Infecção

Question 1

Qual o local mais comum do osso de ocorrer osteomielite na criança? Por quê?

Answer 1

The relative absence of phagocytic cells in the metaphyses of bones in children may explain why acute hematogenous osteomyelitis is more common in this location.

Question 2

Quais fatores dependentes do paciente estão relacionados ao desenvolvimento da osteomielite?

Answer 2

Patient-dependent factors include nutrition, immunological status, and infection at a remote site.

Question 3

Quanto de energia um evento traumático ou um processo infeccioso aumenta o metabolismo basal?

Answer 3

Basal energy requirements of a traumatized or infected patient increase from 30% to 55% of normal.

Question 4

Como pode ser avaliado o status nutricional de um paciente?

Answer 4

Nutritional status can be determined preoperatively by (1) anthropometric measurements (height, weight, triceps skin fold thickness, and arm muscle circumference), (2) measurement of serum proteins or cell types (lymphocytes), and (3) antibody reaction to certain antigens in skin testing. Nutritional support is recommended before elective surgery for patients with recent weight losses of more than 10 lb, serum albumin levels less than 3.4 g/dL or lymphocyte counts of less than 1500 cells/mm.

Question 5

Qual a formula do cálculo nutricional?

Answer 5

[(1.2 × serum albumin) + (0.013 × serum transferrin)] − 6.43. If the sum is 0 or a negative number, the patient is nutritionally depleted and is at high risk for sepsis.

Question 6

Quais são os principais mecanismos de defesa do organismo?

Answer 6

The body’s main defense mechanisms are (1) neutrophil response, (2) humoral immunity, (3) cell-mediated immunity, and (4) reticuloendothelial cells.

Question 7

A quais tipos de bacterias está sujeito um paciente com diminuição da imunidade humoral e mediada por células?

Answer 7

Abnormal neutrophils or humoral and cell-mediated immunities have been implicated in infections caused by encapsulated bacteria in infants and elderly patients, in the increased incidence of Pseudomonas infections in heroin addicts, and in Salmonella and Pneumococcus infections in patients with sickle cell anemia.

Question 8

Quais doenças diminuem a contagem de neutrófilos?

Answer 8

Diabetes, alcoholism, hematological malignancy, and cytotoxic therapy are common causes of neutrophil abnormalities.

Question 9

A partir de que niveis de neutrofilos o paciente fica susceptível a infecções? Quais são os germes?

Answer 9

If the neutrophil count decreases to less than 55/mm3 , infections caused by Staphylococcus aureus, gram-negative bacilli, Aspergillus organisms, and Candida organisms become a major threat.

Question 10

Pacientes com hipogamaglobulinemia e esplenectomizados estão sujeitos a infecção por qual tipo de bacterias?

Answer 10

Patients with hypogammaglobulinemia or who have had a splenectomy are at increased risk of infection caused by encapsulated bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria organisms. Septic arthritis caused by unusual organisms such as Mycoplasma pneumoniae and Ureaplasma urealyticum has been reported and should be suspected in patients with hypogamma- globulinemia and culture-negative septic arthritis.

Question 11

Paciente com deficiencia no sistema complemento estão sujeito a infecção por quais organismos?

Answer 11

When a defect in a component of the complement cascade is present, S. aureus and gram-negative bacillus infections are common.

Question 12

Quais fatores podem levar a uma deficiencia secundária da imunidade mediada por células? A quais organismos o paciente está sujeito à infecção?

Answer 12

Corticosteroid therapy, malnutrition, lymphoma, systemic lupus erythematosus, immunodeficiency in elderly patients, and autoimmune deficiency syndrome all can cause a secondary cell-mediated deficiency, which predisposes the host to fungal and mycobacterial infections and also infection with herpesvirus and Pneumocystis jiroveci.

Question 13

Em qual local da pele geralmente as bactérias residem e se reproduzem?

Answer 13

the hair follicles and sebaceous glands where bacteria normally reside and reproduce.

Question 14

Quais dedos geralmente são perfurados durante o ato cirurgico?

Answer 14

Most frequently, the perforation occurs on the index finger or thumb of the nondominant hand.

Question 15

De quanto em quanto tempo as luvas cirurgicas devem ser trocadas durante uma cirurgia?

Answer 15

At a minimum, surgical gloves should be changed every 2 hours.

Question 16

O fluxo de ar laminar na sala de cirurgia diminui em quanto a porcentagem de bactérias suspensas no ar?

Answer 16

Airborne bacterial concentrations in the operating room may be reduced by at least 80% with laminar-airflow systems and even more with personnel-isolator systems.

Question 17

Além do fluxo laminar de ar, qual outro processo também diminui a porcentagem de bactérias suspensas na sala cirúrgica?

Answer 17

Ultraviolet light also has been shown to decrease the incidence of wound infection by reducing the number of airborne bacteria; not recommended by the Hospital Infection Control Practice Advisory Committee.

Question 18

Como reage o organismo do paciente ao procedimento cirurgico ortopédico em relação às bacterias?

Answer 18

During the first 24 hours, infection depends on the number of bacteria present. During the first 2 hours, the host defense mechanism works to decrease the overall number of bacteria. During the next 4 hours, the number of bacteria remains fairly constant, with the bacteria that are multiplying and the bacteria that are being killed by the host defenses being about equal. These first 6 hours are called the “golden period,” after which the bacteria multiply exponentially. The administration of prophy- lactic antibiotics expands the golden period.

Question 19

Qual bacteria mais comum na pele?

Answer 19

S. aureus, although the frequency of Staphylococcus epidermidis is increasing.

Question 20

Em relação a quimioprofilaxia, qual antibiotico deve ser administrado para o paciente alergico a penicilina? Qual antibiotico não deve ser usado de rotina?

Answer 20

Clindamycin can be given if a patient has a history of anaphylaxis to penicillin. Routine use of vancomycin for prophylaxis should be avoided.

Question 21

Em que momento da cirurgia o antibiótico deve ser administrado? Quando deve ser repetido?

Answer 21

Ideally, antibiotic therapy should begin immediately before surgery (ideally 30 minutes before skin incision). Must be repeated every 4 hours intraoperatively or whenever the blood loss exceeds 1000 to 1500 mL.

Question 22

Quanto tempo deve durar a quimioprofilaxia com antibióticos?

Answer 22

Prophylactic antibiotics should not be extended past 24 hours even if drains and catheters are still in place.

Question 23

Comente sobre a colonização de MRSA entre cirurgiões e residentes.

Answer 23

Schwarzkopf et al. prospectively studied the prevalence of S. aureus colonization in orthopaedic surgeons and their patients and found that among surgeons and residents there was a higher prevalence of MRSA compared with a high-risk group of patients.

Question 24

Qual é a tríade clássica da infecção?

Answer 24

he classic triad is fever, swelling, and tenderness (pain).

Question 25

Durante um episódio de infecção aguda, qual porção do diferencial sanguineo aumenta?

Answer 25

The diferential shows increases in neutrophils during acute infections.

Question 26

Em relação ao PCR e VHS, como eles se comportam durante um episódio de infecção aguda?

Answer 26

Peak elevation of the ESR occurs at 3 to 5 days after infection and returns to normal approximately 3 weeks after treatment is begun. CRP, synthesized by the liver in response to infection, is a better way to follow the response of infection to treatment. CRP increases within 6 hours of infection, reaches a peak elevation 2 days after infection, and returns to normal within 1 week ater adequate treatment has begun.

Question 27

Na análise do aspirado articular, quais valores celulares sugerem infecção?

Answer 27

In septic arthritis, the cell count usually is greater than 80,000/mm3, with more than 75% of the cells being neutrophils.

Question 28

No caso de uma biopsia por congelação, quais contagens de células brancas sugerem infecção?

Answer 28

Intraoperative frozen section also should be obtained in cases in which infection is suspected. A white blood cell count greater than 10 per high-power field is considered indicative of infection, whereas a count less than 5 per high-power field all but excludes infection.

Question 29

Por que a avaliação radiológica não é um bom método para avaliar infeção aguda?

