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Introduction

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Musculoskeletal infections are common; they can affect all parts of the musculoskeletal system; and they can be dangerous and even life threatening. Much has been learned in the last 20 years to treat a wide range of musculoskeletal infections effectively. Often a team including orthopedic surgeons, plastic surgeons, infectious disease specialists, as well as internists, nutritionists, and therapists, must collaborate to orchestrate the multidisciplinary care that may be required to treat these patients optimally. This chapter summarizes the pathogenesis, diagnosis, and treatment of infections relevant to orthopedics. The management of osteomyelitis, septic arthritis, and soft tissue infections is discussed and highlighted with clinical examples.

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Because this subject is so important, other chapters in this book include discussions of special aspects of infection. Chapter 3 (Musculoskeletal Trauma Surgery) discusses appropriate management of open fractures, traumatic arthrotomies, and gunshot wounds to minimize the risk of infection. Chapter 5 (Disorders, Diseases, & Injuries of the Spine) describes the clinical identification and management of osteomyelitis of the spine, diskitis, and epidural abscess. Chapter 7 (Adult Reconstructive Surgery) outlines the care of patients with prosthetic joint infections. Chapter 9 (Foot & Ankle Surgery) carefully details the management of diabetic foot ulcers and infections. Chapter 10 (Hand Surgery) discusses the treatment of paronychia, felons, chronic hand infections, human bites, and web space abscesses. Chapter 11 (Pediatric Orthopedic Surgery) reviews acute hematogenous osteomyelitis, septic arthritis especially of the hip joint, puncture wounds of the foot, skeletal tuberculosis, and spinal diskitis.

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Pathogenesis

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General

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All clinical infections must be thought of in terms of the attacking microbes and the host’s defenses. Infections are more likely to occur if the organisms are more virulent and if the inoculum is larger. Bacteria can gain entry into the body from direct penetrating trauma, by hematogenous spread from adjacent or remote sites of infection, or during surgical exposures. This wide spectrum of clinical possibilities ranges from fight bites to seeding from bacterial endocarditis to intraoperative breaks in sterile technique.

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In acute osteomyelitis in children, the metaphysis is commonly involved. It is thought that the end vessels of the nutrient artery empty into much larger sinusoidal veins, causing a slow and turbulent flow of blood at this junction. These conditions predispose bacteria to migrate through adjacent gaps in the endothelium and adhere to the matrix. Also, low oxygen tension in this region may compromise phagocytic activity of white blood cells. Thrombosis caused by infection results in a region of avascular necrosis that may lead to abscess formation. As pus accumulates and pressurizes, it can track through the cortex via the haversian system and Volkmann canals to collect beneath the periosteum. Subperiosteal abscesses may stimulate the formation of a periosteal involucrum. Once out of the cortex, pus can also track through soft tissues to the surface of the skin, forming a draining sinus.

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The physis and joint ...

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