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MSK: Part 7 Flashcards

1
Q

How does meningococcal arthritis occur

A
  1. Deposition of circulating immune complexes containing meningococcal antigens
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2
Q

How is meningococcal arthritis treated

A

PENICILLIN

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3
Q

What causes tuberculous arthritis

A

MYCOBACTERIUM TUBERCULOSIS

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4
Q

What joints are commonly effected in tuberculous arthritis

A

Hip
Knee
Intervertebral discs

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5
Q

Pathophysiology of tuberculous arthritis

A

caveating granulomas

Rapid destruction of cartilage and adjacent bone

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6
Q

Clinical presentation of tuberculous arthritis

A

Fever
Night Sweats
Weight Loss

Pain, swelling and dysfunction

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7
Q

Diagnosis of tuberculous arthritis

A
  1. Culture synovial fluid
  2. Biopsy synovial fluid or intervertebral disc - CT guided
  3. X-ray may be normal but shows joint-space reduction and bone destruction
    4
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8
Q

Treatment for tuberculous arthritis

A

9 months:

Rest joint and spine immobilised in cute phase

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9
Q

What is osteomyelitis

A

Bone marrow inflammation localised to one bone

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10
Q

What causes osteomyelitis

A

Haematogenous spread or due to local infection

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11
Q

What age group is effected by osteomyelitis

A

Children

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12
Q

How do adults get osteomyelitis

A

Secondary infection or direct trauma

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13
Q

Main causes of osteomyelitis

A
  1. Staph Aureus
  2. Coagulase negative staphylococci
  3. Haemophilus influenza
  4. Salmonella (SSA)
  5. Pseudomonas aeriguinosa and seratia marcesans in IVDU
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14
Q

Risk factors for osteomyelitis

A
  1. Diabetes mellitus
  2. Peripheral vascular disease
  3. Malnutrition
  4. Inflammatory arthritis
  5. Debilitating disease
  6. Decreased immunity
  7. Sickle cell disease
  8. Immunosuprresive drugs
  9. Trauma
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15
Q

Two ways bacteria can get into th bone

A
  1. Direct inoculation of infection into the bone via trauma
  2. Contigous spread of infection into the bone (not as easy):

Without breaking skin
Infection of adjacent soft tissue spreading into bone

Haematogenous seeding (hard to do)

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16
Q

What age group usually has osteomyelitis caused by spread of infection into th bone

A 
Elderly:
Diabetes mellitus
Chronic ulcers
Vascular disease
Joint replacement 
Prostheses
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17
Q

What is haematogenous seeding

A

Infection from skin spreading to the blood then to the bone (Staphylococcus aureus from cannula on skin to blood then into bone)

EXAMPLE

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18
Q

What bones are usually effected in children in haematogenous seeding

A

Long bones - metaphysics (wide portion of a long bone between the epiphysis and the narrow diaphysis - contains growth plate) of the long bone

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19
Q

Why is the metaphysis most commonly effected in haematogenous seeding

A
  1. Here blood flow is slower, endothelial basement membrane is absent and the capillaries lack or have inactive phagocytic lining cells - all these factors predispose to bacteria migrating from blood into bone and the growth of bacteria in the bone
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20
Q

Where is haemotgenous seeding in adults

A

Vertebra

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21
Q

Why is the vertebra target for haematogenous seeding

A

With age, vertebra becomes more vascular thereby making bacterial seeding of the vertebral endplate more likely

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22
Q

What condition can cause risk for haematogenous seeding

A
  1. IVDU (in younger - clavicle and pelvis)
  2. Dialysis
  3. Sickle cell disease
  4. Urethral catheterisation and UTI
  5. Endocarditis
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23
Q