Answer 29

Bone destruction is not apparent on radiographs, however, until an infection has been present for 10 to 21 days. In addition, 30% to 50% of the bone matrix must be lost to show a lytic lesion on radiographs.

Question 30

Como o processo infeccioso altera a imagem na TC?

Answer 30

CT can help determine the extent of medullary involvement. Pus within the medullary cavity replaces the marrow fat, causing an increased density on the CT scan. CT diagnosis of acute osteomyelitis is based on detection of intraosseous gas, osteolysis, sot tissue masses, abscesses, or foreign bodies.

Question 31

Quais são os 3 radioisotopos mais utilizados nas cintilografias?

Answer 31

The three most commonly used radioisotopes are technetium, gallium and indium.

Question 32

Como diferenciar uma celulite, osteomielite e um processo degenerativo pela cintilografia?

Answer 32

Cellulitis causes increased activity during the low and equilibrium phases and a decreased or normal uptake in the delayed phase. Osteomyelitis causes increased uptake in all three phases. Increased uptake in the delayed phase but not in the low or equilibrium phase suggests 99m degenerative joint disease.

Question 33

Quais são os achados clássicos da osteomielite na RNM?

Answer 33

The classic findings of osteomyelitis on MRI are a decrease in the normally high marrow signal on T1 images and a normal or increased signal on T2 images. Although MRI is good for detailing marrow involvement and discitis, it does little to detect early cortical bone involvement.

Question 34

Qual o momento ideal para se colher material para cultura?

Answer 34

Every efort should be made to obtain a culture specimen before antibiotic therapy is begun.

Question 35

Quais os materiais preferidos para realizarem cultura?

Answer 35

The preferred specimen in most bacterial and yeast infections is aspirated fluid (joint or purulent luid). A deep wound biopsy or a curetted specimen ater cleaning the wound is acceptable. In certain bacterial and fungal infections, a tissue biopsy specimen from the edge of the wound is preferable. Aerobic and anaerobic swabs are more commonly used, but aspirated fluid or a tissue biopsy specimen is preferable.

Question 36

O que é o MIC?

Answer 36

The lowest concentration of an antibiotic that inhibits growth of the patient’s isolate is designated the minimal inhibitory concentration (MIC).

Question 37

O que é minimal bactericidal concentration?

Answer 37

The lowest concentration of antimicrobial agent that allows survival of less than 0.1% of the original cultured inoculum.

Question 38

O que é serum bactericidal concentration (SBC)?

Answer 38

The lowest dilution of the patient’s serum that kills 99.9% of a standard inoculum is called the SBC.

Question 39

Quais são os organismos mais comumente isolados? E nas proteses?

Answer 39

S. aureus is most frequently isolated in infectious arthritis. After this, N. gonorrhoeae is more common in adults younger than 30 years, and H. inluenzae type B is more common in children younger than 2 years. These three bacteria, along with various Streptococcus species, constitute most known isolates in joint infections. In contrast, prosthetic joint infections most often are caused by skin lora, such as S. epidermidis and other coagulase-negative Staphylococcus and gram-negative bacilli that are transient skin colonizers.

Question 40

Qual organismo tem sua incidencia aumentando em osteomielite em neonatos e portadores de anemia falciforme?

Answer 40

S. aureus is the most frequent isolate in osteomyelitis, but Salmonella organisms have an increased incidence in patients with sickle cell anemia or neonatal osteomyelitis.

Question 41

Qual a função do desbridamento na osteomielite?

Answer 41

Débridement reduces the inoculum and removes necrotic and avascular bone, bacteria, and harmful bacterial products.

Question 42

Se um paciente não responder a antibioticoterapia entre 36 e 48h o que pode estar acontecendo?

Answer 42

If the patient does not respond to antibiotic treatment in 36 to 48 hours, the wrong antibiotic has been chosen or an abscess has formed.

Question 43

Quais são os antibioticos geralmente associados ao cimento ósseo?

Answer 43

tobramycin, vancomycin, and gentamicin

Question 44

Com o uso de tobramicina e vancomicina no cimento osseo, em que momento ocorre o pico de concentração desses antibioticos e quanto tempo esse pico ocorre?

Answer 44

With tobramycin and vancomycin, the peak concentration of antibiotic delivered to local tissue occurs on the first day and lasts for only approximately 1 week.

Question 45

Quais efeitos o uso de quinolonas e tobramicina podem trazer ao organismo?

Answer 45

Quinolones have shown detrimental efects on chondrocytes and fracture healing; and tobramycin at intermediate levels of concentration (400 μg/mL) can decrease cell replication.

Question 46

Quantas linhagens de HIV foram identificadas até hoje?

Answer 46

Two strains of HIV have been identified: HIV-1, which is the strain most common in the United States, and HIV-2, which has been reported primarily in Europeans, Africans, and rarely in the United States.

Question 47

Qual célula humana o HIV parasita?

Answer 47

The HIV retrovirus is trophic for the CD4 surface receptors of T lymphocytes. The virus causes deregulation and destruction of these T lymphocytes, ultimately resulting in an immunodeicient state.

Question 48

Quando ocorre a osteomielite?

Answer 48

Osteomyelitis occurs when an adequate number of a suficiently virulent organism overcomes the host’s natural defenses (inlammatory and immune responses) and establishes a focus of infection.

Question 49

A partir de qual valor de CD4 as infecções oportunistas podem ocorrer?

Answer 49

When the CD4 cell count is less than 200/mm3 , opportunistic infections occur and clinical manifestations of AIDS begin.

Question 50

Quais são as doenças oportunistas mais comuns nos pacientes com HIV?

Answer 50

P. jiroveci pneumonia and malignancies such as Kaposi sarcoma are the most common opportunistic diseases associated with AIDS in the United States.

Question 51

Quais são os 4 estagios da infecção pelo HIV?

Answer 51

The stages are (1) acute primary HIV infection, (2) chronic asymptomatic HIV infection, (3) symptomatic HIV infection, and (4) advanced HIV-associated opportunistic disease or AIDS.

Question 52

Quais são as manifestações musculoesqueleticas mais comuns nos pacientes com HIV?

Answer 52

The most common musculoskeletal syndromes in HIV-infected patients are manifestations of drug toxicity, reactive arthritis, infectious arthritis, myositis, tendinitis, and bursitis.

Question 53

Quais são os principios gerais na avaliação de um paciente com HIV?

Answer 53

(1) Any musculoskeletal syndrome that occurs in non–HIV-infected patients can occur in HIV-infected patients; (2) HIV infection can alter the clinical presentation, severity, and course of musculoskeletal problems; and (3) early diagnosis of infections is especially important to prevent their spread in an immunocompromised patient.

Question 54

Quais são os organismos mais isolados em artrite septica e bursite em pacientes com HIV?

Answer 54

Gram-positive bacteria, such as S. aureus and S. pneumoniae, commonly found in noninfected patients with septic arthritis and bursitis, also are the most frequently reported organisms causing septic arthritis and bursitis in HIV-infected individuals. Primary osteomyelitis has been reported in HIV-infected patients, but usually it is the result of direct extension from a septic joint.

Question 55

Quais as possiveis causas de miosite nos pacientes com HIV?

Answer 55

Muscle pain or myositis is a common complaint in HIV- infected patients, including idiopathic polymyositis, poly-myositis secondary to zidovudine toxicity, and pyomyositis.

Question 56

Quais são os 3 fatores que devem ser reconhecidos no risco de transmissão de HIV de um paciente para um cirurgião?

Answer 56

Three factors that must be known to calculate an orthopaedic surgeon’s risk of incurring HIV from punctures in the operating room are (1) the frequency of punctures, (2) the percentage of surgical patients who are HIV positive, and (3) the risk of HIV transmission per needle stick from known HIV-positive patients.

Question 57

Quais a formas de transmissão de HIV são de grande risco?

Answer 57

Greatest risk for occupational transmission of HIV involved parenteral injection of blood through orthopaedic pins or hollow-core needles.

