Infection of Musculoskeletal system

1. INFECTION OF THEINFECTION OF THE
MUSCULOSKELETALMUSCULOSKELETAL
SYSTEMSYSTEM

2. BACTERIAL INFECTIONBACTERIAL INFECTION
• SKIN- Staph aureus,epidermidis,SKIN- Staph aureus,epidermidis,
DiptheroidsDiptheroids
• Mouth and Throat- Streptococci,Mouth and Throat- Streptococci,
Heamophilus, TuberculosisHeamophilus, Tuberculosis
• Stomach- TuberculosisStomach- Tuberculosis
• Small intestine- Tuberculosis, BacteroidesSmall intestine- Tuberculosis, Bacteroides
• Nose- Staph, Strep, Leprosy,Nose- Staph, Strep, Leprosy,
• Colon- Enterobacteriaceae, Tuberculosis,Colon- Enterobacteriaceae, Tuberculosis,
Strep facecalis, bacteroidesStrep facecalis, bacteroides

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6. • Bacteraemia- Bacteria circulate in bloodBacteraemia- Bacteria circulate in blood
• Septicemia- organisms as well as theirSepticemia- organisms as well as their
toxins circulate in bloodtoxins circulate in blood
• Toxaemia- toxins in blood rather thanToxaemia- toxins in blood rather than
bacteriabacteria

7. • Portal of entry of organism into thePortal of entry of organism into the
vascular channelvascular channel
• 1. direct extension into the vascular1. direct extension into the vascular
channelschannels
• 2. Following the lymphatic channels and2. Following the lymphatic channels and
emptying into the venous systememptying into the venous system
• 3. embolic spread from secondary3. embolic spread from secondary
thrombusthrombus

8. Musculoskeletal infectionsMusculoskeletal infections
• Soft tissue infectionSoft tissue infection
• Open fractureOpen fracture
• Joint infectionJoint infection
• osteomyelitisosteomyelitis

9. CellulitisCellulitis
• MC- Staph aureus, Staph epidermidis,MC- Staph aureus, Staph epidermidis,
Strep pyogenesStrep pyogenes
• MRSA has increased incidenceMRSA has increased incidence

10. Soil ContaminationSoil Contamination
• Gram negative organisms- ClostirdiumGram negative organisms- Clostirdium
perfringensperfringens

11. • Disinfectant and antiseptics used to cleanDisinfectant and antiseptics used to clean
hospitals and wards are also used for skinhospitals and wards are also used for skin
preparation in emergency Dept.preparation in emergency Dept.
• MC infection is PseudomonasMC infection is Pseudomonas

12. Drug dosesDrug doses
• Gram PositiveGram Positive
• Frist choice- Neficilin 2g 6hrly or ClindamycinFrist choice- Neficilin 2g 6hrly or Clindamycin
900mg 8hrly900mg 8hrly
• Alternate – Vancomycin500mg 8hrly orAlternate – Vancomycin500mg 8hrly or
CephalothinCephalothin
• MRSA- Vancomycin 500mg TID or NeficilinMRSA- Vancomycin 500mg TID or Neficilin
• Group A and B Staph. Penicilin G 2* 10Group A and B Staph. Penicilin G 2* 1066
4hrly4hrly
22ndnd
choice- CLindamycin or Cephalothinchoice- CLindamycin or Cephalothin
• Enterococcus- Ampicilin 2gm 6hrlyEnterococcus- Ampicilin 2gm 6hrly
22ndnd
choice Vancomycinchoice Vancomycin

13. Gram NegativeGram Negative
• Frist choice-Frist choice-
• Tobramycin 5mg/kgBW 8hrlyTobramycin 5mg/kgBW 8hrly
• Ampicillin 2gm 6hrlyAmpicillin 2gm 6hrly
• Cefotaxime 2gm 8hrlyCefotaxime 2gm 8hrly
• Cefazolin 2gm 8hrlyCefazolin 2gm 8hrly
• Ticarcilin 3gm 4hrlyTicarcilin 3gm 4hrly
• Gentamycin 5mg/kgBW 8hrlyGentamycin 5mg/kgBW 8hrly

