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Year 3: Block 1: MSK system > Bone and soft tissue infection > Flashcards

Bone and soft tissue infection Flashcards

1
Q

What is a bone infection known as

A

Osteomyelitis

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2
Q

What is a joint infection known as

A

Septic Arthritis

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3
Q

Types of osteomyelitis

A

acute
chronic

specific (e.g. TB)
non-specific (most common)

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4
Q

What organisms mainly affect children <1

A

staph A, Group b strep, E.coli

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5
Q

What organisms mainly affect Older children (3)

A

Staph aureus, Strep pyogenes, Haemophilus influenzae

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6
Q

What organisms mainly affect adults ? (4)

A

Staph A
coagulase negative staphylococci Mycobacterium tuberculosis
Pseudomonas aeroginosa

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7
Q

Acute Osteomyelitis = can also be caused by other causes - what are they? (4)

A

Diabetic foot and Pressure sores - mixed infection including anaerobes

Sickle cell disease – Salmonella spp

Mycobacterium marinum (fishermen, filleters)

Candida (debilitating illness, HIV AIDS)

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8
Q

Acute Osteomyelitis Pathology - what long bones does it affect (3)

A

metaphysis
distal femur
proximal tibia
proximal humerus

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9
Q

Acute Osteomyelitis Pathology - what joints does it affect? (2)

A

with intra-articular metaphysis
hip
elbow (radial head)

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10
Q

Different causes of acute Osteomyelitis (8)

A 
role of trauma?
 vascular stasis 
acute inflammation – increased pressure 
 suppuration
 release of pressure 
	(medulla, sub-periosteal, into joint)
 necrosis of bone (sequestrum)
 new bone formation (involucrum)
 resolution  - or not (chronic osteomyelitis
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11
Q

Acute Osteomyelitis Clinical Features - Infant - where are features most common? (7)

A 
may be minimal signs, or may be very ill
failure to thrive
poss. drowsy or irritable
metaphyseal tenderness + swelling
decrease ROM
positional change
commonest around the knee
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12
Q

Acute Osteomyelitis Clinical Features - Child (5)

A

severe pain
reluctant to move (neighbouring joints held flexed); not weight bearing
may be tender fever (swinging pyrexia) + tachycardia
malaise (fatigue, nausea, vomiting – “nae weel” - fretful
toxaemia

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13
Q

Acute OsteomyelitisClinical Features - Adult - where are features most common?

A

Primary OM seen commonly in thoracolumbar spine
backache
history of UTI or urological procedure
elderly, diabetic, immunocompromised

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14
Q

What type of acute OM is more common in adults? when does this often happen?

A

Secondary
often after open fracture, surgery (esp. ORIF)
mixture of organisms

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15
Q

Acute Osteomyelitis -Diagnosis (5)

A

history and clinical examination (pulse + temp.)
FBC + diff WBC (neutrophil leucocytosis)
ESR, CRP
blood cultures x3 (at peak of temperature – 60% +ve)
U&Es – ill, dehydrated

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16
Q

Acute Osteomyelitis - Differential Diagnosis

GIVE EXAMPLES (5)

A

soft tissue infection

cellulitis - (deep) infection of subcutaneous tissues (Gp A Strep)
erysipelas - superficial infection with red, raised plaque (Gp A Strep)
necrotising fasciitis - aggressive fascial infection (Gp A Strep, Clostridia)
gas gangrene - grossly contaminated trauma (Clostridium perfringens)
toxic shock syndrome - secondary wound colonisation (Staph aureus)

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17
Q

Acute Osteomyelitis Diagnosis- TESTS (6)

A 
X-ray (normal in the first 10-14 days) 
ultrasound 
aspiration
Isotope Bone Scan (Tc-99, Gallium-67)
labelled white cell scan (Indium-111)
MRI
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18
Q

When will periosteal changes show on radiograph

A

10-20 days

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19
Q

Medullary changes (radiograph) are?

A
  • lytic areas
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20
Q

late osteonecrosis on radiograph is

A

sequestrum

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21
Q

late periosteal new bone on radiograph is

A

involucrum

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22
Q

Technetium scan is used in the

A

early and late phases

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23
Q

Acute Osteomyelitis - Microbiological diagnosis

A

blood cultures in haematogenous osteomyelitis and septic arthritis
bone biopsy
tissue or swabs from up to 5 sites around implant at debridement in prosthetic infections
sinus tract and superficial swab results may be misleading (skin contaminants

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24
Q

Acute Osteomyelitis - Treatment

A

supportive treatment for pain and dehydration – general care, analgesia
rest & splintage

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25
Q

Acute Osteomyelitis - Treatment - antibiotics

A

antibiotics
route (IV/oral switch – 7-10 days?)
duration (4-6 wks – depends on response, ESR)
choice - empirical (Fluclox + BenzylPen) while waiting

26
Q

3 features antibiotics have

A

spectrum of activity
penetration to bone
safety for long term administration

27
Q

Why may there be antibiotics failure in treatment ?

A 
drug resistance – e.g.  lactamases
bacterial persistence - ‘dormant’ bacteria in dead bone
poor host defences - IDDM, alcoholism…
poor drug absorption
drug inactivation by host flora
poor tissue penetration
MRSA
28
Q

Acute Osteomyelitis -Treatment - Surgery

indications

A

aspiration of pus for diagnosis & culture
abscess drainage (multiple drill-holes, primary closure to avoid sinus)
debridement of dead/infected /contaminated tissue
refractory to non-operative Rx >24..48 hrs

29
Q

Acute Osteomyelitis -Treatment - (3)

A

timing, drainage, lavage

infected joint replacements - one stage revision/ two stage revision/ antibiotics only

30
Q

Acute Osteomyelitis - Complications (6)

A 
septicemia, death
metastatic infection
pathological fracture
septic arthritis
altered bone growth
chronic osteomyelitis
31
Q

Chronic Osteomyelitis may follow

A

AOM

32
Q

Chronic Osteomyelitis - when may it start? (4)

A

de novo
following operation
following open # (poss. many years earlier)
immunosuppressed, diabetics, elderly, drug abusers, etc.

repeated breakdown of “healed” wounds

33
Q

Chronic Osteomyelitis - Organisms causing?