Question 58

Quis são as chances de um ortopedista ser contaminado por HIV?

Answer 58

These figures put the annual risk to the orthopaedic surgeon between 0.025% and 0.5%, acumulative (>40 years of practice) risk of 0.6%.

Question 59

O uso de duas luvas durante procedimentos diminui a chance de contato com sangue do paciente em qual porcentagem?

Answer 59

Double gloving reduces the risk of blood contact from 29% to 13%; however, the gloves must be changed at least every 2 hours or every hour for trauma cases.

Question 60

O uso de quimioprofilaxia após o contato com sangue contaminado diminui em qual porcentagem o chance de soroconversão pelo HIV?

Answer 60

A decrease in seroconversion rates of 79% has been shown with the use of chemoprophylaxis ater exposure using zidovudine and lamivudine, chain terminators for reverse transcriptase. Adding a protease inhibitor, indinavir, further decreases antiretroviral activity. hese drugs should be started within 2 hours of exposure and generally are recommended for at least a 4-week course.

Question 61

Qual a população mais acometida por osteomielite aguda hematológica?

Answer 61

Acute hematogenous osteomyelitis is more common in males in all age groups afected.

Question 62

Como é a distribuição da osteomielite aguda hematogênica nas crianças?

Answer 62

The age distri­bution of acute hematogenous osteomyelitis in children is bimodal, generally afecting children younger than age 2 years and children aged 8 to 12 years. Half of all children with osteomyelitis are younger than 5 years of age.

Question 63

Por que crianças menores que 2 anos estão susceptiveis a diminuição do membro e deformidade angular após osteomielite?

Answer 63

In children younger than 2 years, some blood vessels cross the physis and may allow the spread of infection into the epiphysis. For this reason, infants are susceptible to limb shortening or angular deformity if the physis or epiphysis is damaged from the infection. Otherwise, the physis acts as a barrier that prevents the direct spread of a metaphyseal abscess into the epiphysis.

Question 64

Por que a região metafisária é mais susceptivel à osteomielite aguda na criança?

Answer 64

The metaphysis has relatively fewer phagocytic cells than the physis or diaphysis, allowing infec­tion to occur more easily in this area.

Question 65

Osteomielite na região diafisária ocorre com que frequencia?

Answer 65

The diaphysis rarely is involved, and exten­sive sequestration occurs infrequently except in the most severe cases.

Question 66

Como funciona a fise na criança acima de 2 anos em relação a osteomielite aguda?

Answer 66

In children older than 2 years, the physis efectively acts as a barrier to the spread of a metaphyseal abscess. Because the metaphyseal cortex in older children is thicker, however, the diaphysis is at greater risk in these patients. If the infec­tion spreads into the diaphysis, the endosteal blood supply may be jeopardized.

Question 67

Em pacientes esqueleticamente maduros, qual o local mais comum de desenvolvimento de osteomielite hematologica aguda?

Answer 67

Although it can occur anywhere and in any part of the bone, generally the vertebral bodies are afected.

Question 68

Como ocorre a pioartrite na criança abaixo de 2 anos? Qual é articulação mais acometida?

Answer 68

In children younger than 2 years, the common blood supply of the metaphysis and epiphysis crosses the physis and can allow spread of a metaphyseal abscess into the epiphysis and eventually into the joint. The hip joint is the most commonly afected in young patients; however, the physes of the proximal humerus, radial neck, and distal fibula also are intraarticular, and infection in these areas can lead to septic arthritis as well.

Question 69

Qual patógeno é mais comum nas osteomielites em pacientes usuários de drogas injetáveis?

Answer 69

Pseudomonas is the most common infecting organism found in intravenous drug abusers with osteomyelitis.

Question 70

Osteomielite fúngica é mais comum em qual tipo de paciente?

Answer 70

Fungal osteo­myelitis is seen increasingly in chronically ill patients receiv­ing long­term intravenous therapy or parenteral nutrition.

Question 71

Qual patogeno é mais comum em pacientes com hemoglobinopatias?

Answer 71

Salmonella osteomyelitis has long been associated with SS or SC hemoglobinopathies. This infection tends to be diaphyseal rather than metaphyseal.

Question 72

Qual é o patogeno mais comum em crianças saudáveis de 2 a 4 semanas de vida?

Answer 72

Group B Streptococcus is the most likely infecting organism found in otherwise healthy infants 2 to 4 weeks old.

Question 73

Qual o patogeno mais comum nas osteomielites em crianças de 6 meses a 4 anos de idade?

Answer 73

Haemophilus influenzae infections occur primarily in children 6 months to 4 years old.

Question 74

Quais doenças podem mimetizar osteomielite na radiografia? Qual exame pode ser utilizado para diferenciar?

Answer 74

Conditions that may be mistaken for osteomyelitis on plain radiographs include septic arthritis, Ewing sarcoma, osteosarcoma, juvenile arthritis, sickle cell crises, Gaucher disease, and stress fractures. Technetium­ 99m bone scans can conirm the diagnosis 24 to 48 hours after onset in 90% to 95% of patients; a negative technetium­bone scan efectively rules out the diagnosis of osteomyelitis.

Question 75

Qual a aparência da osteomielite na RNM?

Answer 75

On T1­-weighted MR images, osteomyelitis typi­cally has low signal intensity; on T2­-weighted and short-­tau inversion recovery (STIR) images, it has a high marrow signal intensity.

Question 76

Quais são os principios de Nade para o tratamento de osteomielite aguda hematogenica?

Answer 76

In 1983, Nade proposed five principles for the treat­ment of acute hematogenous osteomyelitis that are still appli­cable today: (1) an appropriate antibiotic is efective before abscess formation; (2) antibiotics do not sterilize avascular tissues or abscesses, and such areas require surgical removal; (3) if such removal is efective, antibiotics should prevent their re­formation, and primary wound closure should be safe; (4) surgery should not damage further already ischemic bone and sot tissue; and (5) antibiotics should be continued ater surgery.

Question 77

Quais são as duas indicações cirurgicas para a osteomielite aguda?

Answer 77

The two main indications for surgery in acute hematogenous osteomyelitis are (1) the presence of an abscess requiring drainage and (2) failure of the patient to improve despite appropriate intravenous antibiotic treatment.

Question 78

Qual procedimento deve ser realizado na limpeza de um abscesso na criança?

Answer 78

When a subperi­osteal abscess is found in an infant, several small holes should be drilled through the cortex into the medullary canal. If intramedullary pus is found, a small window of bone is removed.

Question 79

Torniquete pode ser utilizado na limpeza de um abscesso?

Answer 79

Use a tourniquet whenever possible. Elevate the extremity for a few minutes before inlating the tourniquet. Do not exsanguinate the limb with an elastic bandage if infection is present.

Question 80

Como deve ser imobilizada a tibia apos a drenagem de um abscesso?

Answer 80

A long-leg posterior plaster splint is applied with the foot in a neutral position, the ankle at 90 degrees, and the knee at 20 degrees of flexion.

Question 81

Geralmente quanto tempo de antibiotico endovenoso é dado para uma criança com osteomielite aguda?

Answer 81

Generally, a 6-week course of intravenous antibiotics is given.

Question 82

Qual porcentagem de pacientes com infecção primária desenvolvem osteomielite subaguda?

Answer 82

Subacute osteomyelitis is relatively common, reported to occur in over a third of patients with primary bone infections.

Question 83

Como é a contagem da série branca nos pacientes com osteomielite subaguda?

Answer 83

White blood cell counts generally are normal. The erythrocyte sedimentation rate is elevated in only 50% of patients, and blood cultures usually are negative. Even with an adequate bone aspirate or biopsy specimen, a pathogen is identiied only 60% of the time. Plain radiographs and bone scans generally are positive

Question 84

Como é a classificação de osteomielite subaguda de Gledhill e modificada por Roberts et al.?

