul><li>severe pain </li></ul><ul><li>reluctant to move </li></ul><ul><li>fever </li></ul><ul><li>malaise </li></ul><ul><li>toxemia </li></ul>
  10. 10. Acute Osteomyelitis Infant <ul><li>failure to thrive </li></ul><ul><li>drowsy </li></ul><ul><li>irritable </li></ul><ul><li>metaphyseal tenderness </li></ul><ul><li>decrease ROM </li></ul><ul><li>commonest around the knee </li></ul>
  11. 11. Acute Osteomyelitis Adult <ul><li>commonly thoracolumbar spine </li></ul><ul><li>fever </li></ul><ul><li>backache </li></ul><ul><li>history of UTI or urological procedure </li></ul><ul><li>old ,diabetic ,immunocompromised </li></ul>
  12. 12. Acute Osteomyelitis Diagnosis <ul><li>History and clinical examination </li></ul><ul><li>FBC, ESR, B.C. </li></ul><ul><li>X-ray (normal in the first (10-14) days </li></ul><ul><li>Ultrasound </li></ul><ul><li>Bone Scan Tc 99, Gallium 67 </li></ul><ul><li>MRI </li></ul><ul><li>Aspiration </li></ul>
  13. 13. Acute Osteomyelitis
  14. 14. Acute Osteomyelitis Differential Diagnosis <ul><li>cellulitis </li></ul><ul><li>acute septic arthritis </li></ul><ul><li>acute rheumatism </li></ul><ul><li>sickle cell crisis </li></ul><ul><li>Gaucher’s disease </li></ul>
  15. 15. Acute Osteomyelitis Treatment <ul><li>supportive treatment for pain and dehydration </li></ul><ul><li>splintage </li></ul><ul><li>antibiotics </li></ul><ul><li>surgery </li></ul>
  16. 16. Acute Osteomyelitis Complications <ul><li>septicemia </li></ul><ul><li>metastatic infection </li></ul><ul><li>septic arthritis </li></ul><ul><li>altered bone growth </li></ul><ul><li>chronic osteomyelitis </li></ul>
  17. 17. Subacute Osteomyelitis Clinical features <ul><li>long history (weeks, months) </li></ul><ul><li>pain, limp </li></ul><ul><li>swelling occasionally </li></ul><ul><li>local tenderness </li></ul>
  18. 18. Subacute Osteomyelitis Pathology <ul><li>Brodies abscess </li></ul><ul><li>a well defined cavity </li></ul><ul><li>in cancellous bone </li></ul>
  19. 19. Subacute Osteomyelitis Investigation <ul><li>X ray </li></ul><ul><li>Bone scan </li></ul><ul><li>Biopsy(50%) grow organism </li></ul>
  20. 20. Subacute Osteomyelitis Treatment <ul><li>antibiotics for 6 months </li></ul><ul><li>surgery </li></ul>
  21. 21. Other types of OM <ul><li>Sclerosing OM (non suppurative OM) </li></ul><ul><li>Post-operative </li></ul><ul><ul><li>early (within 3 months) </li></ul></ul><ul><ul><li>late </li></ul></ul>
  22. 22. Chronic Osteomyelitis <ul><li>May follow acute OM </li></ul><ul><li>May start De Novo </li></ul><ul><li>following operation </li></ul><ul><li>following open # </li></ul>
  23. 23. Chronic Osteomyelitis Organism <ul><li>usually mixed infection </li></ul><ul><li>mostly staph. Aureus E. Coli . Strep Pyogen, Proteus </li></ul>
  24. 24. Chronic Osteomyelitis Pathology <ul><li>cavities </li></ul><ul><li>dead bone </li></ul><ul><li>cloacae </li></ul><ul><li>involucrum </li></ul><ul><li>histological picture is one of chronic inflammation </li></ul>
  25. 25. Chronic Osteomyelitis
  26. 26. Chronic Osteomyelitis Sequestrum
