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Year 3 - Musculoskeletal > Infections in bone and joints > Flashcards

Infections in bone and joints Flashcards

1
Q

What is osteomyelitis?

A

A bone infection

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2
Q

What is septic arthritis?

A

A joint infection

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3
Q

Who is most commonly effected by acute osteomyelitis?

A
  • Children mostly
  • Boys >girls
  • Those with a history of trauma
  • Diabetics
  • Rheumatic Arthritis
  • Immunocompromised
  • Steroid users
  • Sickle cell
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4
Q

Acute osteomyelitis, source of infection - Haematogenous spread?

A

Children and elderly

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5
Q

Acute osteomyelitis, source of infection - Local spread from infection spread?

A

> Trauma, open fracture
Bone surgery
Joint replacement

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6
Q

Acute osteomyelitis, source of infection?

A

> Haematogenous
Local from contiguous site of infection
Vascular insufficiency

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7
Q

Acute osteomyelitis, source of infection - in infants?

A

Infected umbilical cord

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8
Q

Acute osteomyelitis, source of infection - in children?

A

> Boils
Tonsilitis
Skin abrasions

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9
Q

Acute osteomyelitis, source of infection - in adults?

A

> UTI

> Arterial line

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10
Q

Acute osteomyelitis, causative organism - In infants, <1 year?

A

> S aureus
Group B Strep
E. coli

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11
Q

Acute osteomyelitis, causative organism - In older children?

A

> S aureus
Strep pyogenes
Haemophilus influenzae

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12
Q

Acute osteomyelitis, causative organism - In adults?

A 
> S aureus, most common
> Coagulase negative Strep (Prosthesis)
> Propionibacterium spp (Prosthesis)
> Mycobacterium tuberculosis
> Pseudomonas aeroginosa, especially secondary to penetrating foot injuries, IVDAs
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13
Q

Acute osteomyelitis, causative organism - In diabetic foot and pressure sores?

A

Mixed infection including anaerobes

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14
Q

Acute osteomyelitis, causative organism - In sickle cell disease?

A

Salmonella spp

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15
Q

Acute osteomyelitis, causative organism - In fishermen, filleter?

A

Mycobacterium marnum

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16
Q

Acute osteomyelitis, causative organism - In debilitation, HIV, AIDs, other immunocompromised?

A

Candida

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17
Q

Acute osteomyelitis - where is affected?

A

Long bones - Metaphysis

  • Distal femur
  • Proximal tibia
  • Proximal humerus

Joints with intra-articular metaphysis:

  • Hip
  • Elbow (Radial head)
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18
Q

Acute osteomyelitis - Pathology?

A

1) Start at metaphysis
2) Vascular tasks
3) Acute inflammation
4) Suppuration
5) Release of pressure
6) Necrosis of bone (Sequestrum)
7) New bone formation (Involucrum)
8) Resolution, or not (chronic)

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19
Q

Acute osteomyelitis, clinical features - In infants?

A 
> May be minimal signs, or may be very ill
> Failure to thrive
> Drowsy or irritable
> Metaphyseal tenderness + swelling
> Decrease ROM
> Positional change
> Most common around the knee
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20
Q

Acute osteomyelitis, clinical features - In children?

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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21
Q

Primary acute osteomyelitis, clinical features - In adults?

A

> Primary OM seen commonly in thoracolumbar spine
Backache
History of UTI or urological procedure
Elderly, diabetic, immunocompromised

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22
Q

Secondary acute osteomyelitis, clinical features - In adults?

A

> Secondary OM much more common
Often after open fracture, surgery (esp. ORIF)
Mixture of organisms

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23
Q

Causative organism in cellulitis?

A

Group A Strep

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24
Q

Causative organism in Erysipelas?