Answer 84

Classification of subacute osteomyelitis: type 1, central metaphyseal lesion; type 2, eccentric metaphyseal lesion with cortical erosion; type 3, diaphyseal cortical lesion; type 4, diaphyseal lesion with periosteal new bone formation, but without deinite bony lesion; type 5, primary subacute epiphyseal osteomyelitis; and type 6, subacute osteomyelitis crossing physis to involve metaphysis and epiphysis.

Question 85

Quais são os organismos predominatemente isolados nas osteomielites subagudas?

Answer 85

S. aureus and Staphylococcus epidermidis are the predominant organisms identified in subacute osteomyelitis.

Question 86

Qual o tratamento geral para a osteomielite subaguda?

Answer 86

Biopsy and curettage followed by treatment with appro­priate antibiotics generally are recommended for all lesions that seem to be aggressive: “biopsy all cultures and culture all biopsies.” For lesions that seem to be a simple abscess in the epiphysis or metaphysis, biopsy is not recommended. These lesions, which are characteristic of subacute hematogenous osteomyelitis, should be treated with intravenous antibiotics for 48 hours followed by a 6 ­week course of oral antibiotics.

Question 87

O que é o abscesso de Brodie?

Answer 87

A Brodie abscess is a localized form of subacute osteomyelitis that occurs most oten in the long bones of the lower extremi­ties of young adults.

Question 88

Qual a queixa comum do paciente com abscesso de Brodie?

Answer 88

Intermittent pain of long duration is the presenting complaint, along with local tenderness over the afected area.

Question 89

Qual a aparencia radiografica do abscesso de Brodie na radiografia?

Answer 89

On plain radiographs, a Brodie abscess gener­ally appears as a lytic lesion with a rim of sclerotic bone, but it can have a markedly varied appearance.

Question 90

Quais organismos geralmente são isolados nos abscessos de Brodie?

Answer 90

Organisms of low virulence are believed to cause the lesion. S. aureus is cultured in 50% of patients; in 20%, the culture is negative.

Question 91

Geralmente como é a cultura da osteomielite cronica?

Answer 91

In chronic osteomyelitis, secondary infections are common, and sinus track cultures usually do not correlate with cultures obtained at bone biopsy. Multiple organisms may grow from cultures taken from sinus tracks and from open biopsy specimens of surrounding soft tissue and bone.

Question 92

Como é a classificacão fisiológica de Cierny and Mader para osteomielite crônica?

Answer 92

Class A hosts have a normal response to infection and surgery. Class B hosts are compromised and have deficient wound healing capabilities. When the results of treatment are potentially more damaging than the presenting condition, the patient is considered a class C host.

Question 93

Como é a classificação anatomica de Cierny and Mader para osteomielite cronica?

Answer 93

Type I, a med­ullary lesion, is characterized by endosteal disease. In type II, supericial osteomyelitis is limited to the surface of the bone and infection is secondary to a coverage defect. Type III is a localized infection involving a stable, well­demarcated lesion characterized by full­thickness cortical sequestration and cavitation (in this type, complete débridement of the area would not lead to instability). Type IV is a difuse osteomy­elitic lesion that creates mechanical instability, either at pre­ sentation or ater appropriate treatment, and requires complex reconstruction.

Question 94

Como é descrita a classificação de Jones para osteomielite cronica hematogenica na criança?

Answer 94

Three main types are identiied based on radiographic appear­ance: type A, Brodie abscess; type B, sequestrum involucrum; and type C, sclerotic. Type B, sequestrum involucrum, has four subtypes: B1, localized cortical sequestrum; B2, seques­trum with structural involucrum; B3, sequestrum with scle­rotic involucrum; and B4, sequestrum without structural involucrum. Physeal damage is indicated by the addition of “P” (proximal) or “D” (distal) to the classification.

Question 95

Qual é o exame padrão-ouro para diagnóstico de ostemielite crônica?

Answer 95

The “gold standard” is to obtain a biopsy specimen for histological and microbiological evaluation of the infected bone.

Question 96

Qual é o melhor radiofármaco para diferenciar osteomielite cronica e artropatia neuropática no pé diabético?

Answer 96

Indium­–la­beled leukocyte scans are more sensitive than technetium or gallium scans and are especially useful in diferentiating chronic osteomyelitis from neuropathic arthropathy in the diabetic foot.

Question 97

O que é o sinal da paprica?

Answer 97

Puntate bleeding bone is achieved, indicating healthy tissue. (quando realizado curetagem)

Question 98

A tecnica de Papineau é dividida em quantas fases?

Answer 98

The operation is divided into three stages and usually requires several surgeries: (1) débridement and stabilization, (2) cancellous autografting, and (3) skin closure.

Question 99

Quais são os métodos descritos para preenchimento de defeito osseo após curetagem do osso com osteomielite?

Answer 99

The methods described to eliminate this dead space are (1) bone grafting with primary or secondary closure; (2) use of antibiotic PMMA beads as a temporary filler of the dead space before reconstruction; (3) local muscle flaps and skin grating with or without bone grating; (4) microvascular transfer of muscle, myocutaneous, osseous, and osteocutaneous flaps; and (5) the use of bone transport (Ilizarov technique).

Question 100

Na tecnica de Papineau, quais métodos podem ser utilizados para estabilização da região curetada?

Answer 100

Stabilize the bone with an external ixator or intramedullary nail if needed.

Question 101

Na tecnica de Papineau, de quanto em quanto tempo deve ser realizado o debridamento seriado?

Answer 101

Repeat débridement and irrigation with VAC change every 48 to 96 hours until a healthy viable tissue bed is obtained.

Question 102

Qual a concentração local do antibiótico quando usado associado ao cimento ósseo em relação a concentração quando utilizado antibiótico sistemico?

Answer 102

Pharmacokinetic studies have shown that the local concen­trations of antibiotic achieved are 200 times higher than levels achieved with systemic antibiotic administration.

Question 103

Como preparar a mistura antibiotico/cimento ósseo em relação a quantidade de cada produto?

Answer 103

Currently, most commercially available bone cements have a prepackaged form available with gentamicin (500 mg/40­g pack). We generally add 2 to 4 g of vancomy­cin, with or without 1 g of tobramycin, to each 40­g pack before adding the monomer.

Question 104

Quais são as categorias das substâncias absorvíveis usadas com antibióticos para preenchimento de defeitos ósseos?

Answer 104

The biodegradable substances used as antibiotic delivery systems can be classified into three main categories: proteins, bone grat materials and substitutes, and synthetic polymers.

Question 105

Em relação aos flaps musculares utilizados na perna, quais são os musculos utilizados em cada segmento?

Answer 105

The gastrocnemius muscle is used for defects around the proximal third of the tibia, and the soleus muscle is used for defects around the middle third. A microvascular free muscle transfer is required for defects around the distal third of the tibia.

Question 106

O que é uma transferência microvascular?

Answer 106

A microvascular transfer of tissue may consist of muscle that is covered with a skin graft or a myo­cutaneous, osseous, or osteocutaneous flap.

Question 107

O uso de fixador externo circular sobre uma haste para alongamento ósseo é utilizado para que tamanho de defeito segmentar?

Answer 107

Use of distraction osteogenesis with ring fixation over an intramedullary rod has been used for the treatment of segmental defects of up to 13 cm.

Question 108

O que é a osteomielite esclarosante de Garré?

Answer 108

Sclerosing osteomyelitis is a chronic form of disease in which the bone is thickened and distended but abscesses and seques­tra are absent.

Question 109

Qual a causa da osteomielite esclerosante de Garré?

Answer 109

Its cause is unknown, but it is thought to be an infection caused by a low­grade, possibly anaerobic bacterium.

Question 110

Qual tratamento para osteomielite esclerosante de Garré? Quais são os diagnósticos diferenciais?

Answer 110

No treatment has been predictably helpful, but fenestration of the sclerotic bone and antibiotics are advisable. The condition must be distinguished from osteoid osteoma and Paget disease.

Question 111

Nas fraturas por osteomielite, quais métodos de estabilização são preferencialmente utilizados?

Answer 111

Plates and medullary nails have been used to fix infected fractures, but they should be avoided if possible. External fixation or cast immobilization usually is preferred.

