The Infection of Bones And Joints - Standard Treatment Guidelines

The common infection of bones and joints are mainly due to pyogenic organisms. It usually occurs in small children in the metaphysical regions of long bones, usually to a focus of infection elsewhere in the body through hematogenous/ lymphatic. The offending organisms are staphylococcus commonly: other organisms are less common like streptococcus, Ecoli etc.

The bacteria get lodged in the metaphysis where they continue to grow, block small vessels which causes necrosis of bone. Pus focus rapidly which may transverse laterally under the periostenum, form an abscess or may even burst on the surface. This is the tone when treatment should be started aggressively lest it should get converted into chronic osteomyelitus.

The Ministry of Health and Family Welfare has issued the Standard Treatment Guidelines Critical Care for The Infection of Bones And Joints. Following are the major recommendations:

Definition

Osteomyelitus is an acute or chronic inflammatory process. Within bone, bone marrow and surrounding soft tissue that develops. Secondary to infection with bacterial organisms (and rarely fungi).

ii) Incidence of the condition in our country It is very common condition in our country

iii) Differential diagnosis

• Cellulitis


• Ewing’s Sarcoma


• Osteosarcoma


• Arthritis

iv) Prevention and counseling – early diagnosis and treatment

Can prevent considerable morbidity.

v) Optimal diagnoster criteria, investigation, treatment and Referral criteria.

Situation 1:- At secondary hospital/Non-Metro situation: limited technology and resources.

a. Clinical Diagnosis

Signs of acute inflammation

High temperature

Rapid pulse

Extreme degree of pain (Rest/movement)

Local tenderness

b. Investigation

Complete hemogram, culture and sensitivity of aspirated material, ZN staining, Gram’s staining.

Xray:

• Simple radiograph


• Sinogram

c. Treatment

• Rest – The limb of the patient to be put on rest


• Antibiotic – broad specters antibiotic to be started - to be Changed according to culture and sensitivity


• Out patient – if abscess is present regardless of the stage of disease effective drainage is to be done.


• Day Care – Multiple drill holes, rectangular window, thorough Debridement


• In patient – Immobilization, saucerisation, IV antibiotic, sequestrectomy


• Referral Criteria – No improvement in patients, general condition, deterioration of patients, conditions and other associated complications

Situation 2:- Super specialty facility in metro location where higher end technology is available.

a. Clinical Diagnosis – Signs of acute inflammation, high temperature, rapid pulse, extreme degree of pain, Local tenderness

b. Investigations:- Complete hemogram, Blood Culture, culture and sensitivity of aspirated material, ZN staining, Gram’s staining.

Xray:

• Simple radiograph


• Sinogram

Bone scan

CT Scan

ELISA against different antigens of organisms and antibody detection in serum Histopathological study

i) FNAC

ii) Open Biopsy

MRI

Radioisotope labeled Leukocyte scanning

PET scanning

c. Treatment

• Rest – The limb of the patient to be put on rest


• Antibiotic – broad spectrum antibiotic to be started - antibiotics to be according to sensitivity


• Out patient – if abscess is present regardless of the stage of disease effective drainage is to be done.


• Day Care – Multiple drill holes, rectangular window, thorough debridement


• In patient – Immobilization, saucerisation, IV antibiotic, sequestrectomy


• Referral Criteria – No improvement in patients, general condition, deterioration of patients, conditions and other associated complications

Who does what:-

Doctor:- Early diagnosis and treatment

The diagnosis and treatment is to be started as early as possible. Delaying the treatment can only increase the severity of the disease. Sometimes patient need to be referred.

Nurse:- Patient care

The patient need to be hospitalized in the early stages of the disease to avoid chronicity of the disease for proper patient care.

Technician:- Investigation

Guidelines Developed by Ministry of Health and Family Welfare :

Group Head Coordinates of Development Team Dr. P.K. DAVE, Rockland Hospital, New Delhi Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. Sharma, Professor Central Instiute of Orthopaedics, Safdarjung Hospital, New Delhi