NHIỄM TRÙNG VIÊM XƯƠNG và VIÊM KHỚP, điều TRỊ (CHẤN THƯƠNG CHỈNH HÌNH)

Duration of antibiotic treatment• These broad generalizations serve as an average duration of treatment... Indication for operative drainage• The failure of response to antibiotic treatm

NHIỄM TRÙNG:

VIÊM XƯƠNG & VIÊM KHỚP

ĐIỀU TRỊ

Commonly used antibiotics for

musculoskeletal infections

Daily dosage of antibiotic treatment

• These are some broad generalizations for infants over 1 month of age and for children

Duration of IV antibiotic treatment

• Base duration of parenteral antibiotics on clinical

response

Duration of antibiotic treatment

• These broad generalizations serve as an average

duration of treatment

Abscess protects bacteria from

antibiotics

• The abscess prevents antibiotic penetration,

Indication for operative drainage

• The failure of response to antibiotic treatment is often

an indication for drainage

Methods of drainage

• These are the common methods of drainage

Surgical drainage

of acute or subacute osteomyelitis

• The infection is drained locally, with care taken to avoid injury to the growth plate WIth time, bone fills in the defect.

Acute osteomyelitis

• If the cortex is intact, explore by making drill holes [A] Remove the drill and observe the drainage If the drainage is purulent [B], window the cortex to provide better drainage [C] If only blood drains [D], explore with additional drill holes until the site of abscess is found [E] Window the cortex with a small osteotome [F] Avoid an excessively large window to reduce the risk of pathological fracture Gently curette the medullary cavity to ensure

Drainage of osteomyelitis

• Drain by windowing the cortex and exploring

adjacent bone with a curette (yellow arrow).

• Drain through an anterior skin line axillary incision to minimize residual scarring [H] Drain both the joint and the bursa for the biceps tendon Place a small drain

and secure it with a single skin suture to prevent

premature displacement Close the skin with a few

subcutaneous sutures at the margins 12

• Place in a sling with the arm held to the thorax with a dressing

• Drain through a direct lateral approach [J] between the triceps and biceps muscles Open the joint capsule just anterior to the lateral collateral ligament.

• Drain most by needle aspiration Open drainage is performed on the dorsomedial or lateral aspect

of the joint [K] Avoid the superficial radial nerve

on the lateral side.

Hip drainage

• Anterior drainage is preferable [E], as the approach is less likely

to damage the joint vascularity, and the residual scar [F and G]

is more acceptable

• Ít trật khớp háng sau

mổ, so với đường Watson-Jones

Knee drainage

• Knee drainage is through either a

medial or lateral approach [D]

Ankle drainage

• Drain through a lateral approach either posterior [B] or anterior [C] to the fibula

Acute osteomyelitis

• Avoid penetrating the growth plate by imaging if

necessary [G] Avoid an excessively large window to

reduce the risk of pathological fracture

Drainage in difficult locations

• Monitor position of curette with fluoroscopy and avoid the physis (red arrow) Usually, a drain is placed (yellow arrow)

• If bone resection is significant, immobilize with a cast to prevent fracture Continue antibiotic

treatment until the ESR becomes normal.

Post-Drainage Management

• Antibiotics Start IV antibiotic treatment immediately

after taking the joint fluid for culture Gram stains are sometimes useful to identify the category of organism

to help with selection of an antibiotic

• Drains Remove the drain only after significant drainage

has ceased Drains usually can be removed in 2–3 days

• Activities Allow active use as the child becomes

comfortable Physical therapy usually is unnecessary because joint motion recovers spontaneously

Drainage of persistent subacute distal

tibial osteomyelitis

• Tenderness and inflammation and radiographic

changes were indications for operative drainage Avoid placing the curette across the physis (red arrow)

Defect is healing four weeks later (yellow arrow)

• Sometimes bone grafting is performed [M]; however, in most cases fill the space with adjacent muscle [N]

• Consider the need for sending a specimen to

pathology, as sometimes tumors and infection are

confused

Saucerization of chronic osteomyelitis

• If the infection spreads and devascularizes a segment of

bone, this dead bone becomes a sequestrum (black) under the involucrum (dark brown) Manage by saucerization to remove the sequestrum and infected tissue The healthy overlying soft tissue fills in the saucer.

Severe genu valgum due to infection

• This child lost the lateral half of the distal femoral

growth plate due to osteomyelitis in early infancy The deformity is progressive and difficult to correct

Limb lengthening for residual of

osteomyelitis

• This boy developed osteomyelitis

of the left upper femur in the neonatal period (red arrow) The growth plate was damaged,

resulting in deformity of the femoral head (yellow arrows) and limb shortening of 8 cm The shortening was corrected by an Ilizarov leg lengthening

technique The bone is divided and gradually distracted while being stabilized with the external fixator

Distribution of septic arthritis

• From data of Jackson and Nelson (1982)

Organisms in septic arthritis

• These organisms are listed according to relative frequency

Antibiotic management of septic arthritis by age group

• The usual infecting organism and appropriate

antibiotic are categorized by age group.

Arthroscopic drainage of septic arthritis of the knee

• This is an acceptable method of drainage