14. • AlternateAlternate
• Mezlocilin, Imipenem, amikacin,Mezlocilin, Imipenem, amikacin,
Ceforoxime, CeftazidimeCeforoxime, Ceftazidime
• Anaerobic-Anaerobic-
• Clindamycin 900mg 8hrlyClindamycin 900mg 8hrly
• Pencillin G 2 X 10Pencillin G 2 X 1066
units 4hrlyunits 4hrly
• Alternate- Metronidazole, CefoxitineAlternate- Metronidazole, Cefoxitine

15. OsteomyelitisOsteomyelitis
• Infection of the boneInfection of the bone
• Types- Acute or ChronicTypes- Acute or Chronic
– Haematogenic or ExogenousHaematogenic or Exogenous
– Pyogenic or GranulomatousPyogenic or Granulomatous

16. SequestrumSequestrum
• Microscopic or macroscopic fragment ofMicroscopic or macroscopic fragment of
necrotic, usually cortical, bone usuallynecrotic, usually cortical, bone usually
found at the nidus of the infection with infound at the nidus of the infection with in
the bone.the bone.
• These fragments usually start as part ofThese fragments usually start as part of
the cortex and are surrounded by pus andthe cortex and are surrounded by pus and
infected granulation tissue.infected granulation tissue.
• Devitalized by toxins, enzymes,Devitalized by toxins, enzymes,
intraosseous pressure.intraosseous pressure.

19. InvolucrumInvolucrum
• This is a condition takes place when newlyThis is a condition takes place when newly
formed reactive bone occurs at theformed reactive bone occurs at the
interface between diseased bone andinterface between diseased bone and
healthy tissue.healthy tissue.

20. Haematogenous osteomyelitisHaematogenous osteomyelitis
• Classified based onClassified based on
• 1. duration- acute and chronic1. duration- acute and chronic
• 2. Etiology2. Etiology
• 3. Host response3. Host response
• Acute osteomyelitis- bacterial innoculationAcute osteomyelitis- bacterial innoculation
or colonization without any host response,or colonization without any host response,
characterized by acute inflamation,characterized by acute inflamation,
periostitis and radiolucency, first 6 weeks.periostitis and radiolucency, first 6 weeks.

21. • Chronic osteomyelitis- later stage ofChronic osteomyelitis- later stage of
disease when involucra, sequestra, radiodisease when involucra, sequestra, radio
lucency with surrounding radio densitylucency with surrounding radio density
and sinuses or fistulae are formed.and sinuses or fistulae are formed.
• Types- Active or inactive(dormant)Types- Active or inactive(dormant)
– Acute and chronic- opposite ends or diseaseAcute and chronic- opposite ends or disease
progression.progression.

22. Source of infectionSource of infection
• Minor traumaMinor trauma
• Tonsils, lungsTonsils, lungs
• Middle ear,Intestinal canalMiddle ear,Intestinal canal
• Predisposing factors- leukemia,Predisposing factors- leukemia,
lymphoma, diabetes, malaria, scarletlymphoma, diabetes, malaria, scarlet
fever, measles, diphtheria and influenza-fever, measles, diphtheria and influenza-
these decrease the host resistancethese decrease the host resistance
• Typhoid- usually chronic osteomyelitisTyphoid- usually chronic osteomyelitis

23. PathogenesisPathogenesis

24. Virulence depends onVirulence depends on
• 1. resistance of the patient- eradicates the1. resistance of the patient- eradicates the
organism before suppurationorganism before suppuration
• 2. Less favourable- chronic or brodie’s2. Less favourable- chronic or brodie’s
abscess may occurabscess may occur
• 3. suppuration and sequestration –3. suppuration and sequestration –
prostraglandin E and F2 and cathepsin-prostraglandin E and F2 and cathepsin-
responsible for the bone destructionresponsible for the bone destruction

26. • Abscess, limited by growth plate, spreadsAbscess, limited by growth plate, spreads
transversely along Volkmann canals and elevatestransversely along Volkmann canals and elevates
periosteum; extends subperiosteally and mayperiosteum; extends subperiosteally and may
invade shaft. In infants under 1 year of age, someinvade shaft. In infants under 1 year of age, some
metaphyseal arterial branches pass throughmetaphyseal arterial branches pass through
growth plate, and infection may invade epiphysisgrowth plate, and infection may invade epiphysis
and jointand joint

27. • Infectious process may erode periosteumInfectious process may erode periosteum
and form sinus through soft tissues andand form sinus through soft tissues and
skin to drain externally. Process influencedskin to drain externally. Process influenced
by virulence of organism, resistance ofby virulence of organism, resistance of
host, administration of antibiotics, andhost, administration of antibiotics, and
fibrotic and sclerotic responses.fibrotic and sclerotic responses.