Question 112

Qual população mais acometida pela osteomielite cronica multifocal?

Answer 112

The disease is most common in children, with a peak age of 10 years.

Question 113

Quais são os locais mais comumente afetados pela osteomielite cronica multifocal?

Answer 113

It most often affects the metaphysis of long bones, especially the tibia, femur, and clavicle.

Question 114

Qual é o achado radiografico comum em pacientes com osteomielite cronica multifocal com acometimento na coluna?

Answer 114

Vertebra plana is frequent in patients with this disease.

Question 115

Qual condição pode estar associada a osteomielite cronica multifocal?

Answer 115

Another associated condi­tion is palmar-­plantar pustulosis, which manifests as a pus­tular rash on the soles of the feet and palms of the hands.

Question 116

Quais são os critérios diagnósticos para infecção cronica multifocal?

Answer 116

The following have been proposed as criteria for the diagnosis of CRMO: two or more bone lesions mim­icking osteomyelitis, radiographic and bone scan indings consistent with osteomyelitis, 6 months or more of chronic and relapsing symptoms, failure of response to at least 1 month of appropriate therapy, and a lack of other identifiable cause.

Question 117

Qual o tratamento para osteomielite cronica multifocal?

Answer 117

No efective treatment for CRMO has been found, and if the results of cultures are negative, antibiotic treatment is not indicated.

Question 118

Qual é o germe associado a osteomielite do pé após perfuração?

Answer 118

The association of Pseudomonas osteomyelitis with puncture wounds to the foot is well documented in the literature;

Question 119

Quais são as caracteristicas da osteomielite por anaerobico?

Answer 119

Anaerobic soft tissue infections usually start in injured or ischemic tissue. Frequently, a putrid discharge and gas production are present, and extensive tissue necrosis tends to burrow through subcutaneous and fascial planes. Ana­erobic infections have been frequently associated with diabetic gangrene.

Question 120

Qual é a abordagem cirurgica para osteomielite cronica do calcaneo?

Answer 120

Gaenslen approach through the plantar surface of the heel is indicated for resecting the diseased bone of chronic osteomyelitis.

Question 121

Na abordagem de Gaenslen, a incisão na fascia plantar deve ser realizada entre quais músculos?

Answer 121

Incise the plantar aponeurosis in the plane between the abductor digiti quinti and flexor digitorum brevis muscles.

Question 122

Na osteomielite do ilio, quais doenças os sintomas iniciais podem mimetizar?

Answer 122

Early symptoms may suggest acute appendicitis or pyogenic arthritis of the hip joint.

Question 123

Qual a região de formação de abscesso na osteomielite do pubis e do isquio?

Answer 123

In osteomyelitis of the ischium and pubis, an abscess develops either beneath the external or internal obturator muscles or in the ischiorectal fossa.

Question 124

Osteomielite da tuberosidade isquiática é comum em quais pacientes?

Answer 124

Osteomyelitis of the ischial tuberosity is common in bedridden and paraplegic patients who develop pressure sores with secondary infection, necro­sis, and osteomyelitis.

Question 125

Na osteomielite de metatarso, qual região do osso deve ser preservada na criança?

Answer 125

Resect the entire shaft, but preserve the physis whenever possible in children.

Question 126

Quais cuidados devem ser tomados na ressecção da fibula devido a osteomielite?

Answer 126

The entire fibula can be resected if necessary, but the distal fourth contributes to ankle stability and should be retained whenever possible. If the proximal end is resected, the lateral collateral ligament of the knee and the biceps femoris tendon should be firmly anchored to the tibia.

Question 127

Qual a tecnica utilizada para ressecção da asa do iliaco?

Answer 127

Técnica de Badgley

Question 128

Qual é a porcentagem de malignização secundária de um foco de osteomielite crônica e quais são os tipos histológicos descritos?

Answer 128

The prevalence of malignancy arising from chronic osteomyelitis has been reported to be 0.2% to 1.6%. Most of these are squamous cell carcinoma arising from a sinus track, but reticulum cell carcinoma, fibrosarcoma, and other malig­nancies have been reported.

Question 129

Quais são os fatores de risco para o desenvolvimento de pioartrite?

Answer 129

The risk factors for developing joint sepsis included rheumatoid arthritis, osteoarthritis, a prosthetic joint, low socioeconomic status, intravenous drug abuse, alcoholism, diabetes, previous intraarticular corticosteroid injection, and cutaneous ulcers.

Question 130

Em qual população a pioartrite é mais prevalente? Em qual população a pioartrite é mais sequelante?

Answer 130

Septic arthritis occurs most frequently in adults; however, the most serious sequelae from infection occur in children, especially if a hip joint is involved and treatment has been delayed.

Question 131

Quais são as articulações mais acometidas por pioartrite?

Answer 131

The lower extremity weight-bearing joints are predominantly afected (61% to 79%);

Question 132

Qual metodo diagnostico pode ser utilizado para detecção de coleções intra-articulares?

Answer 132

Ultrasonography, in contrast to radiographs, can be used to detect even small collections of fluid deep in the joints. Non–echo-free efusions from clotted hemorrhagic collections are characteristic of a septic joint.

Question 133

Quais são os organismos comumente isolados, por idade e fator de risco?

Answer 133

CLINICAL FACTOR
PATIENT AGE
Neonate = SA
2 yr = SA
Young adults (healthy, sexually active) = NG
Elderly adults = SA (50%), strepto, bacilo-GN

STRUCTURAL ABNORMALITIES
Aspiration or injection Trauma = SA

PROSTHESIS
Early infection = S. epidermidis
Late infection = cocco-GP, anaerobios

MEDICAL CONDITIONS
Injecting drug use = bacilo GN atipico (pseudomonas)
Rheumatoid arthritis = SA
Systemic lupus erythematosus, sickle cell anemia = Salmonela
Hemophilia = SA (50%), strepto, bacilo-GN
Immunosuppression = SA, micobacteria, fungos

Question 134

Como é a patogenese da pioartrite?

Answer 134

Why joints are afected and other vulnerable organs are not is unclear; however, collagen receptors found on Staphylococcus aureus (the most common nongonococcal infecting cause of hematogenous septic arthritis) may play a role. Also, the lack of a limiting basement membrane in the capillaries of synovium may allow intravascular bacteria to reach the extravascular space of synovial tissue through gaps between capillary endothelial cells. In addition, synovial fibroblasts inhibit phagocytosis of bacteria.

Question 135

Na pioartrite, em quanto tempo ocorre a destruição articular total?

Answer 135

Complete destruction of articular cartilage occurs at approximately 4 weeks.

Question 136

Como é a pioartrite por N. gonorrhea?

Answer 136

Often the infection is polyarticular and may be associated with a papular rash. Gonococcal arthritis generally has a favorable outcome if treated with appropriate antibiotics, and drainage usually is unnecessary.

Question 137

Quais são os princípios de manejo das pioartrites?

Answer 137

The principles in the management of acute septic arthritis include (1) adequate drainage of the joint, (2) antibiotics to diminish the systemic efects of sepsis, and (3) resting the joint in a stable position.

Question 138

Quais valores de leucócitos e porcentagem de PMN presente no aspirado articular indicam pioartrite?

Answer 138

Typically, synovial leukocyte counts greater than 50,000/mm3 indicate infectious arthritis; leukocyte counts of 28,000/mm3 or less have been implicated, especially in immunocompromised patients. In addition to the total leukocyte count, the proportion of polymorphonuclear neutrophils, if greater than 90%, indicates infection.

Question 139

Quais pioartrites devem ser abordadas cirurgicamente?

Answer 139

Except for gonococcal arthritis, which usually can be treated efectively with antibiotics, drainage should be performed for all other infectious arthritis.

Question 140

Após a resolução do quadro infeccioso, como deve ser realizado a reabilitação do paciente com pioartrite?

Answer 140

As the infection resolves, therapy to restore normal joint function is begun, including functional splinting initially to prevent deformity, isometric muscle strengthening, and active range-of-motion exercises.

