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Jungle Orthopaedics
ORTHOPAEDIC PROBLEMS IN A PRIMITIVE SETTING
Diplomate American Board of Orthopaedic Surgery
Date of production in this revised format: February 15, 2001
Monograph NO. 5 - Bone and Joint Infections in Children
Septic Arthritis
- Typically involves weight-bearing joints
- Generally only one joint involved
- Knee and hip are most commonly involved joints
- Onset--fever, pain, swelling, painful limitation of motion, joint held in position of comfort (in case of hip this is slight flexion, abduction, and external rotation to relax the capsule)
- Lab: CBC, ESR, blood cultures, x-rays WBC and ESR often but not always elevated
Hip: - in this joint early diagnosis and treatment is imperative, because the increased intracapsular pressure can compromise the circulation to the femoral head, resulting in avascular necrosis. In other joints the vessels to the physis and epiphysis lie outside the capsule and are not subject to compression.
Pathogens:- Overall staph aureus is the most common pathogen.
- In about one-third of cases no pathogen can be identified, even with a very thorough bacteriological examination.
- There is an age-predilection regarding the type of pathogens found: > Newborn:
- Staph aureus
- Group B streptococci--occasionally gonococcus
- Hemophilus influenza
- Streptococci of various types, including pneumococci
- Staph aureus
- Gonococcus in only about 6% of cases but it is the most common cause of polyarticular disease
Treatment:
Parenteral therapy is indicated for all cases of suspected septic arthritis. Choose the antibiotic on the basis of the gram stain, pending culture results. If gram stain is negative choose antibiotics on basis of most common organisms found in that age group:
- Neonate = ampicillin/gentamycin
- Infant - cefuroxime
- Child- Oxacillin, nafcillin, cefazolin, cephapirin
Usually 5-7 days of parenteral, followed by oral for 3-6 weeks.
NOTE: Ciprofloxacin not recommended in children--potential damage to joint cartilage
Surgery: Always drain hip surgically, to decompress it. This must be done early. Posterior approach probably safest in inexperienced hands.
Other joints: can lavage if necessary, but probably best to do incision and drainage to get pus out of joint as quickly as possible. Pus is destructive to joint cartilage. Do not use intraarticular antibiotics as they are quite irritating to the synovium.
SPECIAL NOTE: Infants can have silent meningitis, especially with hemophilus influenza. Must either do CSF examination or use antibiotic that will cross the blood-brain barrier.
Acute Osteomelitis
- Early diagnosis is desirable, because decompression of an acute abscess within the bone can minimize the spread of the infection within the bone. X-rays early may show only loss of normally defined tissue planes, due to swelling. The most frequently involved sites are usually long bones, especially femurs, tibias and humeri.
- Fever and other signs of sepsis may or may not be present.
- WBC may be normal at first in many cases.
- Bone scan is useful, but false negative scans are not uncommon.
- Blood cultures may be positive.
- Definitive diagnosis can be made by subperiosteal or rnetaphyseal needle aspiration. If subperiosteal pus is found, there is no need to decompress the bone. If no pus is found subperiosteally, then the needle should be introduced into the metaphysis, or drill holes made into the rnetaphysis. If pus is found the bone should be windowed to decompress the abscess.
- In neonates there may be only swelling, flexion contractures and overlying inflamatory reaction. Very commonly neonatal osteomyelitis is multifocal.
- The mainstays of treatment are adequate drainage and antibiotic therapy, guided by the Gram stain and culture results.
- In osteomyelitis of metatarsals following puncture wounds of sole, pseudomonas is often the causative organism.
- Antibiotics usually should be given parenterally for 5-7 days, followed by oral for 3-6 weeks.
Lyme Arthritis
Lyme arthritis gets its name from a town in the state of Connecticut, USA, where the disease was first discovered and described. It is caused by a spirochete, which is carried by a tick. When an infected tick bites a person, that person can get Lyme disease.
The earliest sign is an expanding skin lesion, called ERYTHEMA CHRONICA MIGRANS. It is a red area, with a pale center. This lesion comes days to weeks (3-32 days) after the bite, and may be accompanied by flu-like symptoms.
Weeks to months later (up to two years) the patient develops neurologic, cardiac or joint involvement. The arthritis presents as intermittent attacks of asymmetric joint swelling and pain, usually involving large joints, especially knees.
The knees are usually more swollen than painful, often hot, but rarely red. Baker's cysts may form and rupture early. However, both large and small joints may be affected. A few patients have symmetric polyarthritis.
Attacks last a few weeks to a few months, typically recurring for several years, accompanied by fatigue, but few other constitutional symptoms.
Synovial fluid: WBC 500-110, 000 -- average 25,000. Mostly polys.
- Protein 3-8 Gms/deciliter
- Glucose level greater than 2-3 times serum level.
- RA negative
- 10% of cases become chronic with pannus and erosion of cartilage.
Treatment for established arthritis:
- Penicillin parenterally - i. m. benzathene penicillin 2. 4 million units weekly X 3 wks. -- or I. V penicillin
Symptoms:
- asymmetric arthritis of large joints, usually, especially knees
- intermittent attacks
- knees usually not as painful as swollen, often hot, rarely red
- may affect large and small joints
- may be symmetric and polyarthritis
- attacks last weeks to months
- typically recur for several years fatigue with attacks