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MSK > Bone Infections > Flashcards

Bone Infections Flashcards

1
Q

What is osteomyelitis

A

Infection of the bone

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2
Q

What is the pathology of osteomyelitis

A

Acute inflammation
Suppuration (pus)
Release of pressure if discharges
Sequestrum (necrosis) due to interrupted blood supply
Involcrum (new bone formation) over necrotic
Resolution or chronic

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3
Q

Where can infection discharge into

A

Joint spaces

Skin via sinuses

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4
Q

When should you always suspect OM

A

Diabetic feet
Deep pressure sores
Non-healing ulcers

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5
Q

How does OM spread

A

Haematogenous
Local spread from trauma / surgery / ulcer
2 to local infection with or without vascular insufficiency

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6
Q

What local infections can OM spread from

A 
Infected umbilical cord
Abscess 
Pneumonia
UTI
Arterial line
Urological procedure
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7
Q

What are common organisms in children

A

S.Aureus
E.coli
Strep pyogenes
H. influenza

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8
Q

What are common organisms in adults

A

S.aureus = most common
Strep pyogenes
Pseudomonas

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9
Q

What organisms is common in sickle cell

A

Salmonella

May think sickle crisis so always X-ray

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10
Q

What organism in Butcher

A

Brucella

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11
Q

What organisms in immunocompromised (HIV / malignancy / surgery)

A

Candida
Mycobacterium TB
Propionibacterium

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12
Q

What STI can cause

A

Gonococcus

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13
Q

Where is OM common in children

A

Metaphysis of long bone

Femur / tibia

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14
Q

What are signs of OM in children

A 
Severe pain 
Decreased ROM 
FTT
Drowsy 
Swelling 
Fever
Tachycardia
N+V
Malaise
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15
Q

Where is OM common in adults

A

Thoracolumbar - IVDA
Feet - DM
Epiphysis of bone

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16
Q

What are signs of OM in adults

A 
Backache
Gradual onset
Limited ROM
Local tenderness / warmth / erythema
Signs less marked in adults
Signs of systemic infection
Hx UTI / ORIF / surgery
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17
Q

What are RF for OM

A 
Children
M>F
Trauma - open fracture 
DM 
RA
Immunocompromised 
Chronic disease
IVDA
Alcohol use
Sickle cell
Vascular insufficiency
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18
Q

What investigations for OM

A

Bloods - FBC, U+E, CRP
Blood culture x3
Bone biopsy - rarely required
MRI = best imaging for diagnosis

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19
Q

What is gold standard for Dx

A

Bone biopsy + blood culture

Needed to exclude cancer as look similar on imaging

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20
Q

What are other options

A

Aspiration of material near bone
X-ray - commonly used 1st
Isotope bone scan
USS

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21
Q

When would isotope bone scan be used

A

Prosthesis

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22
Q

What does X=ray show

A

Destructive changes after 10-14 days
Destruction of bone
Gas bubbles
Hazy

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23
Q

How do you treat OM

A

Treat pain and dehydration (analgesia + fluiD)
Rest + splint
Ax for 6 weeks
Surgery

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24
Q

What Ax

A

Vanc + cefotaxime till sensitivities known

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25
Q

What surgery do you do

A

Aspiration of pus
Abscess drainage
Debridmeent of necrotic bone
Replace infected joint

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26
Q

What are complications of OM

A 
Septicaemia
Metastatic infection
Pathological fracture 
Septic arthritis
Altered bone growth / deformity
Chronic OM
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27
Q

Differentials of OM

A 
Malignancy
Acute septic arthritis
Inflammatory arthritis
Trauma
Transient synovitis
Soft tissue infection 
TB
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28
Q

What is pathology of chronic OM

A

Retained sequestra and involcrum

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29
Q

What organisms in chronic OM

A

S.aureus
E.coli
Strep pyogenes
Proteus

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30
Q

When do you suspect chronic

A

Vascular insufficiency
Non healing tissue over bone
Bone felt on probing ulcer

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31
Q

How does chronic oM present

A 
Repeated breakdown of healed wounds 
Chronically discharging sinus
Flare ups 
Pain
Fever
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32
Q

Who is at risk of chronic

A

Immunosuppressed
DM = very high risk
Elderly
IVDA

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33
Q

How do you Dx

A

X-ray shows thick irregular bone

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34
Q

How do you Rx

A 
Long term Ax >12 weeks
Excision of sequestra
Amputation
Correct deformity
Treat soft tissue
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35
Q

What are complications of chronic OM

A

Pathological fracture
Growth disturbance
SCC

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36
Q

What causes subacute OM

A

Impaired resistnace
Lowered bacterial virulence
Antibiotic use

37
Q

What are signs

A

Long history of pain, limp, swelling and warmth

38
Q

What is Brodie’s abscess

A

Subacute OM in older children

Present with painful limp but no systemic fears

39
Q

How do you Dx

A

X-ray - lucency
Biopsy
Bone scn

40
Q

How do you treat

A

Ax

Curettage surgery

41
Q

What is Ddx of Brodies’

A

Ewing’s sarcoma
Osteoid osteoma
TB

42
Q

What is septic arthritis

A

Acute synovitis with joint effusion

43
Q

What is pathology

A

Articular cartilage attacked
Complete destruction
Replaced with fibrocartilage

44
Q

When should you consider SA

A

Any acutely inflammed joint as can destroy in under 24 hours

May not present typically if obese etc.