Question 141

Qual a região para puncionar a articulação do tornozelo?

Answer 141

To avoid injuring important structures, the needle is inserted 2.5 cm proximal and 1.3 cm anterior to the tip of the lateral malleolus. This is just lateral to the peroneus tertius tendon.

Question 142

Quais são as vias de acesso para drenagem da articulação do tornozelo? Qual delas é a mais segura?

Answer 142

Anterolateral, anteromedial, posterolateral, and posteromedial. The posterolateral approach has proved safer and more efective than any other approach.

Question 143

Qual é a articulação mais acometida por pioartrite?

Answer 143

The knee joint is the most frequently afected.

Question 144

Qual a região de punção da articulação do joelho?

Answer 144

The needle is inserted on the lateral side at the level of the superior pole of the patella. It is advanced through the lateral retinaculum and into the joint.

Question 145

Quais são as vias de acesso para drenagem da articulação do joelho?

Answer 145

In acute septic arthritis, usually anteromedial arthrotomy or arthroscopic drainage and antibiotic treatment are adequate. If the posterior compartment of the knee is distended, and a popliteal abscess is well established, parallel anterior incisions combined with posterolateral and posteromedial (Henderson) incisions usually are best. If possible, posterior drainage should be avoided because the infection may spread through the fascial planes of the thigh and leg. A posterior midline approach should not be used to drain an infected knee because it exposes the popliteal vessels to pus and to pressure from the drain and creates a potentially contracting scar across the joint.

Question 146

Qual é o metodo de escolha para debridamento do joelho em adultos?

Answer 146

Arthroscopic drainage is the preferred treatment for acute septic arthritis of the knee in adults.

Question 147

Qual é a vantagem da via de Klein para drenagem do compartimento posterior do joelho?

Answer 147

Klein’s approach to the posteromedial aspect of the joint takes advantage of the fact that the bursae between the semimembranosus tendon and the medial head of the gastrocnemius muscle often communicate with the knee joint. Consequently, an incision into these bursae often leads directly into that joint.

Question 148

Qual é a posição que o quadril deve ser imobilizado após drenagem?

Answer 148

After an infected hip in an infant or child has been surgically drained, the hip should be supported in abduction to reduce the risk of pathological dislocation.

Question 149

Qual articulação mais comumente desenvolve pioartrite bilateral?

Answer 149

Bilateral septic arthritis is seen more oten in the hip than in other joints and occasionally is associated with spinal infection.

Question 150

Quais são as vias para puncionar o quadril?

Answer 150

A lateral, anterior, or medial approach can be used to aspirate the hip joint.

Question 151

Como é descrita a tecnica para punção lateral do quadril?

Answer 151

Insert the needle at a 45-degree angle with the surface of the thigh just inferior and anterior to the greater trochanter. Advance the needle medially and proximally close to the bone for 5 to 10 cm, depending on the size of the patient, and into the joint.

Question 152

Como é descrita a tecnica de punção anterior do quadril?

Answer 152

Palpate the femoral artery in line with the inguinal ligament. Insert the needle 2.5 cm lateral and 2.5 cm distal to this point at a 45-degree angle to the skin surface. Advance the needle 5 to 7.5 cm medially and proximally into the joint.

Question 153

Como é a tecnica de punção medial do quadril?

Answer 153

Flex and abduct the leg; this is usually a more comfortable position for patients with septic arthritis. Place the needle inferior to the adductor longus tendon, and using image intensification, advance it in a plane below the palpated femoral artery until the femoral head or neck is reached. Aspirate the joint.

Question 154

Quais são as vias de acesso para drenagem do quadril? Qual é a preferível nas crianças? Qual é a preferível nos adultos?

Answer 154

Drainage of the hip may be accomplished through a posterior, medial, lateral, or anterior approach. The anterior approach is preferred in small children for several reasons: (1) damage to the major blood supply to the femoral head is avoided, (2) the chance of postoperative dislocation is reduced, and (3) the landmarks for the surgical approach are much clearer in a small child. In an adult, the posterior approach allows dependent drainage and is a more familiar approach for most orthopaedic surgeons.

Question 155

Como é chamada a tecnica de drenagem por via posterior do quadril?

Answer 155

Ober

Question 156

Como é chamada a via de drenagem medial do quadril?

Answer 156

Ludloff

Question 157

A via anterior de drenagem do quadril é desenvolvida entre quais músculos?

Answer 157

Expose the sartorius muscle on the medial side and the tensor fasciae latae and vastus lateralis muscles on the lateral side. Use blunt dissection to separate these muscles.

Question 158

A luxação patológica do quadril após pioartrite ocorre geralmente em qual população?

Answer 158

Pathological dislocation occurs predominantly in children.

Question 159

Qual movimento deve ser realizado para reduzir um quadril patológico por pioartrite?

Answer 159

The dislocation is reduced by abduction and gentle rotation;

Question 160

Quais desfechos pode ter a cabeça femoral de um paciente com pioartrite de quadril em crianças

Answer 160

If osteomyelitis results in sequestration of the femoral head in children younger than 12 years old, however, the head may be totally reabsorbed, or it may be replaced by new bone after its circulation is restored.

Question 161

O que pode ocorrer se um abscesso pélvico for drenado por baixo do ligamento inguinal?

Answer 161

Drainage above the inguinal ligament is not advised because a fecal istula may result, and the abscess cannot be thoroughly evacuated.

Question 162

Quais são os resultados da ressecção do quadril pela tecnica de Girdlestone?

Answer 162

This operation may result in a nearly useless pseudarthrosis or ankylosis. Marked shortening of the afected extremity results. For these reasons, this operation is a last resort.

Question 163

Como é a via de acesso na ressecção do quadril pela técnica de Girdlestone?

Answer 163

Begin a transverse incision 2.5 cm posterior and distal to the anterior superior iliac spine, and extend it laterally until the center of the incision is about 2.5 cm proximal to the greater trochanter.

Question 164

Como é a técnica de Klein para tratamento de osteomielite do quadril em pacientes paraplégicos?

Answer 164

Klein et al. described a technique for the treatment of chronic sepsis of the hip in paraplegic patients; it consists of three separate measures to control the infection: (1) a Girdlestone procedure, (2) transposition of the vastus lateralis muscle into the void let by the removal of the femoral head and neck and acetabular wall, and (3) external fixation to prevent unrestrained motion of the femoral shaft that might damage the transposed muscle. The external fixator spans the hip joint with a posterior pelvic-femoral frame.

Question 165

Qual é o exame mais sensível para diagnóstico de pioartrite da sacroiliaca?

Answer 165

The most sensitive diagnostic study is CT.

Question 166

Como é realizado a punção da articulação sacroiliaca?

Answer 166

An 18-gauge spinal needle is introduced in the midline at the level of the sacroiliac joint at a 45-degree angle with the transverse plane and at a 30-degree angle with the sagittal plane. The needle is passed laterally and distally at these angles, and image intensification is used to guide it into the sacroiliac joint 0.5 cm from its most inferior margin.

Question 167

A pioartrite esternoclavicular e acromioclavicular geralmente está associada a quais eventos?

Answer 167

Usually the sternoclavicular and acromioclavicular joints are afected only when acute septic arthritis involves other joints or in heroin addicts.

Question 168

Como é realizada a punção articular do ombro?

Answer 168

he shoulder may be aspirated anteriorly, posteriorly, or later- ally. Because the luctuant area usually is palpable anteriorly, and the bony landmarks can be identiied more easily, the needle is inserted here most often. The aspiration site is located half the distance between the coracoid process and the anterolateral edge of the acromion. The needle is directed posteriorly through the joint capsule, and the joint is aspirated.

Question 169

Quais são as vias de acesso para drenagem do ombro?

Answer 169

The shoulder may be drained through an anterior incision or a posterior incision, but the anterior incision is preferable.

Question 170

Como é a via de acesso para a drenagem anterior do ombro?

Answer 170

Begin an anterior longitudinal incision at the anterior border of the acromion, and extend it 5 to 7.5 cm over the center of the humeral head.

