Bone and Joint Infection

Dr. Zainab Abdulwahab

Clinical case

Three year old child with history of trivial trauma to left leg for
one day duration, was febrile, loss of appetite, the leg was in
pain, redness, diffuse swelling and tenderness.

Joint movements were pain free.

White blood cell was 12000, C-reactive protein was positive.

Plain x ray of leg was normal in both AP and lateral view.

Possibilities

• Trivial trauma………..fracture of tibia?

• Febrile………………..cellulitis, osteomyelitis

• Loss of appetite........... inflammatory process

• Diffuse swelling and tenderness ……..tumour of bone

• Joints movements normal………...not septic arthritis

• WBC is high, C-reactive protein +ve .......cellulitis, osteomyelitis

• Plain x-ray normal............cellulitis, osteomyelitis

Osteomyelitis (bone infection)

Types
• Acute hematogenous

• Subacute

• Chronic
─ Post traumatic
─ Post operative
What is acute haematogenous Osteomyelitis?

• Acute haematogenous osteomyelitis is mainly a

disease of children.

• It is less than 3 cases per 100 000 per year.

• BUT IN OUR COMMUNITY IS MORE.

 Factors predisposing to bone infection

General Causes: Local causes:

• Malnutrition and general debility • Venous stasis in the limb
• Diabetes mellitus • Peripheral vascular disease
• Corticosteroid administration • Loss of sensation
• Immune deficiency • Iatrogenic invasive measures
• Immunosuppressive drugs • Trauma
How micro-organisms can reach the bones
and joints?

Direct: Through skin

Indirect: Via blood

 Why mainly invade the metaphysis?

• End arteriole coiling in the metaphysis

before entering the sinusoid, that
leads to stasis of blood / which is a
good media for bacteria to proliferate.
• Low in macrophages.
Q) Why in new-born infants bone and joint
infection easily coexist?
A) Because the physis is under-developed thus the
metaphyseal arteries give blood supply to the
epiphysis directly, while in older children the physis
is well developed which acts as a barrier against
infection from reaching the epiphysis, and the
blood supply of the epiphysis and metaphysis are
separated.
 Host response (Pathology)

• Inflammation

• Suppuration

• Reactive new bone formation (involucrum)

• Resolution (healing)

• Necrosis (sequestrum and chronicity with sinus

formation)
 Main causal microorganism?

• Staphylococcus aureus (over 70% of cases in children

and adults).
• Beta hemolytic Streptococcus:
• Group A beta-hemolytic streptococcus (S. Pyogenes),
found in chronic skin infections.
• Group B streptococcus (especially in new-born babies).
• Alpha hemolytic diplococcus: S. pneumoniae.
• Haemophilus influenzae: Gram negative, fairly common
pathogen for osteomyelitis and septic arthritis in children
between 1 and 4 years of age.
 ?How we can confirm clinically

History: upper respiratory tract infection, UTI ….etc.

On examination
• Pain
• RED, Swelling in metaphysis of long bone
• Tenderness
• Fever
• Lethargy
• Loss of appetite
 How to clinically confirm it?

• Aspiration of pus from the metaphyseal sub-

periosteal abscess or through bone aspiration,
then the sample is sent for cytology, culture
and sensitivity.
• Blood tests (CBC, ESR, CRP).
• Blood culture.
 Diagnosis by imaging

• Plain x Ray

• Ultrasound

• MRI

• Radioscintigram (radionuclide scan)

 Plain x-ray

a faint extra-cortical
outline due to
periosteal new bone
formation. Later the
periosteal thickening
becomes more
obvious and there is
patchy rarefaction of
the metaphysis; later
still the ragged
features of bone
destruction appear.

Metaphyseal resorption and periosteal reaction which appear

after 14 days.
Osteopenia + periosteal reaction after 14 days.
Pathological fracture
Dead bone = sequestrum
New bone = involucrum
Ultrasound
MRI of proximal tibia
Bone scan
 Treatment

• General supportive treatment: …

Analgesia, i.v fluid and blood transfusion.

• Splintage …… back slab, skin traction.

• Antibiotic … according to culture and

sensitivity.