A

Group A Strep

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25
Causative organism in necrotising fasciitis?
- Group A Strep | - Clostridia
26
Causative organism in gas gangrene?
Clostridium perfringens
27
Causative organism in toxic shock syndrome?
S aureus
28
What is cellulitis?
Soft tissue infection - (deep) infection of subcutaneous tissues (Gp A Strep)
29
What is Erysipelas?
Soft tissue infection - superficial infection with red, raised plaque (Gp A Strep)
30
What is necrotising fasciitis?
Soft tissue infection - aggressive fascial infection (Gp A Strep, Clostridia)
31
What is gas gangrene?
Soft tissue infection - grossly contaminated trauma (Clostridium perfringens)
32
Acute osteomyelitis, diagnosis?
> 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 > Aspiration > Imaging
33
Acute osteomyelitis, diagnosis - imaging techniques?
> X-ray (normal in the first 10-14 days) > Ultrasound > Isotope Bone Scan imaging (Technectium-99 labelled siphosphonate, Gallium-67 citrate delayed) > Labelled white cell scan (Indium-111) > MRI
34
What is seen on radiograph in acute osteomyelitis, early on?
Minimal changes
35
What is seen on radiograph in acute osteomyelitis, 10-20days?
Periosteal changes
36
What is seen on radiograph in acute osteomyelitis?
> Early radiographs minimal changes > 10-20 days early periosteal changes > Medullary changes - lytic areas > Late osteonecrosis - sequestrum > Late periosteal new bone - involucrum
37
What is sequestrum?
Late osteonecrosis
38
What is involucrum?
Late periosteal new bone formation
39
When are blood cultures useful in osteomyelitis?
- Heamatogenous osteomyelitis | - Septic arthritis
40
How do you treat acute osteomyelitis?
> Supportive therapy for pain and dehydration > Rest and splintage > Abx: - Duration = 4-6 weeks, depends on response, monitor ESR - Choice = Empirical (Fluclox + Benzylpenicillin) whilst waiting for microbiology > Surgery
41
Prior to antibiotics what was the mortality in acute osteomyelitis?
70%
42
What is important in antibiotic choice in acute osteomyelitis?
> Spectrum of activity > Penetration to bone > Safety for long term administration
43
Why may Abx fail in acute osteomyelitis?
> 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, etc.!!
44
What are the indications for surgery in acute osteomyelitis?
Indications: > 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
45
Complications of acute osteomyelitis?
``` > Septicemia, death > Metastatic infection > Pathological fracture > Septic arthritis > Altered bone growth > Chronic osteomyelitis ```
46
Cause of chronic osteomyelitis?
> Acute osteomyelitis > De novo: - Following operation - Following open fracture - Immunocompromised, diabetics, elderly, drug abusers.. > Repeated breakdown of healed tissue
47
Chronic osteomyelitis, causative organism?
> Often mixed > Mostly S aureus, E coli, Strep progenes, Proteus > Flare-up usually contains same organism(s)
48
Chronic osteomyelitis, Pathology?
> Cavities, possibly sinus(es) > Dead bone (retained sequestra) > Involucrum > Histological picture is one of chronic inflammation
49
Chronic osteomyelitis, complications?
> Chronically discharging sinus + flare-ups > Ongoing (metastatic) infection (abscesses) > Pathological fracture growth disturbance + deformities > Squamous cell carcinoma (0.07%)
50
Chronic osteomyelitis, treatment?
> Long-term antibiotics: - Local (gentamicin cement/beads, collatamp) - Systemic (orally/ IV/ home AB) > Eradicate bone infection- surgically > Treat soft tissue > Deformity/reconstruction > Amputation
51
Acute Septic Arthritis - Route of infection?
> Haematogenous > Eruption of bone abscess > Direct invasion: - Penetrating wound (iatrogenic? – joint injection) - Intra-articular injury - Arthroscopy
52
What can a bone abscess lead to?
1) Acute septic arthritis | 2) Acute osteomyelitis
53
Acute Septic Arthritis - | Organisms?
``` Common: > Staphylococus aureus > Haemophilus influenzae > Streptococcus pyogenes > E. coli ```
54
Acute Septic Arthritis - Pathology?
1) Acute synovitis with purulent joint effusion 2) Articular cartilage attacked by bacterial toxin and cellular enzyme 3) Complete destruction of the articular cartilage 4) then, either: > Complete recovery or > Partial loss of the articular cartilage and subsequent OA or > Fibrous or bony ankylosis
55
End result of acute septic arthritis?
Either: > Complete recovery or > Partial loss of the articular cartilage and subsequent OA or > Fibrous or bony ankylosis
56
Acute Septic Arthritis, clinical presentation - Neonate?
Picture of septicaemia > irritability > resistant to movement > ill
57
Acute Septic Arthritis, clinical presentation - Child/adult?
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
58
Most common site(s) of acute septic arthritis in an adults?
Often involves superficial joint - Knee, ankle, wrist
59
Investigation in acute septic arthritis in an adult?
``` Investigation: > FBC, WBC, ESR, CRP, blood cultures > X ray > Ultrasound > Aspiration ```