A

often mixed infection
usually same organism(s) each flare-up
mostly Staph. Aureus, E. Coli, Strep. pyogenes, Proteus

34
Q

Chronic Osteomyelitis - Pathology (4)

A

cavities, poss. sinus(es)
dead bone (retained sequestra)
involucrum
histological picture is one of chronic inflammation

35
Q

Chronic Osteomyelitis - Complications (5)

A

chronically discharging sinus + flare-ups
ongoing (metastatic) infection (abscesses)
pathological fracture
growth disturbance + deformities
squamous cell carcinoma (0.07%)

36
Q

How do you treat Chronic osteomyelitis - antibiotics

A

long-term antibiotics?
local (gentamicin cement/beads, collatamp)
systemic (orally/ IV/ home AB)

37
Q

How do you treat Chronic osteomyelitis - (5)

A

eradicate bone infection- surgically (multiple operations)
treat soft tissue problems
deformity correction?
massive reconstruction?
amputation? (how many operations/years later?

38
Q

Acute Septic Arthritis- What is theRoutes of infection (3)

A 
haematogenous
eruption of bone abscess
direct invasion
penetrating wound (iatrogenic? – joint injection)
intra-articular injury
arthroscopy
39
Q

Acute Septic Arthritis - the route of infection has a

A

metaphyseal septic focus

→ either septic arthritis

→ or osteomyelitis

40
Q

Organisms causing Acute Septic Arthritis (4)

A

Staphylococus aureus
Haemophilus influenzae
Streptococcus pyogenes
E. coli

41
Q

Acute Septic Arthritis Pathology (3)

A

acute synovitis with purulent joint effusion

articular cartilage attacked by bacterial toxin and cellular enzyme

complete destruction of the articular cartilage

42
Q

Acute Septic Arthritis Sequelae (3) - what happens?

A 
complete recovery
 or
partial loss of the articular cartilage and subsequent OA
 or
fibrous or bony ankylosis
43
Q

Acute Septic Arthritis - Neonate - what do we always picture?

A

septicaemia

irritability
resistant to movement
ill

44
Q

Acute Septic Arthritis Child/Adult - main features

physical features?

A

Acute pain in single large joint

reluctant to move the joint (any movement – c.f. bursitis where RoM OK)
increase temp. and pulse
increase tenderness

45
Q

Acute Septic Arthritis in anAdult often involves what joint?

A 
superficial joint (knee, ankle, wrist)
- rare in adults and may be delayed diagnosis
46
Q

Acute Septic Arthritis - Adult - investigations (5)

A

FBC, WBC, ESR, CRP, blood cultures
X ray
ultrasound
aspiration

47
Q

Acute Septic Arthritis Adult – Infected Joint Replacement is the

A

most common cause of septic arthritis in adult

48
Q

Acute Septic Arthritis Adult – Infected Joint Replacement- most common organism ?

A

Staph

rare but a disaster - can cause death

49
Q

Acute Septic Arthritis- Differential Diagnosis (7)

A 
acute osteomyelitis
trauma
irritable joint
haemophilia
rheumatic fever
gout 
Gaucher’s disease
50
Q

Acute Septic Arthritis - Treatment (surgical/antibiotics)

A

general supportive measures

antibiotics (3-4 weeks)

surgical drainage & lavage - emergency (“never let the sun set on pus” ); open or arthroscopic lavage;
infected joint replacements - one stage revision, two stage revision, antibiotics only?

51
Q

Tuberculosis- Bone and Joint - what are the 3 different classifications?

A

extra-articular (epiphyseal / bones with haemodynamic marrow)
intra-articular (large joints)

vertebral body

multiple lesions

52
Q

Tuberculosis - Clinical Features (8)

A 
insidious onset &amp; general ill health
contact with TB
pain (esp. at night), swelling, loss of weight
low grade pyrexia
joint swelling
decrease ROM 
ankylosis 
deformity
53
Q

TB - pathology

A

primary complex (in the lung or the gut)

secondary spread

tuberculous granuloma

Aids/HIV?

54
Q

How does Tb spinal present?

A

little pain

present with abscess or kyphosis

55
Q

Tuberculosis -Diagnosis (5)

A 
long history
involvement of single joint
marked thickening of the synovium
marked muscle wasting
periarticular osteoporosis
56
Q

Tuberculosis- Investigation, biopsy numbers?

A

FBC , ESR
Mantoux test
Sputum/ urine culture

Joint aspiration and biopsy
AAFB identified in 10-20%
culture +ve in 50% of cases

57
Q

Tuberculosis- Investigation - radiography features you look for?

A

XRAY
soft tissue swelling
periarticular osteopaenia
articular space narrowing

58
Q

Tuberculosis -Differential Diagnosis (5)

A 
transient synovitis
monoarticular RA
haemorrhagic arthritis
pyogenic arthritis
Tumour
59
Q

TuberculosisTreatment - INITIAL

A

chemotherapy
initial - rifampicin
isoniazid - 8 weeks
ethambutol

60
Q

TuberculosisTreatment - After initial

A

rifampicin and isoniazid 6-12 month
rest and splintage
operative drainage rarely necessary

Year 3: Block 1: MSK system (22 decks)

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