• Drainage …… if no response to previous

protocol ( 48 hours), surgery indicated.
 Antibiotic therapy

Initially ‘best guess

Staphylococcus aureus is the most common at all ages.

Up to 6 months of age
• Staphylococcus aureus
• Group B streptococcus and
• Gram-negative organisms.
• Flucloxacillin + cefotaxime is given or flucloxacillin +
benzylpenicillin + gentamicin (for Gram-negative organisms).
 Antibiotic therapy

6 months - 6 years of age

• Haemophilus influenzae/ flucloxacillin +cefotaxime or

cefuroxime.

Older children and previously fit adult

• Staphylococcal/ flucloxacillin+ fusidic acid

 Antibiotic therapy

• Patients who are allergic to penicillin … second or third

generation cephalosporin.

• Elderly and previously unfit patients, Gram-negative

flucloxacillin + second or third-generation cephalosporin.
 Antibiotic therapy

Patients with sickle-cell disease: Staphylococcal infection,

salmonella and/or other Gram -ve organisms

• Third-generation cephalosporin or a

• Fluoroquinolones (ciprofloxacin).

Heroin addicts and immunocompromised patients……..same

 Antibiotic therapy

Patients at risk of methicillin-resistant Staphylococcus aureus

(MRSA)

• Vancomycin + a third-generation cephalosporin.

• Intravenously given antibiotics/ CRP returning to normal

takes 2–4 weeks. 
• orally given antibiotics/ CRP fall takes another 3–6 weeks.
 Complications

• Metastatic infection

• Suppurative arthritis

• Altered bone growth

• Chronic osteomyelitis
 Subacute Haematogenous Osteomyelitis

• Also called (Brodie’s abscess)

• Causes of subacute
osteomyelitis are:
1. The organism being less
virulent.
2. The patient is more
resistant.
 Post-Traumatic Osteomyelitis

• The most common cause of

osteomyelitis in adults.
• Causes are: Open fractures
and use of foreign implants.
• Most common causative
organism is Staph. aureus.
 Chronic Osteomyelitis

• Follow open fracture or operation.

• Mixed infection
• In presence of implant… staph. epidermidis
 Pathology of chronic
O.M.

• Discrete areas
• Sequestra
• Sclerosis
• Pathological fracture
• Sinuses
 Investigations

Sinogram

• Blood tests
• Culture of sinus discharge
 Treatment

• Antibiotics
• Local treatment
• Surgical treatment in Chronic osteomyelitis which includes:
1. Double-lumen tube
2. SQUESTRECTOMY
3. PAPINEAU TECHNIQUE
4. ILIZOROV method
 SURGERY IN CHRONIC O.M

SQUESTRECTOMY PAPINEAU TECHNIQUE

ILIZOROV method
 ACUTE SUPPURATIVE ARTHRITIS

SEPTIC ARTHRITIS
Joint infected via two routes:
• Direct
• Indirect
The causal organisms:
• Staphylococcus aureus
• Haemophilus influenzae in children 1 -4years
• Streptococcus,
• Escherichia coli and Proteus
 Pathology

(1) complete resolution

(2) partial loss of articular cartilage
(3) loss of articular cartilage bony ankylosis
(4) bone destruction and deformity of the joint.
 Clinical Features

Infants
Special care should be taken not to miss a concomitant
osteomyelitis in an adjacent bone end.
Children …. Present as (‘pseudoparesis’)
Adults… superficial joints are involved
 Images

• Ultrasound
• Plain x-ray
• MRI
• Bone scan
 Investigations

• Joint aspiration

• Blood tests

• Blood culture
 Differential diagnoses

• Osteomyelitis.

• Acute haemarthrosis.

• Transient synovitis.

• Gout.
 Treatment

• GENERAL SUPPORTIVE CARE: Fluid + analgesia

• SPLINTAGE: Back slab or skin traction

• ANTIBIOTICS

• DRAINAGE: arthroscopy
or open arthrotomy.
 Complications

Pathological dislocation .1
 Complications

Ankylosis .2
 Complications

Corrective osteotomy .3
In osteomyelitis Sequestrum is new born formation.

• False

• True

Answer: False. Involucrum is new bone formation.

Sequestrum is dead bone.
Brodie's abscess is chronic osteomyelitis.

