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Monteggia fracture in children

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- Antibiotics play an important role in preventing and treating infections in orthopedic surgery and injuries. The document discusses protocols for antibiotics in open fractures, surgical prophylaxis, and bone infections. - For open fractures, the antibiotic protocol depends on the Gustilo classification and wound characteristics. For surgical prophylaxis, timing, antibiotic choice (usually cefazolin), and duration (no more than 24 hours after surgery) are discussed. - Bone infections require coverage of likely pathogens, with protocols varying based on factors like patient age, infection origin, and presence of implants. Duration typically lasts 4-6 weeks depending on the infection.

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Antibiotics Protocols in orthopedics Dr Razi Ullah Resident orthopedics Surgeon ATH
Infection in orthopedic surgery is one of the most dreaded complications. It is associated with prolonged morbidity, disability and increased mortality. Out of nearly 30 million operations in the United States each year more than 2% are complicated with surgical site infections. The mortality rate increases 23 times after infection.
Antibiotics are the cornerstone of prevention and management of orthopedics infection. We will discuss protocols of antibiotics in 1. Open fractures 2.Surgical prophylaxis 3. Bone infection
Protocol of Antibiotics in open fractures Gustilo type 1 and 2 First generation cephalosporin for 24 hours Type 3A First generation cephalosporin plus a aminoglycoside since 72 hours since last incision and drainage Type 3B highly contaminated farm injuries First generation cephalosporin plus aminoglycoside plus high dose penicillin 72 hours since last incision and drainage
Freshwater wounds Flouroquinolones or third or fourth generation cephalosporin Saltwater wounds Doxycycline and fourth generation cephalosporin or flouroqunolones
Protocol for Surgical prophylaxis There is enough evidence to say that prophylactic antibiotics should be used in orthopedics to reduce surgical site infection We will discuss timing,choice and duration of antibiotics for prophylaxis in surgical patients
Timing of administration The timing of administration remains controversial. Evidence shows that initiating prophylaxis after the skin is incised, is ineffective. Most of the studies agree that prophylactic antibiotics should ideally be administered 3060 min before skin incision Administration >60 min before surgery/incision is associated with higher risk of surgical infections
The prophylaxis has least effect when antibiotic is given after the application of a tourniquet
Which antibiotics? The antibiotic selected should in general, be inexpensive, nontoxic and of limited spectrum. The most prevalent organisms in prosthetic related infections are Gram-positive Staphylococcus aureus and epidermidis
According to American Society of Health System Pharmacists (ASHP) cefazolin was the most used antibiotic in preoperative prophylaxis, combination of cefazolin with gentamicin was the second common regimen while 3rd generation cephalosporin were 3rd widely used antibiotics.
In a study, 3rd generation cephalosporins were most commonly used for arthroplasty prophylaxis and 2nd generation cepholospirins were used for fracture fixation.
Duration of antibiotics The controversy persists in administration of antibiotics varying from a single dose to 3 doses to 5 days or 14 days The ideal duration of postoperative antibiotics is not yet clearly defined although most reports say that there is no additional benefit when prophylactic antibiotics are given more than 24 h postsurgery
Musmar et al. suggests that antibiotics should be discontinued within 24 h after end of surgery to prevent emergence of resistance Thonse et al. recommended prophylactic antibiotic regimen at time of induction of anesthesia and two subsequent doses at 8 and 16 h postoperatively. Another study by Andersson et al. suggest same recommendations of 3 doses within 24 h.
Niimi et al. in a retrospective study compared the outcome of 1-day intravenous administration with that of long term intravenous administration in arthroplasty cases. They used antibiotics for 1-day (n = 233) and for at least 3 days (n = 104) None of these patients developed wound infection during follow up (minimum 12 months). They concluded that 1-day antibiotic infusion was as effective as long term antibiotic infusion preventing infection after arthroplasty.
Protocol of antibiotics in osteomyelitis Empirical antibiotics Coverage for the most likely infecting organism should be started till gram stain results appear or if negative. Recommendations for the initiation of empiric antibiotic (according to age of the patient and mechanism of infection
Hematogenous osteomyelitis ( newborn to adult combination of penicillinase-resistant synthetic penicillin (Oxacillin or nafcillin) +third-generation cephalosporin. MRSA vancomycin or clindamycin +third-generation cephalosporin, Linezolid is also used in these circumstances.
Sickle cell disease:S aureus and Salmonellae species-- ----fluoroquinolone antibiotic (not in children). A third-generation cephalosporin (eg, ceftriaxone) is an alternative choice In diabetic foot----S aureus and Pseudomonas aeruginosa----ceftazidime or cefepime. Ciprofloxacin is an alternative treatment.
