MSK - Level 1 Flashcards
Description of septic arthritis?
- Infection producing inflammation in native/prosthetic joint or more than one joint
- Medical emergency and can destroy joint or develop sepsis <24 hour
- Reaches via bloodstream, adjacent osteomyelitis or external skin puncture wounds
Epidemiology of septic arthritis?
- Knee in >50% cases, followed by hip, shoulder, ankle and wrists
- 1-2% incidence
Risk Factors of septic arthritis?
o Age>80 o Rheumatoid arthritis/Gout o DM o Immunosuppresion o Renal failure o Prosthetic joints/Recent surgery o IVDU
Causative organisms of septic arthritis?
o S.aureus (most common) o Streptococcus o N.gonorrhoea o TB o Salmonella o Coagulase neg staph – prosthetic joints
Symptoms and signs of septic arthritis?
o Monoarticular
o Red, painful, swollen joint developing acutely
o Pain on active and passive movement and often held in position of most comfort (slightly flexed)
o May be fever, rigors, shaking, vomiting
- Signs may be less marked in elderly, IVDU, immunocompromised
Investigations needed in septic arthritis?
- Bloods
o FBC, ESR, CRP, blood cultures - Joint aspiration
o Send for leukocyte count, Gram staining, microscopy and culture, ?AAFB
o Infectious aspiration – yellow, turbid, purulent, >10000 cells, neutrophils, Gram stain and culture +ve
o Normal aspiration – colourless/pale yellow, clear, 200-1000 cells, mononuclear cells, Gram stain and culture -ve - X-rays
o Normal or soft tissue swelling with displacement of capsular fat planes and swelling of soft tissue
o Later, bone destruction occurs - CT/MRI scan reserved for difficult cases
Initial Management of septic arthritis? Orthopaedic management after referral?
o Analgesia
o IV Flucloxacillin for 2 weeks then oral switch for 4 weeks
If penicillin allergic - Clindamycin
If MRSA – Vancomycin
If gonococcal – cefotaxime
Empirical and start after aspiration
o Refer to Orthopaedic team for Joint irrigation/drainage, Analgesia, Splinting (In position of function, once infection under control then mobilisation will promote healing)
Management of osteomyelitis/septic arthritis?
- Flucloxacillin for 6 weeks
o Consider adding fusidic acid or rifampicin for 1st 2 weeks
o If penicillin allergic – clindamycin
o If MRSA – vancomycin
Prognosis of septic arthritis?
o Mortality is 10-20%
o Around half regain baseline joint function after treatment
Description of giant cell arteritis?
- Chronic immune-mediated vasculitis characterised by granulomatous inflammation in walls of medium and large arteries
- Preferentially extracranial branches of carotid artery and branches of ophthalmic artery
- GCA and polymyalgia rheumatica often occur together in 50%
Epidemiology of giant cell arteritis?
- Incidence rare before 50 and peaks at 70
- White people 7x more common
- 3x more common in women
Symptoms of giant cell arteritis?
Headache Unilateral over temporal region Temporal artery and scalp tenderness When combing hair Jaw claudication Pain while eating Amaurosis fugax Sudden blindness in eye Diplopia Fever, fatigue, anorexia Other – Neuropathy, morning stiffness
Signs of giant cell arteritis?
o Ischaemic disease on fundoscopy
o Temporal arteries – prominent, beaded, tender and pulseless
o Bruits may be heard over carotid
Suspect giant cell arteritis if..?
- Suspect if >50 and:
o New onset localised headache, unilateral in temporal area
o Temporal artery – tender, thickened, nodular, red, pulseless
When to refer people with suspected giant cell arteritis?
- Refer all people for temporal artery biopsy
o If visual impairment – same-day ophthalmology assessment
o If no visual impairment – urgent rheumatology assessment (biopsy within 7 days)
What bloods tests to order in giant cell arteritis?
o ESR, CRP raised
o FBC – normochromic normocytic anaemia, elevated platelets
o LFT – mildly elevated
Initial drug treatment of giant cell arteritis?
Immediate Prednisolone 60mg/d PO
Assess response over 1st 48 hours – if poor seek specialist advice
If develop visual symptoms – seek same-day assessment for IV methylprednisolone
Treatment reduced slowly and required for 1-2 years
Aspirin 75mg OD
Omeprazole 20mg OD
Ongoing management of giant cell arteritis?
o If symptoms controlled – reduce dose of prednisolone slowly
60mg until ESR/CRP normal, then reduce by 10mg every 2 weeks until 20mg daily, then reduce 2.5mg every 2-4 weeks until on 10mg daily, then 1mg evert 1-2 months
o Review a week after dose change and every 3 months for 1st year then 3-6 monthly
Do ESR, CRP, BP and glucose
o Assess fracture risk and whether need bisphosphonates
Managing a relapse of giant cell arteritis?
o If visual disturbance – increase to 60mg prednisolone & same-day assessment with ophthalmologist
o If jaw claudication – increase to 60mg daily &seek specialist advice
o If headaches, or PMR – increase dose and seek specialist advice
Prognosis of giant cell arteritis?
o Relapses common – especially when steroid treatment reduced or withdrawn too quickly
o Exacerbations occur in 30-50% of people during first 2 years
Complications of giant cell arteritis?
o Visual Loss – total or partial o Aortic aneurysm, aortic dissection, large artery stenosis and aortic regurgitation o CVD o Peripheral neuropathy o Confusion and encephalopathy