60
What is the most common cause of acute septic arthritis in an adult?
Injected joint replacement - Rare, only 1-1.5% - Disaster = Amputation, death etc - S aureus still most common
61
Differential diagnosis in acute septic arthritis?
``` > Acute osteomyelitis > Trauma > Irritable joint > Haemophilia > Rheumatic fever > Gout > Gaucher’s disease ```
62
Treatment in acute septic arthritis?
> 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?
63
Classification of tuberculosis in bone and joints?
Classification: > Extra-articular (epiphyseal / bones with haemodynamic marrow) > Intra-articular (large joints) > Vertebral body
64
Tuberculosis, bone and joints - clinical features?
> Insidious onset & general ill health > Contact with TB > Pain (esp. at night), swelling > Loss of weight > Low grade pyrexia > Joint swelling > Decrease ROM > Ankylosis > Deformity
65
Tuberculosis, bone and joints - pathology?
> Primary complex (in the lung or the gut) > Secondary spread > Tuberculous granuloma > n.b. role of nutrition/ other disease (e.g. HIV AIDS)
66
Tuberculosis, bone and joints - pathology?
> Primary complex (in the lung or the gut) > Secondary spread > Tuberculous granuloma > n.b. role of nutrition/ other disease (e.g. HIV AIDS)
67
Tuberculosis, bone and joints - Diagnosis?
``` > Long history > Involvement of single joint > Marked thickening of the synovium > Marked muscle wasting > Periarticular osteoporosis ```
68
Tuberculosis, bone and joints - Investigations?
> FBC , ESR > Mantoux test* > Sputum/ urine culture > Xray: - soft tissue swelling - periarticular osteopaenia - articular space narrowing > Joint aspiration and biopsy - AAFB identified in 10-20% - culture +ve in 50% of cases
69
Tuberculosis, bone and joints - Differential diagnosis?
``` > Transient synovitis > Monoarticular RA > Haemorrhagic arthritis > Pyogenic arthritis > Tumour ```
70
Tuberculosis, bone and joints - Differential diagnosis?
``` > Transient synovitis > Monoarticular RA > Haemorrhagic arthritis > Pyogenic arthritis > Tumour ```
71
Tuberculosis, bone and joints - Treatment?
``` chemotherapy 1) Initial: - rifampicin = 8 weeks - isoniazid = 8 weeks - ethambutol = 8 weeks then: - rifampicin and isoniazid for 6-12 months ``` 2) Rest and splintage 3) Operative drainage rarely necessary
72
Tuberculosis, bone and joints - Treatment, chemotherapy first 8 weeks?
- rifampicin = 8 weeks - isoniazid = 8 weeks - ethambutol = 8 weeks
73
Tuberculosis, bone and joints - Treatment, chemotherapy after the first 8 weeks?
Rifampicin and isoniazid for 6-12 months
74
When does acute osteomyelitis most commonly occur in adults?
In those immunocompromised, sickle cell, diabetes etc
75
Where is Propionibacternirm spp found on the body?
In the axilla
76
If someone was to step on a nail which organism is likely to cause acute osteomyelitis?
Pseudomonas aeroginosa
77
Which age group is most likely to have acute osteomyelitis caused by H influenzae?
4-8 yrs of age
78
When do you see acute osteomyelitis caused by fungal infections?
In those who are immunocompromised
79
If the released into the joint within acute osteomyelitis what is likely to occur?
Septic arthritis
80
Who is more likely to be affected by multi-site acute osteomyelitis?
Infants
81
What is the most common site of primary acute osteomyelitis in adults?
The spine
82
What are the most common organisms which cause acute osteomyelitis in adults?
UTI --> E. coli
83
What is lost in septic arthritis?
Mobility of the joint
84
What can viral infection lead to within children?
Transient synovitis (Effusion into the hip)
85
What can you see if using ultrasound in acute osteomyelitis?
Periosteal swelling from pus
86
Which imaging modality is more commonly used in acute osteomyelitis now?
MRI
87
What is the big complication risk of chronic osteomyelitis?
Squamous cell carcinoma
88
If there is a penetrating wound near a joint how is this managed?
They are taken to theatre and the wound and joint is washed out
89
What is the risk of a deeper joint being affected by acute septic arthritis?
Deeper joint is harder to recognise and is less tender and often leads to late diagnosis as a consequence
90
Which organism is more likely to cause acute septic arthritis in an adult who has received a joint replacement?
Staph epidermis
91
If there is acute inflammation of a joint with a loss of ROM which pathology should be considered?
Acute septic arthritis
92
How is acute septic arthritis managed?
> Early = Aggressive ABx prior to pus > Once there is pus surgical drainage and lavage is required > Infected joint replacement = One stage/ two stage revisions
93
Which site is most common in bone/joint related TB?
The vertebral bodies
94
Which site is most common in intra-articular TB?
The knee
95
When does pain typically occur in bone/joint TB?
Pain at night
96
If there is a decreased ROM in bone/joint TB what is this suggestive of?
Fibrosis

Year 3 - Musculoskeletal (30 decks)

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