Loco PBL 5: Osteomyelitis and Severs Disease

Question 1

What is Severs disease?

Answer 1

Calcaneal apophytis; Inflammation of the growth plate in the heel bone (calcaneus) of growing children due to repetitive stress to the heel

Question 2

What are the symptoms of Severs disease?

Answer 2

Heel pain aggravated by physical activity on posterior, plantar side of the heel

Question 3

What is the cause of Severs disease?

Answer 3

Overuse of the bones and tendons in the heel; due to the full of the calf muscles on the calcanea tendon that inserts into the calcaneal bone

Question 4

What is a risk factor for Severs disease?

Answer 4

Over-pronating and being a child (as the heel bone grows quicker than the growth plate in the growth spurt). More common in boys too.

Question 5

How is Severs disease diagnosed?

Answer 5

Medial-lateral compression of the calcaneus in the area of the growth plate (compression test) - if there is pain Severs disease is the likely cause ; alongside history and presentation

Question 6

How is Severs disease treated?

Answer 6

RICE, stretching of hamstrings, and sometimes NSAIDs to relieve pain

Question 7

What is the prognosis for Severs disease?

Answer 7

Will go away on its own with rest within 2-8 weeks

Question 8

Why are children going through puberty at a greater risk of Severs disease?

Answer 8

Ad the growth plate in the heel hasn’t fused yet

Question 9

What is the average age for Severs disease in boys?

Answer 9

9-11

Question 10

When do girls go through puberty?

Answer 10

8-13 on average

Question 11

When do boys go through puberty?

Answer 11

10-15 on average

Question 12

What is osteomyelitis?

Answer 12

Infection and inflammation of the bone

Question 13

What are the signs and symptoms of osteomyelitis?

Answer 13

Fever (38 degrees+), bone pain, unwell, affected part is tender , swelling, redness and warmth iat site

Question 14

What is the cause of osteomyelitis?

Answer 14

Infection in the bone from bacteria (staphylococcus aureus is most common)

Question 15

What bacteria may cause osteomyelitis?

Answer 15

Staphylococcus aureus (found in skin or nose), streptococcus pneumonia and streptococcus pyogenes

Question 16

By what three pathways may bacteria invade the bone?

Answer 16

Haematogeneously (through the blood), contiguously (from local areas of infection) or from a penetrating trauma

Question 17

Which part of the bone is most commonly implicated in osteomyelitis?

Answer 17

The metaphysis (contains growth plate); lies between the diaphysis (shaft) and epiphysis (tip) - this is because this area is highly vascular and has slow circulation in the metaphysical capillary loops (as there is growth here so the blood vessels are constantly being degenerated and formed) and therefore it’s easier for haematogeneous spread of infection

Question 18

Describe the pathophysiology of osteomyelitis

Answer 18

Once bone is affected (by one of the routes), there is leukocyte invasion which engulf bacteria and release enzymes which degrade the bone. This causes pus to spread into the blood vessels supplying the bone which leads to impaired blood flow and malnourished bone known as sequestra. The bone will then try to form new bone around this sequestra/necrotic bon known as involcrum

Question 19

What are sequestra formed in osteomyelitis?

Answer 19

A piece of dead bone tissue formed within a disease/injured bone, usually in osteomyelitis (these form the basis of chronic infection)

Question 20

What are ‘involcrum’ formed in osteomyelitis?

Answer 20

The formation of new bone around a sequestrum/necrotic bone

Question 21

How may osteomyelitis be diagnosed?

Answer 21

CRP/ESR elevated, WBC may be elevated, bacterial culture (blood/bone/joint aspirate), MRI or X-ray

Question 22

How may an MRI illustrate osteomyelitis?

Answer 22

T2 weighted image shows increased marrow intensity with surrounding inflammation

Question 23

How may an x-ray illustrate osteomyelitis?

Answer 23

If there is bone destruction (this tends to occur 2 weeks after infection)

Question 24

How is osteomyelitis treated?

Answer 24

Antibiotics

Question 25

How may flucloxacillin be used in the treatment of osteomyelitis?

Answer 25

It is a narrow-spectrum beta-lactam with activity against staphylococcus aureus as it’s beta lactase stablee

Question 26

How may co-amoxiclav be used in the treatment of osteomyelitis?

Answer 26

Consists of amoxicillin trihydrate (beta-lactam antibiotic) and potassium clavulanate (beta lactamase inhibitor) to provide an increased spectrum of action

Question 27

How may fusidic acid be used in the treatment of osteomyelitis?

Answer 27

A form of bacteriostatic antibiotic primarily effective against gram-positive bacteria; it inhibits bacterial replication but doesn’t directly kill the bacteria

Question 28

What kind of bacteria is staphylococcus aureus and streptococcus?

Answer 28

Gram-positive bacteria

Question 29

What is beta-lactamase?

Answer 29

Enzymes produced by bacteria that provide multi-resistance to beta lactam antibiotics

Question 30

How long does treatment for osteomyelitis continue?

Answer 30

Until the CRP levels are back to normal which usually takes between 4-6 weeks

Question 31

How may surgery be used to treat osteomyelitis?

Answer 31

Surgery and washout to remove bacterial infection and allow drainage

Question 32

Why is iodine useful in the treatment of wounds?

Answer 32

Kills 90% of bacteria on the skin within 90 seconds including mould, yeast, protozoa, viruses, gram-negative and gram-positive bacteria and fungi