Prosthesis infections S epidermidis----biofilm---- protect bacteria against phagocytosisd antibiotics. Rifampicin: Must be used in combination with other antibiotics because it acts on the biofilm and avoids recurrence if used within a month of treatment
Start IV: The response to appropriate IV antibiotic usually occur in 48 hr Lack of improvement in fever and pain after this ----- surgical drainage. Then use IV (according to culture) for 2 weeks Oral (combination) for 4 weeks --(revascularization of bone takes 4 weeks
Duration of antibiotic therapy Most infections- eg S. aureus, a total of 6 wk. For group A streptococcus, S. pneumoniae, or H. influenzae type b---, shorter. Immunocompromised patients, mycobacterial or fungal infection ---- prolonged courses of therapy.
Monteggia fracture in children
Radial head dislocation plus proximal ulna fracture or Plastic deformation of the ulna without obvious fracture Peak age is 4-10 years in children
Monteggia fracture in children
Bado Classification Type I ulna fracture with anterior dislocation of the radial head
Type II proximal ulna fracture with posterior dislocation of the radial head
Type III proximal ulna fracture with lateral dislocation of the radial head
Type IV Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head (1-11% of cases)
Monteggia equivalents isolated radial head dislocation with plastic deformity of ulna fracture of the proximal ulna with fracture of the radial neck, and Both bone proximal third fractures with the radial fracture more proximal than the ulnar fracture
Imaging Obtain standard AP and lateral views Assess radiocapitellar line on every lateral radiograph of the elbow A line down the radial shaft should pass through the center of the capitellar ossification center in all elbow positions
Monteggia fracture in children
Monteggia fracture in children
Treatment closed reduction of ulna and radial head dislocation and long arm casting Indicated for BADO I-III when 1.Radial head is stable following reductions 2. Length stable ulnar fracture pattern
Radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length Patients should be immobilized in a long arm cast in 90 to 100 degrees of flexion and supination and followed closely radiographically for 2 to 3 weeks to ensure maintenance of radial head reduction.
Operative Plating of ulna + reduction of radial head 賊 annular ligament repair/reconstruction Indication Bado Types I-III with radial head is not stable following reduction ulnar length is not stable (unable to maintain ulnar length) acute Bado Type IV open fractures older patients 10y if closed reduction is not stable
Technique Annular ligament reconstruction almost never required for acute fractures open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure Chronic Monteggia requires ulnar osteotomy with annular ligament reconstruction via triceps tendon harvesting
Monteggia fracture in children
Complications posterior interosseous nerve neuropraxia (10% of acute injuries)almost always spontaneously resolves Delayed or missed diagnosis is common when evaluation not performed by an orthopaedic surgeon complication rates and severity increase if diagnosis delayed >2-3 weeks
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Monteggia fracture in children

  • 1. Antibiotics Protocols in orthopedics Dr Razi Ullah Resident orthopedics Surgeon ATH
  • 2. Infection in orthopedic surgery is one of the most dreaded complications. It is associated with prolonged morbidity, disability and increased mortality. Out of nearly 30 million operations in the United States each year more than 2% are complicated with surgical site infections. The mortality rate increases 23 times after infection.
  • 3. Antibiotics are the cornerstone of prevention and management of orthopedics infection. We will discuss protocols of antibiotics in 1. Open fractures 2.Surgical prophylaxis 3. Bone infection
  • 4. Protocol of Antibiotics in open fractures Gustilo type 1 and 2 First generation cephalosporin for 24 hours Type 3A First generation cephalosporin plus a aminoglycoside since 72 hours since last incision and drainage Type 3B highly contaminated farm injuries First generation cephalosporin plus aminoglycoside plus high dose penicillin 72 hours since last incision and drainage
  • 5. Freshwater wounds Flouroquinolones or third or fourth generation cephalosporin Saltwater wounds Doxycycline and fourth generation cephalosporin or flouroqunolones
  • 6. Protocol for Surgical prophylaxis There is enough evidence to say that prophylactic antibiotics should be used in orthopedics to reduce surgical site infection We will discuss timing,choice and duration of antibiotics for prophylaxis in surgical patients
  • 7. Timing of administration The timing of administration remains controversial. Evidence shows that initiating prophylaxis after the skin is incised, is ineffective. Most of the studies agree that prophylactic antibiotics should ideally be administered 3060 min before skin incision Administration >60 min before surgery/incision is associated with higher risk of surgical infections
  • 8. The prophylaxis has least effect when antibiotic is given after the application of a tourniquet
  • 9. Which antibiotics? The antibiotic selected should in general, be inexpensive, nontoxic and of limited spectrum. The most prevalent organisms in prosthetic related infections are Gram-positive Staphylococcus aureus and epidermidis
  • 10. According to American Society of Health System Pharmacists (ASHP) cefazolin was the most used antibiotic in preoperative prophylaxis, combination of cefazolin with gentamicin was the second common regimen while 3rd generation cephalosporin were 3rd widely used antibiotics.
  • 11. In a study, 3rd generation cephalosporins were most commonly used for arthroplasty prophylaxis and 2nd generation cepholospirins were used for fracture fixation.