What bone does sickle cell disease cause bacteraemia in

A

Vascular necrosis of the hip

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24
Q

Acute changes to cells in osteomyelitis

A
  1. Inflammatory cells
  2. Oedema
  3. Vascular congestion
  4. Small vessel thrombosis
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25
Chronic changes to cells in osteomyelitis
1. Necrotic bone 'sequestra' 2. New bone formation - involucrum 3. Neutrophil exudates 4. Lymphocytes and histiocytes (tissue macrophages)
26
Pathophysiology of osteomyelitis
1. Inflammatory exudates in the marrow leads to increased intramedullary pressure, with extension of exudate into bone cortex 2. Causes rupture through periosteum and interruption of periosteal blood supply resulting in necrosis 3. This leaves sequestra 4. New bone called involucrum forms over it
27
What is sequestra
Pieces of separated dead bone
28
Clinical Presentation of osteomyelitis
1. Dull pain at site that is aggravated by movement 2. Fever, sweats, riggers and malaise 3. ACUTE: Tenderness, warmth, erythema and swelling 4. CHRONIC: Tenderness, warmth, erythema and swelling Draining sinus tract which is associated with deep/large ulcers that fail to heal despite treatment 6. SEPTIC ARTHRITIS
29
Symptoms if osteomyelitis occurs in the hip, vertebrae or pelvis
Pain and that's it
30
Why would osteomyelitis result in septic arthritis
1. When infection breaks through cortex resulting in discharge of pus into the joint - knee, hip or shoulder
31
Where is septic arthritis caused by osteomyelitis common
Infants - patent transphyseal blood vessels and immature growth plates
32
Differential diagnosis of osteomyelitis
1. CHARCOT JOINT - damage due to sensory nerves affected by diabetes 2. Soft tissue infection (cellulitis and erysipelas) 3. Avascular necrosis of the bone causes: steroids, radiation or bisphosphonate use) 4. Gout 5. Fracture 6. Malignancy
33
Diagnostics of osteomyelitis
1. Imagine (X-rays, bone scans and MRI) 2. FBC 3. Bone biopsy and culture to determine aetiology
34
What would an x-ray show in osteomyelitis
1. Osteopenia 2. Cortical erosions 3. Sclerosis 4. Sequestra 5. Soft tissue swelling
35
When is an MRI for osteomyelitis done
Marrow oedema from 3-5 days Soft tissue inflammation AFTER X-ray (takes time for changes to be seen)
36
FBC results in osteomyelitis
1. ESR and CRP raised 2. Raised WCC in acute 3. Chronic osteomyelitis - normal WCC
37
How is osteomyelitis treated
1. Immobilisation 2. IV TECLOPANIN 3. IV FLUCOXACILLIN 4. ORAL FUSIDIC ACID 5. ESR and CRP monitoring 6. Removal of dead bone (sequestrium)
38
How is tuberculous osteomyelitis caused
Haematogenous spread from a reactivated primary focus in lungs or GI tract
39
Clinical presentation of tuberculous osteomyelitis
1. Local Pain | 2. Swelling if pus collected
40
Diagnostics for tuberculous osteomyelitis
1. BIOPSY - caveating granuloma
41
Treatment for tuberculous osteomyelitis
1. 12 months with same treatment as for pulmonary tuberculosis
42
Where does prosthetic joint infection happen
Hips and Knees
43
Main causes of prosthetic joint infection
Staph A Coagulase negative staphylococci (most frequent after hip replacement) Gram-POSITIVES
44
Risk factors for Prosthetic joint infection
1. Poor infection control 2. Old age 3. Diabetes 4. Obesity
45
How do you prevent infections in prosthetic joints
1. Plastic screen that walls off the anaesthetist from joint 2. Lamina flow theatres with filtered air blowing out of the theatre to make it difficult for organisms to enter 3. Antibiotics placed into bone cement and systemic antibiotics pre-op help minimise infection risk
46
Clinical presentation of prosthetic joints
1. Not acutely infected 2. Systemically well 3. Tender, hot, swollen joint
47
Diagnostics for prosthetic joints
1. Tissue sample from surgery 2. ESR and CRP raised 3. Alpha defensive 4. Joint aspiration - GOLD STANDARD
48
Why is joint aspiration the gold standard for prosthetic joints
1. Identifies organisms and antibiotic sensitivities | 2. MUST BE DONE OFF ANTIBIOTICS FOR 2 WEEKS MINIMUM
49
Treatment for prosthetic joints
1. Antibiotics suppression 2. Debridement and retention of prosthesis 3. Excision arthroplasty 4. One-stage arthroplasty exchange 5. Two-stage arthroplasty exchange 6/ A,mutation in severe infection
50
What are the aims of treatment in prosthetic joint infections
1. Eradicate sepsis 2. Relieve pain 3. Restore function
51
When is excision arthroplasty done
High risk frail and co-morbidities who have infection that is uncontrolled with antibiotic suppression 2. People with low functional demand 3. Effectie in removing infection but not good at restoring function
52
What is one-stage arthroplasty exchange