30. Clinical manifestationClinical manifestation

31. • Child- restless, flushed, headache, dryChild- restless, flushed, headache, dry
toungue, furred, vomitingtoungue, furred, vomiting
• PR – 120-140, temp- 38 to 39deg CPR – 120-140, temp- 38 to 39deg C
• TLC- >25000TLC- >25000
• ESR- 60mm first hrESR- 60mm first hr
• Examination- Apprehensive even aboutExamination- Apprehensive even about
slight limb movement. Later apathy andslight limb movement. Later apathy and
comatosecomatose

32. • Affected limb in position with exerts minAffected limb in position with exerts min
pressure on the inflamed bonepressure on the inflamed bone
• Neighboring joints are flexed in order to relaxNeighboring joints are flexed in order to relax
the capsule and accommodate the effusion.the capsule and accommodate the effusion.
• Swelling- not present in the early stage.Swelling- not present in the early stage.
Evident after sub periosteal effusionEvident after sub periosteal effusion
• Redness of skin- late sign, localized to theRedness of skin- late sign, localized to the
affected metaphysis.affected metaphysis.
• Extreme pain and tenderness over theExtreme pain and tenderness over the
original focus.original focus.

33. • Culture procedureCulture procedure
• Swabbing of the superficial wound.Swabbing of the superficial wound.
• Bone needle biopsy of material obtainedBone needle biopsy of material obtained
during debridement.during debridement.
• Therefore both aerobic and anaerobic andTherefore both aerobic and anaerobic and
fungal infection are identifiedfungal infection are identified
• Numerous culture taken from different sitesNumerous culture taken from different sites
are essentialare essential
• Stop antibiotics for 2 weeks prior to culture.Stop antibiotics for 2 weeks prior to culture.

34. MC isolated organismMC isolated organism
• <1 yr- Group B streptococcus,<1 yr- Group B streptococcus,
Staph.aureus, E.coliStaph.aureus, E.coli
• 1 to 16 yr- Staph.aureus, Strep.pyogenes,1 to 16 yr- Staph.aureus, Strep.pyogenes,
H.influenzaH.influenza
• >16yr- Staph.aureus, Strep.epidermidis,>16yr- Staph.aureus, Strep.epidermidis,
Pseudomonas, E.coli,Pseudomonas, E.coli,
Serratiamarcescens.Serratiamarcescens.

35. Special testingSpecial testing
• Lukergy- WBC agglomerate in theLukergy- WBC agglomerate in the
peripheral venous blood. – also in IHD,peripheral venous blood. – also in IHD,
acute pancreatitis, poly cythemia rubra,acute pancreatitis, poly cythemia rubra,
burn.burn.
• More sensitive than ESRMore sensitive than ESR
• C R P- also a good prognostic indicator -C R P- also a good prognostic indicator -
persistent high levels indicate associatedpersistent high levels indicate associated
septic arthritisseptic arthritis

36. Variations with ageVariations with age
• <6 months- metaphyseal vessels to joint<6 months- metaphyseal vessels to joint
infection.infection.
• Large involucra because periosteum isLarge involucra because periosteum is
elevated with ease in these patientselevated with ease in these patients
• Adults- joint involvement rare, secondaryAdults- joint involvement rare, secondary
septic arthritis commom. Thin periosteumseptic arthritis commom. Thin periosteum
and elevation difficult- multiple soft tissueand elevation difficult- multiple soft tissue
abscessabscess

37. • X-ray findings-X-ray findings-
• Soft tissue changes in 48 hr.Soft tissue changes in 48 hr.
• Loss of normal demarcation lines betweenLoss of normal demarcation lines between
subcutaneous shadow and muscle.subcutaneous shadow and muscle.
• Transverse lines appear of increasedTransverse lines appear of increased
density outward from the muscledensity outward from the muscle
• Demineralization of the metaphysic withinDemineralization of the metaphysic within
10 to 12 days.- MRI and CT10 to 12 days.- MRI and CT