• False.

• True.

Answer: False. Brodie's abscess is subacute osteomyelitis.

The Shoulder
Clinical Assessment

• History: pain, stiffness, deformity, loss of function

• Causes of shoulder pain:
1. Referred pain: cervical spondylosis, mediastinal
pathology, cardiac ischemia.
2. Joint disorders: glenohumeral arthritis,
acromioclavicular arthritis.
3. Rotator cuff disorders: tendinitis, tendon rupture,
Frozen shoulder.
Examination

1. Look: Skin, Shape, Position.

2. Feel: Temperature, Joint line tenderness, Effusion.
3. Move: Active movement (by the patient) & Passive movement
( you move the patient's limb), limb Power examination (0-5).
4. Imaging: X-ray/ Anterio-posterior, lateral & trans-axillary
arthrography, Ultrasound, C.T. scan, MRI
5. Arthroscopy.
Rotator Cuff Disorders

• Anatomy: cuff of conjoint tendons (supraspinatus, infraspinatus,

Teres minor and subscapularis tendons) that insert at the greater
tuberosity of the humerus and pass beneath the coracoacromial arch
(Coracoacromial arch is an osteofibrous structure resulting from the
continuity of the acromion, coracoacromial ligament, and coracoid
process with each other)
• Pathology: Degeneration, Trauma, Vascular reaction/ Wear, Tear and
Repair
• Clinical syndromes are:
1. Acute Tendinitis.
2. Chronic Tendinitis.
3. Rot. cuff tears.
4. Adhesive Capsulitis (frozen shoulder).
Anatomy of rotator cuff tendon.

• Anatomy: The conjoint

tendon passing just
beneath and below the
coracoacromial
ligament.
Pathology
Acute Calcific Tendinitis

• Clinical features: common in young adults, onset of pain is after

overuse, usually severe agonizing pain and restriction of all
movements which subsides in few days.
• X-ray: usually there are no findings, but sometimes calcification at the
level of the insertion of rotator cuff in the greater tuberosity, appears
on x-ray as opacification.
• Treatment: Rest in arm sling, analgesics/ NSAID, local steroid injection
or operation (excision or aspiration of calcification).
Calcific tendonitis

• Calcification at the insertion of rotator cuff tendon appearing in this

image just above the greater tuberosity of humerus.
Chronic Tendinitis (Impingement Syndrome)

• Clinical features: affects adults and middle aged group between (40-
60 yrs), characterized by a painful arc (pain between 60-90 degrees of
abduction) because this range of motion causes maximum
impingement of the rotator cuff tendon in the subacromial region.
• Imaging: X-ray, Ultrasound, MRI
• Complications: subluxed humeral head & Osteoarthritis that also
appear on x-ray.
• Treatment: NSAID or local steroid injection or decompression by
excision of coracoacromial lig. & anteroinferior part of acromion
nowadays by arthroscopy.
Chronic tendinitis

• Image illustrating the painful

arc and an orthopedic
surgeon examining the
rotator cuff tendon.
 Rotator Cuff Tears
• Partial tear: may occur with Supraspinatus tendinitis
• Complete: from sudden strain or complication Of tendinitis or partial rupture.
• Clinical features: common in those between 45-75 years of age. Pain on lifting
the limb & inability to lift arm. If the tear is partial it might recover and pain
might subside completely but weakness of abduction persists. (Neer test), is
used to differentiate partial and complete tears. Abduction paradox & drop
arm sign is a test used to diagnose complete rotator cuff tear.
• Note: passive abduction is full and once the arm has been raised above 90 degrees,
abduction can be completed by the power of the deltoid - "abduction paradox“
• Note: an arm which is gradually lowered from full abduction will suddenly drop once it
moves out of the range under the influence of the deltoid - "drop arm sign"
• Diagnosis: confirmed by US,MRI or Arthroscopy.
• Treatment:
• In partial tear: heat physiotherapy, exercises, inj. of lidocaine locally,
• If the tear is complete in young, surgical repair, and nonoperative treatment in elderly
 Rotator cuff tears
Image illustrating
Neer test (above)
and Abduction
paradox (below).