  27. 27. Acute Septic Arthritis Route of Infection <ul><li>direct invasion penetrating wound </li></ul><ul><li>intra articular inj </li></ul><ul><li>arthroscopy </li></ul><ul><li>eruption of bone abscess </li></ul><ul><li>haematogenous </li></ul>
  28. 28. Acute Septic Arthritis Organism <ul><li>staphylococus aureus </li></ul><ul><li>haemophilus influenzae </li></ul><ul><li>streptococcus pyogenes </li></ul><ul><li>escherishae coli </li></ul>
  29. 29. Acute Septic Arthritis Pathology <ul><li>acute synovitis with purulent joint effusion </li></ul><ul><li>articular cartilage attacked by bacterial toxin and cellular enzyme </li></ul><ul><li>complete destruction of the articular cartilage. </li></ul>
  30. 30. Acute Septic Arthritis Sequelae <ul><li>complete recovery </li></ul><ul><li>partial loss of the articular cartilage </li></ul><ul><li>fibrous or bony ankylosis </li></ul>
  31. 31. Acute Septic Arthritis Neonate <ul><li>Picture of Septicemia </li></ul><ul><ul><ul><ul><li>irritability </li></ul></ul></ul></ul><ul><ul><ul><ul><li>resistant to movement </li></ul></ul></ul></ul>
  32. 32. Acute Septic Arthritis Child <ul><li>Acute pain in single large joint </li></ul><ul><ul><ul><li>reluctant to move the joint </li></ul></ul></ul><ul><ul><ul><li>increase temp. and pulse </li></ul></ul></ul><ul><ul><ul><li>increase tenderness </li></ul></ul></ul>
  33. 33. Acute Septic Arthritis Adult <ul><li>often involve superficial joint (knee, ankle, wrist) </li></ul><ul><li>investigation </li></ul><ul><ul><ul><li>fbc, wbc, esr crp ,blood culture </li></ul></ul></ul><ul><ul><ul><li>x ray </li></ul></ul></ul><ul><ul><ul><li>ultrasound </li></ul></ul></ul><ul><ul><ul><li>aspiration </li></ul></ul></ul>
  34. 34. Acute Septic Arthritis Differential Diagnosis <ul><li>acute osteomyelitis </li></ul><ul><li>trauma </li></ul><ul><li>irritable joint </li></ul><ul><li>hemophilia </li></ul><ul><li>rheumatic fever </li></ul><ul><li>gout </li></ul><ul><li>Gaucher disease </li></ul>
  35. 35. Acute Septic Arthritis Treatment <ul><li>general supportive measures </li></ul><ul><li>antibiotics </li></ul><ul><li>surgical drainage </li></ul>
  36. 36. Tumour And Tumour Like Conditions of Bone <ul><li>benign tumours are common </li></ul><ul><li>the most common malignant bone tumour are secondary metastasis </li></ul><ul><li>second most common malignant bone tumours are haematogenous </li></ul><ul><li>primary malignant tumours are rare </li></ul>
  37. 37. Metastatic Bone Tumours <ul><li>breast </li></ul><ul><li>bronchus </li></ul><ul><li>kidney </li></ul><ul><li>prostate </li></ul><ul><li>thyroid </li></ul><ul><li>GI </li></ul>
  38. 38. Haematogenous Bone Tumours <ul><li>plasmacytoma </li></ul><ul><li>multiple myeloma </li></ul><ul><li>eosinophilic granuloma </li></ul><ul><li>lymphoma </li></ul><ul><li>leukaemia </li></ul>
  39. 39. Bone Cysts <ul><li>simple bone cyst </li></ul><ul><li>fibrous dysplasia </li></ul><ul><li>aneurysmal bone cyst </li></ul>
  40. 40. Benign Bone Tumours <ul><li>osteoma </li></ul><ul><li>osteoid osteoma </li></ul><ul><li>osteochondroma </li></ul><ul><li>enchondroma </li></ul>
  41. 41. Benign Bone Tumours chondromata