45
Q

How does SA spread

A

Direct / local from wound / injury / arthroscopy
Eruption of abscess
Haematogenous

46
Q

What are common orgnaism

A 
S.aureus = most common 
H.influenza
S.pyogenes
E.coli - if elderly + UTI
Gonococcus - think in young patient with acute swollen joint
47
Q

What should you think

A

How did organism get there
- cellulitis / IV line / pneumonia / immunosuppressed
Source of infection can go to joint before it causes fever

48
Q

How does SA present

A 
Very unwell - more than OM
Extreme pain 
Reluctant to move
Decreased ROM
Acute pain
Swollen joint 
Fever - only in 50%
Tachycardia 
Irritable
49
Q

Where does it affect

A

Knee >50%

Anywhere where source

50
Q

RF for SA

A 
Infected prosthetic = most common
Recent joint surgery
Immunosuppressed - DM 
Chronic renal
Joint disease - RA / OA 
IVDA
Age
51
Q

Who might not find it painful

A

On steroids
Immunocompromsied
DM

52
Q

What is 1st line investigation

A

Joint aspiration for gram stain and culture + microscopy to look for crystals

53
Q

What else do you do

A

Bloods - FBC, U+E, LFT, urate
Blood cultures
X-ray / USS but may be normal of joint

54
Q

What criteria for DX

A

Kocher

  • Fever >38.5
  • Non-weight bearing
  • Raised ESR
  • Raised WCC
55
Q

What should you never do

A

NEVER ASPIRATE PROSTHETIC as may put infection in

56
Q

How do you treat

A 
BROAD SPEC AX
SEPSIS 6 
IV van + cefotaxime till sensitivities known 
Splint 
Fluid and analgesia 
Surgical drainage
57
Q

What do you do if complex / immunosuppressed

A

Microbiology

58
Q

When do you always refer to ortho

A

If prosthetic joint

59
Q

What do you do when infection resolves

A

Physio

60
Q

Complications

A

Partial loss of cartilage
OA
Fibrous or bony ankyloses

61
Q

What are differentials of SA

A 
OM
Trauma - haemarthrosis (if anti-coagulant / bleeding disorder) 
Haemophilia 
Gout 
Fracture
Reactive arthritis - think GI / GU Sx 
OA 
Acute exacerbation RA
Gauchers
Malignancy
62
Q

What is acute infection of a prosthetic joint

A

Within 3 months

Infection of hospital origin

63
Q

What is deep late infection

A

3 months - 2 years

Nosocomial origin e.g. staph epidermis during procedure

64
Q

What is late haematogenous

A

> 2 years

Community origin

65
Q

How does joint get infection

A

Direct implantation
Haematogenous
Reactivation of latent

66
Q

What organism

A

S.Aureus

S.epididermis (less pathogenic)

67
Q

Why is it harder for Ax to work

A

Biofilm forms over metal work so can’t penetrate

68
Q

Symptoms

A

Pain

May not have typical infectious

69
Q

What are RF

A 
Obesity 
Age
Bilateral 
Post-op AF
MI
UTI 
ASA
70
Q

How do you Dx

A

NEVER ASPIRATE
Ortho review
X-ray to look for destruction

71
Q

How do you Rx

A

Long term Ax if not fit for surgery
DAIR
One or two stage revision
Amputation

72
Q

What Ax do you add if metal work

A

Rifampicin

73
Q

What is DAIR

A

Debridmeent
Ax
Implant retention

74
Q

What is most effective

A

One stage revision

Take out metal work and put back in with Ax

75
Q

What is two stage

A

Take metal work out
Put Ax in with cement
Replace joint later in 3 months

76
Q

When do you give Ax before culture

A

If life or death but want to know organism

77
Q

Where can TB affect

A

Extra-articular
Intra-articular
Vertebral body = Pott’s

78
Q

How do you get TB in bone

A

Primary complex in lung

Spread via haematogenous or nodal

79
Q

What are the Sx

A 
Insidious onset
Long Hx
Pain worse at night 
Marked muscle wasting
Swelling
Weight loss 
Pyrexia
Decreased ROM
Ankylosis 
Deformity
Peri-articular osteoporosis 
Thickened synovium
80
Q

How does Pott’s present

A 
Gradual onset back pain
Stiffness
Abscess
Kyphosis
Cord compression
81
Q

RF

A

Previous TB infection
Immunocompromised
HIV

82
Q

How do you Dx

A 
Bloods- FBC, ESR
Mantoux test 
Sputum / urine PCR
Joint aspiration and culture - AAFB on ZN
Biopsy / X-ray
MRI for spine
83
Q

What does X-ray show

A

Swelling

Articular space narrowing

84
Q

How do you Rx

A

Standard TB Rx
Immobilise large joint
Drain abscess
Surgical for severe deformity / abscess / paraplegia

85
Q

What is TB Rx

A 
Rifampicin
Isoniazid
Ethambutol
Pyrezamide
May be needed >6 months
86
Q

What is prognosis for TB

A

Good if no neuro involvement

87
Q

Complications of long term Ax / not fit for surgery

A

If need another replacement won’t get as will just become infected as infection throughout blood

88
Q

What causes red / hot / swollen joint

A

IL 1+6 in inflammatory process

MSK (21 decks)

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