(a–d) Partial tear of left supraspinatus: the patient can abduct actively once pain
has been abolished with local anaesthetic.
(e–g) Complete tear of right supraspinatus: active abduction is impossible even
when pain subsides (f), or has been abolished by injection; but once the arm is
passively abducted, the patient can hold it up with her deltoid muscle (g).
Adhesive capsulitis (frozen shoulder)

• Characterized by progressive pain & stiffness usually resolves in about 18

months.
• Etiology: Cause & pathology are still unclear
• Features: Affects those between 40-60 years of age usually, caused by
Trivial trauma then progressive pain for six months then the pain subsides
& stiffness starts & persists for 6-12 months.
• X-ray: shows de-density in humerus, due to osteoporosis caused by
immobility due to pain, arthrography shows contraction of capsule.
• D.D.: Post-traumatic stiffness, Disuse stiffness, regional pain syndrome.
• Treatment: Conservative analgesics anti-inflammatory drugs, heat
physiotherapy for pain or local stiffness. inj. of lidocaine locally. If acute
pain subsides, manipulation under general anesthesia is done. Operative
arthroscopic division of the interval between Supraspinatus &
Infraspinatus may improve movement.
Adhesive capsulitis

First Image illustrating the

mode of progression of pain
and stiffness in frozen
shoulder. second image
illustration limitation of left
arm movement due to
adhesive capsulitis
Questions

• Acute calcific rotator cuff tendinitis is associated with complications

such as subluxation of the head of humerus and osteoarthritis. True
or False?
• Answer: False. Chronic tendinitis is associated with such complications.
• Neer test is used to differentiate between partial and complete
rotator cuff tears. True or False?
• Answer: True
Non - Traumatic Joint Pain
(The Elbow)

Dr. Zainab Abdulwahab

 Objectives

1.Clinical assessment

2.Elbow deformities

3.Tennis and Golf elbow

 Clinical Assessment

History: of pain, stiffness, swelling, deformity, instability, ulnar

nerve symptoms, and loss of function.

Elbow examination: 
• look: carrying angle, valgus or varus deformities and swelling. 
• Feel: bony landmarks, temperature, subcutaneous nodules,
joint line, synovial thickening and the ulnar nerve. 
• Move: flexion & extension, pronation & supination.

General examination: examine the neck for (cervical disc

prolapse), the shoulder for (cuff lesions) and the hand for (nerve
lesions).

Imaging: X-ray (A.P & Lateral) views, C.T scan, MRI, U/S and MRI.
 Elbow Deformities
Cubitus Varus: 
1. Gun-stock deformity, obvious on elbow extension & arm elevation.
2. Caused by malunion of supracondylar fracture.
3. Corrected operatively by wedge osteotomy.

Cubitus Valgus: 
4. Caused by nonunion of lateral condylar fracture.
5. Liable for delayed ulnar nerve palsy, years later might develop
weakness and numbness & tingling of ulnar fingers (little and ring
fingers).
6. Symptomatic patient is treated operatively by anterior transfer of
ulnar nerve (The deformity itself needs no treatment, but for
delayed ulnar palsy the nerve should be transposed to the front of
the elbow)
 Cubitus Varus

Cubitus varus deformity of the right elbow.

Gun Stock Deformity
 Cubitus Valgus

Cubitus valgus deformity of the left elbow, with tardy ulnar nerve palsy.
 Tennis and Golfer’s Elbow
Causes are unknown, seldom due to tennis or golf. Mostly after minor trauma
or repetitive strains on tendon aponeurosis attached to the lateral or medial
humeral epicondyle, often occur as a result of stress or unaccustomed activity
e.g. house paint and carpentry etc.
Tennis elbow: 

1. Pain over the lateral aspect of elbow and it aggravates by

movements like pouring tea, turning a stiff door handle,
shaking hands or lifting with pronation of the forearm.
2. Tenderness over the spot just below the lateral epicondyle
reproduced by extension of the wrist against resistance or
passive flexion the wrist to stretch the common extensors.
3. Treatment: avoid precipitating activity, or injection of local
steroid + Lidocaine, if no response to conservative treatment,
surgical detachment of extensors is performed.
 Tennis Elbow
Clinical evaluation and examination of tennis elbow.
Golfer’s elbow:

1. Pain over medial epicondyle.

2. Reproduced by passive extension of the wrist.
3. Treatment: avoid precipitating activity, or injection of
local steroid + Lidocaine, if no response to
conservative treatment, surgical detachment of
flexors is performed.
Cubitus varus results in tardy ulnar nerve palsy.