38. X-ray of leg, AP and
lateral views,
showing acute
osteomyelitis of
tibia.
(Note early
periosteal reaction-
arrow)

39. Lateral T2 weighted MRI of
distal femur with early acute
osteomyelitis. 10-year-old
female with progressive pain
left knee region and difficulty
walking. Plain
radiographs normal. MRI
showed signal changes distal
femur metaphyseal region
consistent with osteomyelitis

40. AP of T2
weighted MRI of the distal tibia
with late acute osteomyelitis.
Note the inflammatory changes
in the distal tibia metaphysis,
the signal changes beneath the
elevated periosteum, and the
large posterior abscess from
pus breaking through the
periosteum.

41. lateral of T2
weighted MRI of the
distal tibia
with late acute
osteomyelitis.
Note the inflammatory
changes
in the distal tibia
metaphysis,
the signal changes
beneath the
elevated periosteum,
and the
large posterior abscess
from
pus breaking through
the
periosteum.

42. Bone ScanBone Scan
• Bone scan showing increased uptake in rightBone scan showing increased uptake in right
• calcaneus. 11-year-old male with 3 day history of paincalcaneus. 11-year-old male with 3 day history of pain
• in the region of the right ankle and 1 day history ofin the region of the right ankle and 1 day history of
• limping. Ankle held in plantarflexion and heel in varuslimping. Ankle held in plantarflexion and heel in varus
• but there was no obvious swelling. Plain radiographsbut there was no obvious swelling. Plain radiographs
• were normal. MRI was not diagnostic but four phasewere normal. MRI was not diagnostic but four phase
• technetium bone scan markedly positive andtechnetium bone scan markedly positive and
• consistent with osteomyelitis of the calcaneus. Patientconsistent with osteomyelitis of the calcaneus. Patient
• was treated with 6 days of intravenous antibiotics andwas treated with 6 days of intravenous antibiotics and
• additional 5 weeks of oral antibiotics.additional 5 weeks of oral antibiotics.

44. 9-year-old female who presented with 7 days of
increasing pain in the ankle region. Patient treated by
drainage of soft tissue abscess and 6 weeks of
intravenous antibiotics. AP radiograph 6 weeks after
initiation of treatment shows radiolucent changes in
the tibial metaphysis from the bone resorption as well
as areas of sclerosis from new bone forming on
existing trabeculae. Bone formation is also noted
beneath the periosteum that was elevated by the
infectious process breaking through the metaphysis
Radiograph of a healing osteomyelitis

46. Differential DiagnosisDifferential Diagnosis
• Acute Rheumatism- pain, swelling andAcute Rheumatism- pain, swelling and
tenderness but with gradual onset.tenderness but with gradual onset.
Fleeting painFleeting pain
• Erisipelas- marked redness of skin withErisipelas- marked redness of skin with
less painless pain
• Haemophilia- muscle bleed into joint withHaemophilia- muscle bleed into joint with
marked pain and tenderness.marked pain and tenderness.
• Cellulitis- Strep. – no intense pain andCellulitis- Strep. – no intense pain and
general malaise is less.general malaise is less.

47. • Acute pyogenic arthritis- spasm of muscleAcute pyogenic arthritis- spasm of muscle
is marked. Movement at joint is moreis marked. Movement at joint is more
limited. Effusion in joint space is foundlimited. Effusion in joint space is found
earlier.earlier.
• Ewings sarcoma- general illness is little.Ewings sarcoma- general illness is little.