  42. 42. Malignant Bone Tumours <ul><li>osteosarcoma </li></ul><ul><li>Ewing’s sarcoma </li></ul><ul><li>chondrosarcoma </li></ul>
  43. 43. Bone Tumours Clinical Presentation <ul><li>asymptomatic </li></ul><ul><li>pain </li></ul><ul><li>swelling </li></ul><ul><li>history of trauma </li></ul><ul><li>neurological symptoms </li></ul><ul><li>pathological fracture </li></ul>
  44. 44. Bone Tumours Imaging <ul><li>solitary or multiple lesions? </li></ul><ul><li>what type of bone is involved? </li></ul><ul><li>which part of the bone is involved? </li></ul><ul><li>are the margins of the lesion well defined? </li></ul><ul><li>is there bony reaction? </li></ul><ul><li>does the lesion contain calcification? </li></ul>
  45. 45. Bone Tumours Differential Diagnosis <ul><li>haematoma </li></ul><ul><li>infection </li></ul><ul><li>stress fracture </li></ul><ul><li>myositis ossificans </li></ul><ul><li>gout </li></ul>
  46. 46. Bone Tumours Treatment <ul><ul><li>chemotherapy </li></ul></ul><ul><ul><li>radiotherapy </li></ul></ul><ul><ul><li>tumour excision </li></ul></ul><ul><ul><ul><ul><li>limb salvage surgery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>amputation </li></ul></ul></ul></ul>
  47. 47. Tuberculosis Bone And Joint <ul><li>vertebral body </li></ul><ul><li>large joints </li></ul><ul><li>multiple lesions in 1/3 of patient </li></ul>
  48. 48. Tuberculosis Clinical Features <ul><li>contact with TB </li></ul><ul><li>pain, swelling, loss of weight </li></ul><ul><li>joint swelling </li></ul><ul><li>decrease ROM </li></ul><ul><li>ankylosis </li></ul><ul><li>deformity </li></ul>
  49. 49. Tuberculosis Pathology <ul><li>primary complex ( in the lung or the gut) </li></ul><ul><li>secondary spread </li></ul><ul><li>tuberculous granuloma </li></ul>
  50. 50. Tuberculosis Spinal <ul><li>little pain </li></ul><ul><li>present with abscess or kyphosis </li></ul>
  51. 51. Tuberculosis Diagnosis <ul><li>long history </li></ul><ul><li>involvement of single joint </li></ul><ul><li>marked thickening of the synovium </li></ul><ul><li>marked muscle wasting </li></ul><ul><li>periarticular osteoporosis </li></ul><ul><li>+ve Mantoux test </li></ul>
  52. 52. Tuberculosis Investigation <ul><li>FBC , ESR, </li></ul><ul><li>Mantoux </li></ul><ul><li>Xray soft tissue swelling </li></ul><ul><li> periarticular osteoporosis </li></ul><ul><li>joint appear washed out articular space narrowing </li></ul><ul><li>Joint aspiration AAFB identified in 10-20% </li></ul><ul><ul><ul><ul><ul><li>culture +ve in 50% of cases </li></ul></ul></ul></ul></ul>
  53. 53. Tuberculosis differential diagnosis <ul><li>transient synovitis </li></ul><ul><li>monoarticular ra </li></ul><ul><li>haemorhagic arthritis </li></ul><ul><li>pyogenic arthritis </li></ul>
  54. 54. Tuberculosis Treatment <ul><li>chemotherapy </li></ul><ul><li>rifampicin </li></ul><ul><li>isoniazid 8 weeks </li></ul><ul><li>ethambutol </li></ul><ul><li>rifampicin and isoniazid 6-12 month </li></ul><ul><li>rest and splintage </li></ul><ul><li>operative drainage rarely necessary </li></ul>

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