Question 171

Como é a via de acesso para a drenagem posterior do ombro?

Answer 171

Begin the incision at the base of the spine of the scapula, and extend it distally and laterally for 7.5 cm in line with the fibers of the deltoid muscle.

Question 172

Para quais casos a drenagem de pioartrite do ombro por artroscopia está indicada?

Answer 172

Arthroscopic drainage should be reserved for treatment of septic arthritis early in the disease process, particularly before 2 weeks of onset of Gächter stage I or II infections. Loculations and adhesions can be débrided, and a synovectomy can be done.

Question 173

Como Gächter definiu os estágios de infecção?

Answer 173

Stage I: Opacity of fluid, redness of the synovial membrane, possible petechial bleeding, no radiographic alterations.

Stage II: Severe inflammation, fibrinous deposition, pus, no radiological alterations.

Stage III: Thickening of the synovial membrane, compartment formation, no radiological alterations.

Stage IV: Aggressive pannus with infiltration of the cartilage, undermining the cartilage, radiological signs of subchondral osteolysis, possible osseous erosions and cysts.

Question 174

Como é realizado a punção articular do cotovelo?

Answer 174

For elbow aspiration, the physician flexes the elbow and inserts the needle on its posterior aspect just lateral to the olecranon. The needle is advanced through the skin and joint capsule, and the joint is aspirated.

Question 175

Quais são os locais de punção articular do punho?

Answer 175

Aspiration is performed on the dorsal side of the wrist. Several aspiration sites on the dorsum of the wrist can be used. The most common site of aspiration is between the first and second extensor compartments at the radiocarpal level, immediately adjacent to the point where the extensor pollicis longus crosses the extensor carpi radialis longus. Other aspiration sites are between the third and fourth extensor compartments or between the fourth and ith extensor compartments.

Question 176

A drenagem do punho por uma via lateral é feita entre quais músculos?

Answer 176

Make a longitudinal incision 5 cm long between the abductor pollicis longus and extensor pollicis brevis tendons volarly and the extensor pollicis longus tendon dorsally.

Question 177

A drenagem do punho por uma via medial é realizada entre quais músculos?

Answer 177

Make an incision 5 cm long over the ulnar head between the tendons of the flexor and extensor carpi ulnaris. Avoid injuring the dorsal branch of the ulnar nerve.

Question 178

A drenagem da articulação do punho por via dorsal pode ser realizada entre quais músculos?

Answer 178

Make a dorsal longitudinal incision 5 cm long between the extensor pollicis longus and extensor indicis proprius tendons or between the extensor carpi ulnaris and extensor digiti quinti proprius tendons.

Question 179

Como tratar as deformidades do tornozelo após infecção?

Answer 179

When the ankle is fixed in equinus by soft tissue contracture, treatment by Quengel casting or serial wedged casts or by operations such as lengthening of the Achilles tendon with or without posterior capsulotomy generally are efective in restoring plantigrade position of the foot. When fixed equinus is caused by bony ankylosis, cuneiform osteotomy through the joint is indicated.

Question 180

Como corrigir as deformidades do joelho após quadro de infecção?

Answer 180

Soft tissue flexion contractures of the knee can be managed by Quengel or serial wedged casts or may require soft tissue operations. A flexion deformity can be corrected indirectly by a supracondylar osteotomy that causes a compensatory deformity in the opposite direction. This operation should be considered when the flexion deformity is not severe but the joint is unsuitable for manipulation or soft tissue release. In children, the osteotomy should be made well proximal to the physis.

Question 181

Quando está indicada alongamento dos tendões do jarrete nas cirurgias de correção de deformidades do joelho?

Answer 181

If the flexion contracture is greater than 45 degrees, the hamstring tendons should be lengthened before the osteotomy.

Question 182

Quais são os tipos de osteotomias supracondilares do femur usadas para correção da contratura em flexão do joelho?

Answer 182

Tranversa, V-osteotomy (Thompson), cuneiforme (base anterior) e controlled rotational osteotomy (Osgood).

Question 183

Quando está indicada a osteotomia para correção do joelho contraturado em flexo?

Answer 183

Femoral osteotomy is indicated when a functional range of flexion remains beyond the flexion contracture. The osteotomy should be made as near the joint as possible. Full extension can be regained by this operation, but the preoperative range of lexion may be reduced.

Question 184

Quais são os fatores de pior prognóstico para pioartrite do quadril em crianças? Qual deles é o mais importante?

Answer 184

Poor prognostic factors related to septic arthritis of the hip in infants, including (1) an infection that occurred before 22 weeks of age, (2) prematurity, and (3) symptoms that lasted longer than 4 days. The most important factor was delay in diagnosis.

Question 185

A morbidade de um quadril que sofreu de pioartrite está relacionado a quais fatores?

Answer 185

Dor, rigidez, deformidade e instabilidade.

Question 186

Quais são os motivos para atrasar a correção de deformidade do quadril pós pioartrite?

Answer 186

The reasons for this delay are as follows: (1) the danger of reactivating the old infection is reduced; (2) the status of the proximal femur and femoral head should be deinitely determined in children because early radiographs may show what appears to be destruction of the proximal femur with separation and osteonecrosis of the femoral head epiphysis, only to show satisfactory reconstitution on later films; and (3) the strength and general character of the bone improve with time, especially in children, as necrotic bone is revascularized, and abscess cavities are filled in, increasing the likelihood of success after reconstructive surgery.

Question 187

Quais artroplastias podem ser realizadas em pacientes pós piorartrite de quadril com anquilose?

Answer 187

Interposition or cup arthroplasty still may be useful in younger patients with an ankylosed hip. Total hip arthroplasty should be considered only for older patients.

Question 188

Quais procedimentos podem ser realizados para estabilização do quadril?

Answer 188

The hip may be stabilized after acute septic arthritis by (1) arthrodesis, (2) pelvic osteotomy, (3) proximal femoral osteotomy, (4) trochanteric arthroplasty (Colonna) combined with proximal femoral osteotomy, and (5) Harmon or L’Episcopo reconstruction.

Question 189

Qual a proposta da reconstrução L’Episcopo ou Harmon?

Answer 189

In the L’Episcopo or Harmon reconstruction, a new femoral neck is fashioned to articulate with the acetabulum. These operations are useful for young children in whom the femoral head and neck have been absorbed.

Question 190

Como tratar uma contratura em flexão e adução do quadril? E em casos de anquilose?

Answer 190

A flexion and adduction contracture is treated by transferring the crest of the ilium and, when necessary, by an adductor tenotomy. A hip ankylosed in flexion and adduction is treated by intertrochanteric osteotomy, as described here, fixing the hip in neutral rotation, 0 degrees of flexion, and 20 to 30 degrees of abduction (in children). In adults, 25 degrees of flexion and neutral abduction is the best position.

Question 191

Quais são os tipos de osteotomias intertrocantericas para anquilose em flexão e adução do quadril?

Answer 191

a transverse opening wedge osteotomy, a transverse closing wedge osteotomy, or the Brackett ball-and- socket osteotomy.

Question 192

Quais são os prós e contras da osteotomia de abertura intertrocantérica?

Answer 192

The transverse opening wedge osteotomy is simple, and it lengthens the extremity; however, bony apposition is limited, union is delayed in adults, and it is initially unstable.

Question 193

Quais são os prós e contras da osteotomia intertrocantérica de fechamento?

Answer 193

The transverse closing wedge osteotomy provides good bony apposition and is stable; however, it shortens the extremity.

Question 194

Quais são os prós e contras da osteotomia intertrocantérica de Brackett (bola e soquete)?

Answer 194

The Brackett osteotomy achieves stability without shortening the extremity; however, extensive dissection is required. In severe biplane deformities, an accurate and stable osteotomy is difficult to perform.

Question 195

Quais são as populações com risco de contaminação por tuberculose?

Answer 195

Populations most at risk include individuals with acquired immunodeficiency syndrome (AIDS) or other immunodeficiencies, patients with chronic renal failure, substance abusers, homeless or incarcerated individuals, and immigrants from developing countries.