48. PrognosisPrognosis
• Factors-Factors-
• Inadequate treatment- chronicInadequate treatment- chronic
• Delayed treatmentDelayed treatment
• Organism- staph. Is more seriousOrganism- staph. Is more serious
• Bone infected nearer to the trunk is moreBone infected nearer to the trunk is more
seriousserious
• Age- younger the child outlook can beAge- younger the child outlook can be
grave- life and growth epiphysisgrave- life and growth epiphysis

49. Conservative measuresConservative measures
Treatment of general conditonsTreatment of general conditons
• Antibiotics and anti inflammatory drugs-Antibiotics and anti inflammatory drugs-
ASAPASAP
• Flucloxacilin and ampicilin started ivFlucloxacilin and ampicilin started iv
continue until blood culture and sensitivitycontinue until blood culture and sensitivity
are available.are available.
• Anti biotic for 6weeksAnti biotic for 6weeks
• Monitor ESRMonitor ESR

50. • Hydration and Electrolyte replacementHydration and Electrolyte replacement
• Protein replacementProtein replacement
• Immobilization- prevents the spread ofImmobilization- prevents the spread of
infection be reducing the muscle actioninfection be reducing the muscle action
and blood flow. Compressive bandageand blood flow. Compressive bandage
andand
POP slab with window to observe localPOP slab with window to observe local
condition.condition.
• Splint to be used after the acute stage toSplint to be used after the acute stage to
prevent deformity for a period of 2/52prevent deformity for a period of 2/52

51. DrainageDrainage
• Use a tourniquet whenever possible.Use a tourniquet whenever possible.
• Elevate the extremity for a few minutesElevate the extremity for a few minutes
before inflating the tourniquet.before inflating the tourniquet.
• Do not exsanguinate the limb with an elasticDo not exsanguinate the limb with an elastic
bandage if infection is present.bandage if infection is present.
• Make an anteromedial incision 5 to 7.5 cmMake an anteromedial incision 5 to 7.5 cm
long over the affected part of the tibia. Inciselong over the affected part of the tibia. Incise
the periosteum longitudinally; it may bethe periosteum longitudinally; it may be
elevated from bone by a subperiostealelevated from bone by a subperiosteal
abscess, and if so, the compressed pus willabscess, and if so, the compressed pus will
escape.escape.

52. • If no abscess is found, gently elevate the periosteumIf no abscess is found, gently elevate the periosteum
1.5 cm on each side. Try to strip as little periosteum as1.5 cm on each side. Try to strip as little periosteum as
possible; the more periosteum that is stripped, thepossible; the more periosteum that is stripped, the
more an already-compromised blood supply to bone ismore an already-compromised blood supply to bone is
damaged.damaged.
• Regardless of whether a subperiosteal abscess isRegardless of whether a subperiosteal abscess is
present, drill several holes 4 mm in diameter throughpresent, drill several holes 4 mm in diameter through
the cortex into the medullary canal. If pus escapesthe cortex into the medullary canal. If pus escapes
through these holes, use a drill to outline a corticalthrough these holes, use a drill to outline a cortical
window 1.3 × 2.5 cm and remove the cortex with anwindow 1.3 × 2.5 cm and remove the cortex with an
osteotome. Evacuate the intramedullary pus andosteotome. Evacuate the intramedullary pus and
gently remove any necrotic tissue.gently remove any necrotic tissue.
• Close the skin loosely over drains, but do not close theClose the skin loosely over drains, but do not close the
wound if this produces excessive tension on the skin.wound if this produces excessive tension on the skin.

53. • AFTERTREATMENT.AFTERTREATMENT.
• A long leg posterior plaster splint is applied withA long leg posterior plaster splint is applied with
the foot in a neutral position, the ankle at 90the foot in a neutral position, the ankle at 90
degrees, and the knee at 20 degrees of flexion.degrees, and the knee at 20 degrees of flexion.
Once the wound has healed, the splint isOnce the wound has healed, the splint is
removed, and protected weight-bearing withremoved, and protected weight-bearing with
crutches is begun. The patient is followed for 1crutches is begun. The patient is followed for 1
year with periodic roentgenograms.year with periodic roentgenograms.

54. • Posterolateral approach to tibia.Posterolateral approach to tibia.
• A,A, Skin incision.Skin incision.
• B,B, Plane between gastrocnemius, soleus, andPlane between gastrocnemius, soleus, and
flexor hallucis longus posteriorly and peronealflexor hallucis longus posteriorly and peroneal
muscles anteriorly is developed.muscles anteriorly is developed.
• C,C, Flexor hallucis longus arising from posteriorFlexor hallucis longus arising from posterior
surface of fibula.surface of fibula.
• D,D, Distal part of origin of soleus is detached fromDistal part of origin of soleus is detached from
fibula and retracted posteriorly and medially.fibula and retracted posteriorly and medially.
• E,E, Dissection medially across interosseousDissection medially across interosseous
membrane,detaching fibers of tibialis posterior.membrane,detaching fibers of tibialis posterior.

