Acute Orthopaedic infections

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Acute orthopaedic infections, which often present as emergencies, include acute osteomyelitis, acute septic arthritis, acute pyomyositis, acute-on-chronic osteomyelitis, and acute-on-chronic septic arthritis.

Acute osteomyelitis and septic arthritis can co-exist in the same individual. They are more common in children and in patients with sickle-cell disease. When the diagnosis is made in an adult, it is important to exclude immune-suppression. Staph. aureus and epidermidis account for the majority of the above infections. The commonest route of infection is haematogenous and may originate from skin lesions and ENT infections. 

It is important to cover empirically with appropriate antibiotics without necessarily waiting for the culture and sensitivity report.

Cause

  • Staph. aureus
  • Staph. epidermidis
  • Salmonella (common in sickle-cell disease)
  • Haemophilus influenza 
  • Strept. pyogenes
  • Strept. faecalis
  • E. coli
  • Open fractures
  • Iatrogenic
    • Implant surgery
    • Joint aspirations
    • Femoral vessel procedures
    • Intra-osseous infusions and transfusions
    • Umbilical vessel catheterization

Symptoms

  • Fever
  • Pain
  • Inability to move affected limb
  • Swelling
  • Lethargy 
  • Refusal to feed (children)

Signs

  • Febrile
  • Swelling 
  • Inability to use the limb

Investigations

  • FBC, ESR
  • Sickling
  • CRP
  • Blood culture 
  • X-ray of affected part
  • Ultrasound scan of affected part (may also be used for guided aspiration)
  • Gram stain and culture of aspirate
  • MRI (if available)
  • Radionuclide scans

TreatmentTreatment Objectives

  • Eradicate infection
  • Prevent development of chronicity
  • Prevent complications 

Non-pharmacological treatment

  • Splinting 
  • Ultrasound guided aspiration
  • Incision and drainage

Pharmacological treatment 

See sections below

Referral Criteria

  • Refer to an orthopaedic specialist if there is collection of pus and no improvement in 36 hours

Anti-infective therapy

1st Line Treatment

Evidence Rating: [B]

  • Cloxacillin, IV

Adults

500 mg 6 hourly for 2-4 weeks

Children 

5-12 years; 250 mg 6 hourly for 2-4 weeks

1-5 years; 125 mg 6 hourly for 2-4 weeks

< 1 year; 62.5 mg 6 hourly for 2-4 weeks 

And 

  • Ciprofloxacin, IV (to be administered over 60 minutes)

Adults

400 mg 8-12 hourly for 14 days

Children

10 mg/kg (max. 400 mg) 12 houly for 14 days

Note: Monitor BUE and creatinine and perform auditory examinations weekly while on gentamicin 

2nd Line Treatment

Evidence Rating: [B]

  • Clindamycin, IV

Adults

300 mg 6 hourly for 7 days

Children

3-6 mg/kg 6 hourly for 7 days

Or

  • Amoxicillin + Clavulanic Acid, IV

Adults

1.2 g 12 hourly increased to 1.2 g 8 hourly for 7 days in severe infections 

Children

12-18 years; 600 mg to 1.2 g 12 hourly, increased to 1.2 g 8 hourly for 7 days in severe infections

3 months-12 years; 30 mg/kg 12 hourly, increased to 30 mg/kg 8 hourly for 7 days in severe infections

7 days-3 months; 30 mg/kg 8 hourly for 7 days

Preterm and < 7 days; 30 mg/kg 12 hourly for 7 days

For individuals with penicillin sensitivity 

1st Line Treatment

Evidence Rating: [B]

  • Clindamycin, IV

Adults

300 mg 6 hourly for 7 days

Children

3-6 mg/kg 6 hourly for 7 days

And

  • Gentamicin, IV

Adults

40-80 mg 8 hourly for 14 days

Children

1-12 years; 2.5 mg/kg 8 hourly for 14 days

< 1 year; 2.5 mg/kg 12 hourly for 14 days

For individuals with sickle cell anaemia 

Evidence Rating: [B]

  • Cloxacillin, IV

Adults

500 mg 6 hourly for 2-4 weeks

Children 

5-12 years; 250 mg 6 hourly for 2-4 weeks

1-5 years; 125 mg 6 hourly for 2-4 weeks

<1 year; 62.5 mg 6 hourly for 2-4 weeks 

And 

  • Ciprofloxacin, IV, 

Adults

200-400 mg 12 hourly for 2-4 weeks

Children

10 mg/kg 12 hourly for 2-4 weeks

Analgesia

1st Line Treatment
  • Ibuprofen, oral

Adults

200-800 mg 6-8 hourly (max. 2400 mg daily)

Children

10-15 mg/kg 6-8 hourly (max. 40 mg/kg daily)

Or

  • Diclofenac, oral

Adults

50 mg 8 hourly or 100 mg 12 hourly 

Children

> 12 years; 50 mg 12 hourly

< 12 years; not recommended

Or 

  • Diclofenac, IM 

Adults

50-75 mg 8-12 hourly (max. 150 mg daily)

Children 

Not recommended 

Or

  • Morphine, oral

Adults 

15-30 mg 4-6 hourly as required 

Children 

200-500 micrograms/kg 4-6 hourly as required 

Or

  • Morphine, IV/IM

Adults 

2-5 mg 4 hourly as required 

Children 

50-200 micrograms/kg 4 hourly as required

Or

  • Codeine, oral

Adults

15-60 mg 4-6 hourly as required 

Children 

Not recommended 

For control of fever

  • Paracetamol, oral

Adults

500 mg-1g 6-8 hourly

Children

6-12 years; 250-500 mg 6-8 hourly 

1-5 years; 120-250 mg 6-8 hourly 

3 months-1 year; 60-120 mg 6-8 hourly

Or

  • Paracetamol, IV

Adults

> 50 kg; 1g 6 hourly as required 

< 50 kg; 1g 8 hourly as required (max. 3 g daily) 

Children 

12-18 years (>50kg); 1 g 8 hourly as required (max. 3g daily)

12-18 years (<50kg); 15 mg/kg 6 hourly as required (max. 750 mg per dose)

2-12 years (<50kg); 15 mg/kg 6 hourly as required (max. 75 mg per kg per day)