Question 196

Qual a porcentagem de TB extra-pulmonar? Desses, quantos % são de comprometimento osseo?

Answer 196

Extra­ pulmonary involvement is noted in approximately 14% of patients, with 1% to 8% having osseous disease.

Question 197

Qual a taxa de TB vertebral nos pacientes com TB óssea?

Answer 197

Approxi­mately 50% of patients with osseous tuberculosis have pulmonary involvement, and 30% to 50% of patients with osseous disease have vertebral involvement, most often in the lower thoracic spine.

Question 198

Quais são as regiões do esqueleto apendicular geralmente afetadas por TB?

Answer 198

Less frequently observed appendicular involvement usually afects major weight-­bearing joints of the lower extremity, most commonly the hip and knee, followed in frequency by the foot, elbow, and hand.

Question 199

Como é envolvimento regional da TB vertebral?

Answer 199

Usually, active spinal lesions involve a particular segment: two vertebral bodies and the corresponding disc. Some authors have speculated that these areas are afected most oten because of the generous arterial and venous supply and the high oxygen pressure requirement of the tuberculosis bacilli.

Question 200

Como é geralmente a apresentação ossea da TB no corpo vertebral?

Answer 200

A peridiscal presentation occurs in approximately 80% of patients, with the anterior vertebral body afected and contiguous progression through subligamentous burrowing (anterior longitudinal ligament) and eventual extension to the adjacent vertebrae. Less frequently, lesions occur centrally in the vertebral body.

Question 201

Quais são as manifestações clinicas da TB na coluna vertebral?

Answer 201

Patients may have intramedullary granu­lomas, arachnoiditis, segmental collapse with anterior wedging, and gibbus formation (Pott disease). The posterior elements of the spine are rarely the only sites afected.

Question 202

Quais são as características da TB na tomografia?

Answer 202

Calcifications (best seen on CT) within paraspinous abscesses indicate bone destruction and are characteristic of spinal tuberculosis.

Question 203

Quais são os ossos mais envolvidos nos casos de TB do pé?

Answer 203

When present, isolated lesions usually involve the cal­caneus or talus.

Question 204

Quais são os tratamentos propostos para TB nos pés?

Answer 204

When several bones are involved, especially in adults, amputation is the procedure of choice. Curettage is indicated for isolated lesions even when sinuses are present. When lesions involve the subtalar or midtarsal joints, a triple arthrodesis is indicated. When the subtalar and the ankle joints are afected, posterior arthrod­esis of these joints can be done. Involvement of a phalanx or metatarsal often is best treated by excision.

Question 205

Como é o tratamento para TB no joelho?

Answer 205

A knee with a normal­ appearing radiograph or with mildly confined osteomyelitic changes frequently responds to multidrug chemotherapy. These patients usually tolerate early range­-of-­motion and mobiliza­tion procedures. If a patient does not respond adequately to chemotherapy alone, a synovectomy (at times performed arthroscopically), sequestrectomy, or both or curettage of the bony lesion may be required.

Question 206

Como tratar TB no quadril?

Answer 206

If tuberculosis of the hip is diagnosed early, and the disease is limited to the synovium, rest and chemotherapy may be suficient treatment. This situation is more common in chil­dren. If the lesion extends to articular cartilage and bone, and is not extensive, partial synovectomy and curettage oten are successful. If articular cartilage and adjacent bone are extensively involved, arthrod­esis is indicated.

Question 207

Qual região do cotovelo é mais acometida por TB?

Answer 207

The proximal segment of the ulna (olecranon) is more typically afected, which can result in a progressive degenerative process and a significant elbow flexion contracture. Functional positioning becomes paramount in such cases.

Question 208

Qual o aspecto radiológico da TB nos ossos longos e qual o tratamento de escolha?

Answer 208

Radiographs may show a solitary irregular cavity, a series of confluent cavities, or occasionally fusiform enlargement of the shaft. Multiple bones may be involved simultaneously. Effective treatment requires chemotherapy plus evacua­tion of abscesses and sequestrectomies, an operative treat­ment similar to that for chronic pyogenic osteomyelitis. Wounds in tuberculous osteomyelitis can be closed primarily, however, unless secondary pyogenic infection is present.

Question 209

Qual animal está associado à brucelose?

Answer 209

Cabra

Question 210

Qual o local de comprometimento de brucelose ossea?

Answer 210

The worldwide literature indicates that the axial skeleton is the most likely site of osteoarticular involvement, normally occurring as sacroiliitis, spondylitis, or spondylodiscitis. The frequency of a lumbar pathological process was significantly higher than thoracic or cervical ones, with cervical disorders the least frequent.

Question 211

Qual é o tratamento para brucelose ossea?

Answer 211

A 6­-month three-­drug course of rifampin, doxycycline, and streptomycin is recommended for patients with osteo­ articular involvement.

Question 212

Qual região do esqueleto é mais frequentemente afetada pela febre tifóide?

Answer 212

More frequently, the thoracolumbar junction is afected, with accompanying disc involvement.

Question 213

Quais são as alterações músculo-esqueléticas encontradas na sífilis congênita?

Answer 213

In congenital syphilis, periostitis of the temporal bone and palate and cortical thickening of the upper one half of the tibia (“saber shins”) may be seen. Chronic arthralgias may develop and because of neuropathic or vascular involve­ment may lead to the development of a “Charcot joint.”

Question 214

Quais são os picos de incidencia da doença de Lyme?

Answer 214

Two peak age groups are more commonly afected with the disease: children ages 5 to 14 years and adults ages 55 to 70 years.

Question 215

Como é a apresentação clinica da doença de Lyme?

Answer 215

Most patients with Lyme disease present with a charac­teristic bull’s­ eye rash (erythema migrans) within 1 month of the tick bite, although up to 20% of patients may not display this associated rash. Normally, the rash is accompanied by viral­-like symptoms of fever, chills, fatigue, and headaches. Arthralgia, usually polyarthralgia involving both large and small joints and potentially the neck and back, typically accompanies the viral­-like symptoms and characteristic bull’s ­eye rash.

Question 216

Quais são as articulações mais envolvidas na doença de Lyme?

Answer 216

The knee is the most commonly involved joint, fol­lowed by the ankle and wrist.

Question 217

Qual fator está relacionado ao desenvolvimento da doença de Lyme crônica?

Answer 217

Having the alloantigen HLA­-DR4 increases the risk of developing chronic arthritis.

Question 218

Qual local do sistema musculo-esqueletico é mais acometido pela coccidioidomicose?

Answer 218

The axial skeleton is more commonly afected than the appendicular skeleton, and the vertebral column is the most susceptible location of bony involvement for the disease. Joint infections are more likely to be seen in the lower extremities, especially the knee.

Question 219

Qual é a característica da blastomicose ossea?

Answer 219

In a long bone, the infection tends to localize in the epiphysis and extend into the adjacent joint. Lesions in vertebrae mimic tuberculosis.

Question 220

Como é a apresentação clínica da esporotricose?

Answer 220

While a suppurative granulomatous lesion with an ulcerated appearance develops on the skin, there may be lymph, hematoge­nous, or contiguous spread to other structures. This disease can afect the bones, joints, and periarticular soft tissues. Joint spaces may narrow, and eventual subchondral bone demise may occur. Serological tests are useful, as are fungal cultures; however, they are not that sensitive.

Question 221

Qual é o tratamento de escolha para doença de Lyme?

Answer 221

doxycycline

Question 222

Qual é o tratamento de escolha para esporotricose?

Answer 222

Operative intervention may include débridement and chemotherapy with amphotericin.

Question 223

Quais são os ossos mais comumente afetados pela equinococose?

Answer 223

The most commonly afected areas in bone are the vertebrae, pelvis, and the skull. The best treatment for a bone infection resulting from echinococcosis is to resect the involved bone or to amputate. In suspected cases of echinococcosis, diagnostic biopsy or aspiration is contraindicated.