56. •Posterior tibial artery and tibial nerve are
protected by tibialis posterior and flexor hallucis
longus muscles. G and H, Muscles are detached
subperiosteally from posterior surface of tibia.

57. Anteromedial approach to knee joint.Anteromedial approach to knee joint.

58. Fernadez extensile anteriorFernadez extensile anterior
approachapproach
• A,A, Anterolateral incision.Anterolateral incision. B,B, ExtensorExtensor
mechanism exposed.mechanism exposed. C,C, Iliotibial band isIliotibial band is
reflected with Gerdy tubercle. Anteriorreflected with Gerdy tubercle. Anterior
compartment and pes anserinus are detachedcompartment and pes anserinus are detached
and elevated as necessary. Osteotomy of tibialand elevated as necessary. Osteotomy of tibial
tuberosity is outlined, and screw holes aretuberosity is outlined, and screw holes are
predrilled (see text).predrilled (see text). D,D, Patella, patellar tendon,Patella, patellar tendon,
and tibial tuberosity are elevated.and tibial tuberosity are elevated. E,E, Medial andMedial and
lateral menisci are detached anteriorly andlateral menisci are detached anteriorly and
peripherally and are elevated.peripherally and are elevated.

61. F,F, Meniscal repair isMeniscal repair is
performed with 2-0performed with 2-0
nonabsorbablenonabsorbable
sutures Gerdysutures Gerdy
tubercle is reattachedtubercle is reattached
with lag screw. Tibialiswith lag screw. Tibialis
anterior and pesanterior and pes
anserinus areanserinus are
reattached.reattached. G,G, TibialTibial
tuberosity is securedtuberosity is secured
with lag screwswith lag screws
engaging posteriorengaging posterior
cortexof tibia. Capsulecortexof tibia. Capsule
is closed withis closed with
interrupted sutures.interrupted sutures.
Sutures inperiphery ofSutures inperiphery of
menisci are now tiedmenisci are now tied

62. Banks and Laufman posteriorBanks and Laufman posterior
approach to superomedial regionapproach to superomedial region
of tibia.of tibia.
A,A, Incision extends transversely across poplitealIncision extends transversely across popliteal
fossa, then turns distally on medial side of calf.fossa, then turns distally on medial side of calf.
B,B, Skin and deep fascia have been incised andSkin and deep fascia have been incised and
reflected.reflected. C,C, Broken line indicates incision to beBroken line indicates incision to be
made between popliteus and flexor digitorummade between popliteus and flexor digitorum
longus.longus. D,D, Popliteus and flexor digitorum longusPopliteus and flexor digitorum longus
have been elevated subperiosteally to exposehave been elevated subperiosteally to expose
tibia.tibia.

64. Treatment of Chronic StageTreatment of Chronic Stage
• Factors responsible-Factors responsible-
• Presence of unabsorbed and retainedPresence of unabsorbed and retained
sequestrasequestra
• Presence of unoblitrated cavityPresence of unoblitrated cavity
• Change of aerobic cocci to gram negativeChange of aerobic cocci to gram negative
like E.coli, Enterobacter, Pseudomonaslike E.coli, Enterobacter, Pseudomonas
and Proteus or Anaerobes like Bacteroids.and Proteus or Anaerobes like Bacteroids.

65. • Sequestra should be removed with in 2 toSequestra should be removed with in 2 to
3 months before squestra is isolated and3 months before squestra is isolated and
separated from its bed.separated from its bed.