  • 12. Duration of antibiotics The controversy persists in administration of antibiotics varying from a single dose to 3 doses to 5 days or 14 days The ideal duration of postoperative antibiotics is not yet clearly defined although most reports say that there is no additional benefit when prophylactic antibiotics are given more than 24 h postsurgery
  • 13. Musmar et al. suggests that antibiotics should be discontinued within 24 h after end of surgery to prevent emergence of resistance Thonse et al. recommended prophylactic antibiotic regimen at time of induction of anesthesia and two subsequent doses at 8 and 16 h postoperatively. Another study by Andersson et al. suggest same recommendations of 3 doses within 24 h.
  • 14. Niimi et al. in a retrospective study compared the outcome of 1-day intravenous administration with that of long term intravenous administration in arthroplasty cases. They used antibiotics for 1-day (n = 233) and for at least 3 days (n = 104) None of these patients developed wound infection during follow up (minimum 12 months). They concluded that 1-day antibiotic infusion was as effective as long term antibiotic infusion preventing infection after arthroplasty.
  • 15. Protocol of antibiotics in osteomyelitis Empirical antibiotics Coverage for the most likely infecting organism should be started till gram stain results appear or if negative. Recommendations for the initiation of empiric antibiotic (according to age of the patient and mechanism of infection
  • 16. Hematogenous osteomyelitis ( newborn to adult combination of penicillinase-resistant synthetic penicillin (Oxacillin or nafcillin) +third-generation cephalosporin. MRSA vancomycin or clindamycin +third-generation cephalosporin, Linezolid is also used in these circumstances.
  • 17. Sickle cell disease:S aureus and Salmonellae species-- ----fluoroquinolone antibiotic (not in children). A third-generation cephalosporin (eg, ceftriaxone) is an alternative choice In diabetic foot----S aureus and Pseudomonas aeruginosa----ceftazidime or cefepime. Ciprofloxacin is an alternative treatment.
  • 18. Prosthesis infections S epidermidis----biofilm---- protect bacteria against phagocytosisd antibiotics. Rifampicin: Must be used in combination with other antibiotics because it acts on the biofilm and avoids recurrence if used within a month of treatment
  • 19. Start IV: The response to appropriate IV antibiotic usually occur in 48 hr Lack of improvement in fever and pain after this ----- surgical drainage. Then use IV (according to culture) for 2 weeks Oral (combination) for 4 weeks --(revascularization of bone takes 4 weeks
  • 20. Duration of antibiotic therapy Most infections- eg S. aureus, a total of 6 wk. For group A streptococcus, S. pneumoniae, or H. influenzae type b---, shorter. Immunocompromised patients, mycobacterial or fungal infection ---- prolonged courses of therapy.
  • 22. Radial head dislocation plus proximal ulna fracture or Plastic deformation of the ulna without obvious fracture Peak age is 4-10 years in children
  • 24. Bado Classification Type I ulna fracture with anterior dislocation of the radial head
  • 25. Type II proximal ulna fracture with posterior dislocation of the radial head
  • 26. Type III proximal ulna fracture with lateral dislocation of the radial head
  • 27. Type IV Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head (1-11% of cases)
  • 28. Monteggia equivalents isolated radial head dislocation with plastic deformity of ulna fracture of the proximal ulna with fracture of the radial neck, and Both bone proximal third fractures with the radial fracture more proximal than the ulnar fracture
  • 29. Imaging Obtain standard AP and lateral views Assess radiocapitellar line on every lateral radiograph of the elbow A line down the radial shaft should pass through the center of the capitellar ossification center in all elbow positions
  • 32. Treatment closed reduction of ulna and radial head dislocation and long arm casting Indicated for BADO I-III when 1.Radial head is stable following reductions 2. Length stable ulnar fracture pattern
  • 33. Radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length Patients should be immobilized in a long arm cast in 90 to 100 degrees of flexion and supination and followed closely radiographically for 2 to 3 weeks to ensure maintenance of radial head reduction.
  • 34. Operative Plating of ulna + reduction of radial head 賊 annular ligament repair/reconstruction Indication Bado Types I-III with radial head is not stable following reduction ulnar length is not stable (unable to maintain ulnar length) acute Bado Type IV open fractures older patients 10y if closed reduction is not stable
  • 35. Technique Annular ligament reconstruction almost never required for acute fractures open reduction of radial head through a lateral approach if needed in chronic (>2-3 weeks old) Monteggia fractures where radial head still retains concave structure Chronic Monteggia requires ulnar osteotomy with annular ligament reconstruction via triceps tendon harvesting
  • 37. Complications posterior interosseous nerve neuropraxia (10% of acute injuries)almost always spontaneously resolves Delayed or missed diagnosis is common when evaluation not performed by an orthopaedic surgeon complication rates and severity increase if diagnosis delayed >2-3 weeks