1. Radical debridement 2. Implantation of new prosthesis with antibiotic cement 3. Systemic and local antibiotics 4. Avoid bone graft 5. 85% success rate
53
What is two-stage arthroplasty exchange
1. radical debridement 2. Local antibiotic spacer +/- systemic antibiotics 3. Interval stage (suture up and wait for infection to clear) 4. Implantation of new prosthesis with antibiotic cement 5. Routine antibiotic prophylaxis 6. 90-95% success
54
Define major trauma
1. Serious and often multiple injuries where there is a strong possibility of death or disability with an injury severity score greater than 15
55
What is an injury severity score
1. Each injury is scored depending on the abbreviated injury scale 2. Assigned to one of six body regions: Head + Neck Face Chest Abdo Extremity - pelvic skeleton external
56
What is the Abbreviated injury scale
1. Minor - Superficial Laceration 2. Moderate - Fractured sternum 3. Serious - Open fracture humerus 4. Severe - Perforated trachea 5. Critical - Ruptured Liver 6. Unsurvivable - Total aortic transection
57
How is an ISS score made
Only the highest score in each region is counted The 3 highest scores are counted and then squared and then x3 to generate ISS Score of 6 in any region gets automatic ISS of 75
58
What is Juvenile Idiopathic Arthritis
Joint swelling/Stiffness/limitation in those older than 6 weeks but under 16 with not other causes 7 subtypes according to presentation
59
What doctor would a child age 15 see
Paediatrician Normal doctor over 16
60
What usually causes idiopathic arthritis
Autoimmune Gene combinations 1. infection 2. Reactive 3. Trauma 4. Malignancy 5. Connective tissue disease
61
What pathologies can be seen in Juvenile Idiopathic Arthritis
1. Synovitis 2. Persistent oligoarthritis 3. Extended oligoarthritis 4. Rheumatoid factor negative polyarthritis 5. Rheumatoid factor positive polyarthritis 6. Enthesitis 7. Stills disease
62
What are children with JIA at high risk of
UVEITIS - membrane lining the eyes is similar to that of joint and suffer from CHRONIC ANTERIOR UVEITIS They can go blind
63
How do we prevent uveitis in juvenile idiopathic arthritis
OPTHALMIC SCREENING EVERY 3 Months
64
In what individuals is persistent oligoarthritis found in
Less than 6
65
What joint is effected in persistent oligoarthritis
Knee
66
Diagnosis for JIA with persistent oligoarthritis
ANA negative HIGH RISK UVEITIS
67
Treatment for persistent oligoarthritis in JIA
Grow out of it so leave
68
What gender is extended oligoarthritis usually effecting
Girls
69
Peak age of extended oligoarthritis
2-4
70
What has a worse prognosis extended or persistent
Extended
71
What risk is associated with extended oligoarthritis
UVEITIS
72
What defines rheumatoid factor negative polyarthritis in JIA
Acute or insidious onset in more than 5 joints
73
Clinical features of rheumatoid factor negative polyarthritis
SYMMETRICAL malaise, fever and anaemia UVEITIS
74
When does rheumatoid factor positive polyarthritis manifest
Late adolescent in girls
75
What condition is rheumatoid factor positive polyarthritis similar to
RA
76
FBC in rheumatoid factor positive polyarthritis
CCRP antibody is negative
77
Risk in RFPP
UVEITIS related to smoking
78
When does enthsitsis related JIA occur
HLA-B27 positive - spondyloarthritis in young people
79
What age does enthesitis related JIA occur
MALES OVER 6 HIGH RISK UVEITIS IBD associated
80
Symptoms of enthesitis related JIA
IBD Inflammatory back pain or sacroiliac pain
81
When does Stills disease occur
4-6 years
82
What is stills disease
Systemic illness with daily fever - fever spikes daily at same time Evanscent rash and artritis Anaemic, raised platelets and high ferritin Lymphadenopathy , hepatosplenomegaly and serositis
83
Non-medical Treatment for JIA
1. Information and education 2. Support and liaison with school 3. Physiotherapy 4. Occupational therapy 5. Psychology
84
Medical treatment for JIA
1. Steroid joint injections - ENTONOX (laughing gas) for general anaesthetic 2. IBUPROFEN 3. METHOTREXATE 4. Systemic steroids 5. IV INFLIXIMAB
85
Where is osteomyelitis seen in children
Arms + Feet
86
Where is osteomyelitis seen in adults
Feet Spine Hips
87
How does TB spread from ling to bone
HAEMATOGENOUS SPREAD
88
Pathophysiology of osteomyelitis
Leukocytes invade bone to try engulf pathogens However produces pus which spreads into blood vessels and blocks blood = sequestra Bone trys producing now bone to replace necrosed bone = involucrum
89
Complication of osetomyelitis in children
Subperiosteal abscesses
90
What two types of osteomyelitis is there
Sclerotic (increased bone density) Suppurative (pus filled)
91
What is involucrum
Layer of new bone outside existing bone
92
Bone biopsy in osteomyelitis
1. 16sRNA PCR | 2. Inflammation and osteonecrosis

Year 2 (155 decks)

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