66. • Use a pneumatic tourniquet if possible.Use a pneumatic tourniquet if possible.
• Expose the infected area of bone and excise all sinusExpose the infected area of bone and excise all sinus
tracks completely. Incise the indurated periosteum andtracks completely. Incise the indurated periosteum and
elevate it 1.3 to 2.5 cm on each side.elevate it 1.3 to 2.5 cm on each side.
• Use a drill to outline a cortical window at theUse a drill to outline a cortical window at the
appropriate site and remove it with an osteotome.appropriate site and remove it with an osteotome.
• Remove all sequestra, purulent material, and scarredRemove all sequestra, purulent material, and scarred
and necrotic tissue (and necrotic tissue (AA andand BB). If sclerotic bone seals). If sclerotic bone seals
off a cavity within the medullary canal, open it into theoff a cavity within the medullary canal, open it into the
canal in both directions to allow blood vessels to growcanal in both directions to allow blood vessels to grow
into the cavity. A high-speed burr will help to locate theinto the cavity. A high-speed burr will help to locate the
demarcation between healthy and ischemic bone.demarcation between healthy and ischemic bone.
Sequestrectomy and curettage.Sequestrectomy and curettage.

67. • After removing all suspicious matter, carefullyAfter removing all suspicious matter, carefully
excise the overhanging edges of bone and avoidexcise the overhanging edges of bone and avoid
leaving a cavity or dead space. If a cavity cannotleaving a cavity or dead space. If a cavity cannot
be filled by the surrounding soft tissue, a localbe filled by the surrounding soft tissue, a local
muscle flap or a free tissue transfer can be usedmuscle flap or a free tissue transfer can be used
to obliterate the dead space.to obliterate the dead space.
• If possible, close the skin loosely over drainsIf possible, close the skin loosely over drains
and be sure that no excessive skin tension isand be sure that no excessive skin tension is
present. If closure is not possible, pack thepresent. If closure is not possible, pack the
wound open loosely or apply an antibiotic beadwound open loosely or apply an antibiotic bead
pouch and plan for delayed closure or skinpouch and plan for delayed closure or skin
grafting at a later time (grafting at a later time ( CC).).
• Appropriate antibiotics should be used before,Appropriate antibiotics should be used before,
during, and after the operation.during, and after the operation.

68. A,A, Affected bone is exposed, and sequestrum isAffected bone is exposed, and sequestrum is
removed.removed. B,B, All infected matter is removed.All infected matter is removed. C,C,
Wound is either packed open or closed loosely overWound is either packed open or closed loosely over
drains.drains.

70. AFTERTREATMENT.AFTERTREATMENT.
The limb is splinted until the wound has healed, and then it isThe limb is splinted until the wound has healed, and then it is
protected to prevent pathological fracture. Antibiotic treatment isprotected to prevent pathological fracture. Antibiotic treatment is
continued for a prolonged period and should be monitored by ancontinued for a prolonged period and should be monitored by an
infectious disease consultant.infectious disease consultant.

71. Bony and soft tissue defects must be filled to reduce theBony and soft tissue defects must be filled to reduce the
chance of continued infection and loss of function.chance of continued infection and loss of function.
Several techniques have been described for theSeveral techniques have been described for the
management of such defects and have provedmanagement of such defects and have proved
successful when properly performed, but they requiresuccessful when properly performed, but they require
meticulous surgical technique.meticulous surgical technique.
The methods described to eliminate this dead space areThe methods described to eliminate this dead space are
(1)(1)bone grafting with primary or secondary closure,bone grafting with primary or secondary closure,
(2)(2)use of antibiotic polymethylmethacrylate (PMMA)use of antibiotic polymethylmethacrylate (PMMA)
beads as a temporary filler of the dead space beforebeads as a temporary filler of the dead space before
reconstruction,reconstruction,
(3)(3)local muscle flaps and skin grafting with or withoutlocal muscle flaps and skin grafting with or without
bone grafting,bone grafting,
(4)(4)microvascular transfer of muscle, myocutaneous,microvascular transfer of muscle, myocutaneous,
osseous, and osteocutaneous flaps, andosseous, and osteocutaneous flaps, and
(5)(5)the use of bone transport (Ilizarov technique).the use of bone transport (Ilizarov technique).

72. Sickle Cell OsteomyelitisSickle Cell Osteomyelitis
• Three differencesThree differences
• 1. diaphysis of the long bone1. diaphysis of the long bone
• 2. MC organism is Salmonella, Staph.2. MC organism is Salmonella, Staph.
aureus is less common.aureus is less common.
• 3. route of infection- Acute bone infarction3. route of infection- Acute bone infarction

73. Thank youThank you