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

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 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, protecting bacteria 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 Siêu âm xem lối vào Hậu phẫu: •Bột trịn? •Nẹp bột? •Treo tay? • 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 complete drainage 10 Acute osteomyelitis • Avoid penetrating the growth plate by imaging if necessary [G] Avoid an excessively large window to reduce the risk of pathological fracture 20 Drainage in difficult locations • Monitor position of curette with fluoroscopy and avoid the physis (red arrow) Usually, a drain is placed (yellow arrow) 21 • If bone resection is significant, immobilize with a cast to prevent fracture Continue antibiotic treatment until the ESR becomes normal 22 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 23 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) 24 Operative debridement • The site of drainage of chronic osteomyelitis (proximal medial thigh – red arrow) may be distant from the sequestrum Define the sinus tract and infected tissue with a sinogram with methylene blue dye Excise the sequestrum and all infected tissue (red) 25 Chronic Osteomyelitis • Usually, a sequestrum is present [J] Sequestra may be subperiosteal, cortical, or medullary Identify preoperatively with imaging CT scans are usually indicated • Manage most by sequestrectomy [K] and saucerization [L] 26 • 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 27 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 28 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 29 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 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 30 Distribution of septic arthritis • From data of Jackson and Nelson (1982) 31 Organisms in septic arthritis • These organisms are listed according to relative frequency 32 Antibiotic management of septic arthritis by age group • The usual infecting organism and appropriate antibiotic are categorized by age group 33 Arthroscopic drainage of septic arthritis of the knee • This is an acceptable method of drainage 34 ... the growth plate WIth time, bone fills in the defect Acute osteomyelitis Siêu âm xem lối vào Hậu phẫu: •Bột trịn? •Nẹp bột? •Treo tay? • If the cortex is intact, explore by making drill holes [A]