True.

False.

Answer: False. Cubitus valgus results in tardy ulnar nerve palsy.

Tennis elbow is a common flexors tendinitis.

False.

True.

Answer: False
Non - Traumatic Joint Pain
(The Wrist)

Dr. Zainab Abdulwahab

 Objectives

1.Clinical assessment
2.History
3.Examination
4. De Quervain’s disease
5.C.T.S
 Clinical Assessment

History: Pain at the radial side (tenosynovitis of the first

dorsal compartment), tenderness at the ulnar side of the
wrist due to (inferior radio-ulnar joint injury), or pain at the
mid-wrist (due to carpus pathology).

Causes of painful wrist:

1. Joint disorders, infection, kienbock’s disease, carpal
instability, rheumatoid arthritis, osteoarthritis.
2. Periarticular causes include: deQuervain’s tenosynovitis.
3. Referred pain: cervical spondylosis
 History

• Stiffness
• Swelling of joint or tendon sheath
• Deformity
• Loss of function (weak grip): both wrist & hand, because
a firm grip is only possible with strong, stable, painless
wrist that has a reasonable movement.
Examination
• Wrist examination is only complete with the examination of
elbow, forearm & hand, also expose both upper limbs.
• Look
• Feel
• Move

Investigations
• X-ray
• MRI
• Arthroscopy
 Examination

Image showing the movements of the wrist

 DeQuervain’s Disease

• It is tenovaginitis of the 1st dorsal compartment, usually

affects women (30-50 yrs. of age), pain starts after
unaccustomed activity e.g. pruning roses, cutting with
scissors or wringing out clothes.

• Features: Pain & sometimes swelling of the radial side of

the wrist, tendon sheath feels thick & hard, tenderness at
the tip of radial styloid process, and +ve Finkelstein’s sign.

• Treatment: early cases by ultrasound physiotherapy &

local steroid injection, resistant cases by surgical release
of first dorsal compartment sheath.
 Examination

Image illustrating examination and treatment of DeQuervain’s Disease.

a) Tenderness over the styloid process.
b) & c) Finkelstein’s test (Pain on the radial side of the wrist by adduction of thumb
and ulnar deviation of the wrist).
d) Local steroid injection as a treatment of DeQuervain's Disease.
 Carpal Tunnel Syndrome

• It is the commonest nerve entrapment

syndrome, caused by any swelling that is likely to
cause compression & ischaemia of median
nerve.

• Common in women at menopause (40-50 yrs. of

age), in Rheumatoid arthritis, pregnancy &
myxedema.
 Carpal Tunnel Syndrome
• History: Pain & Paresthesia in the distribution of median nerve,
usually severe at night and changing the position of wrist may help
relieve the pain.

• Two sensory tests:

1. Tinel’s test: by percussing over the course of the nerve.
2. Phalen’s test: holding the wrist in full flexion for 1 or 2 mins.
• Both tests reproduce the symptoms (pain and paresthesia of the
radial three and a half fingers). 
• In late cases there will be wasting of the thenar muscles, weak
thumb abduction & sensory dulling in median nerve territory.

• Electrodiagnostic test shows delay of nerve conduction.

• D.Dx/ cervical spondylosis, which may also coincide with CTS.

 C.T.S. examination

a) Atrophy of the thenar muscles in late CTS.

b) Tinel's test
c) Phalen's test.
d) Distribution of pain and paresthesia.
e) Weakness of thumb abduction in late CTS.
 Carpal Tunnel Syndrome

Treatment:

• Night splints might help improving related

symptoms, also steroid inj. temporarily relieves
the symptoms.

• Open surgical division of transverse carpal

ligament provides quick & simple cure, also
endoscopic release is used with slightly quicker
postoperative rehabilitation.
Phalan's test is a clinical test used to detect DeQuervain's
Disease.

True.

False.

Answer: False. Phalen’s test is used to detect C.T.S.