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Clin Med II - Ortho > Osteomyelitis > Flashcards

Osteomyelitis Flashcards

1
Q

Osteomyelitis - definition

A

Infection in bone

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2
Q

Acute Osteomyelitis - definition

A

Associated with inflammatory bone changes by pathogenic bacteria and s/s typically present within 2 weeks after infection

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3
Q

Chronic Osteomyelitis - definition

A

Necrotic bone with s/s that may not occur until 6 weeks after the onset of infection
Generally secondary to open fx, bacteremia or contiguous bone infection

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4
Q

How does Osteomyelitis occur

A

Hematogenous dissemination of bacteria
Invasion from a contiguous focus of infection
Skin breakdown in the setting of vascular insufficiency

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5
Q

Where does Osteomyelitis occur

A 
Spine
Cancellous portions of long bones
Pelvis
Calvicle
Previously injured bone or bone in close proximity to area of infection
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6
Q

Who does Osteomyelitis occur in?

A

Peds
- etiology is uslaly hematogenous
- most common anatomic area - vascular metaphysis of long bones
Adults
- innoculation of organism through open fx or sx fixation of fx
- hematogenous is much less common than in kids - if it occurs, will be in the vertebra, long bones, pelvis or clavicle

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7
Q

Organisms of Osteomyelitis in peds

A 
S. aureus - most common
Group A beta-hemolytic strep
Others
- Strep penumonia
- H. flu (less prevalent now)
- Kingella Kingae
- Group B strep infection (newborns)
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8
Q

Organisms of Osteomyelitis in adults

A 
S. aureus - most common
Pseudomonas aeruginosa
MRSA
Staph epidermidis
Serratia marcescens
E. coli
Atypical organisms in immunocompromised pts
Others
- M. TB
- Candida species
- Coccidoidomycosis immitis
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9
Q

RF for Hematogenous Osteomyelitis

A 
Children
Sickle cell dz
IV drug use
DM
Chronic Renal Dz
Elderly
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10
Q

Why are children at risk for hematogenous Osteomyelitis

A

Metaphyseal regions of long bones are highly vascular and susceptible to minor trauma

> 50% of acute hematogenous osteomyelitis are in pts <5yo

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11
Q

Organism most common for hematogenous osteomyelitis in sickle cell dz pts

A

Salmonellae

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12
Q

IV drug use and hematogenous osteomyelitis

A

Typically osteomyelitis of the spine

S. aureu (most common) then Gram negative, esp. P. aerginose and Serratia species

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13
Q

The elderly and hematogenous osteomyelitis

A 
Thoracic and lumbar vertebra
RF
- DM
- IV catheters
- Urinary catheters
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14
Q

Causes of soft tissue infections that can spread to the bone

A 
Prosthetic joint replacement
Pressure ulcer
Neuro sx
Trauma
Septic arthritis
Cellulits
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15
Q

Vascular insufficiency and osteomyelitis

A

Pts with DM or vascular insufficiency at greatest risk
Foot and ankle are most likely sites
Infection originates from ulcer or skin breakdown
Big source of chronic osteomyelitis

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16
Q

Vascular insufficiency & osteomyelitis - symptoms

A 
Chronic pain
Persistent sinus tract or wound drainage
Poor wound healing
Malaise
Sometimes fever
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17
Q

Vascular insufficiency and osteomyelitis - important clues

A

Pass sterile probe through ulcer to bone

Ulcer >2cm*cm

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18
Q

Polymicrobial infections of vascular insufficiency and osteomyelitis

A

S. aureus

Staph epidermidis

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19
Q

Clinical Presentation - neonates

A 
Vague s/s
Malaise
Lethargy
Pseudo-paralysis
Excessive crying
Irritability
Fever
Local swelling
Pain with palpation
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20
Q

Clinical presentation - children

A

Fever
Pain
Swelling of infected site

21
Q

Clinical presentation - Adults (hematogenous)

A 
Back pain along with
Hx of DM
Ca
Chronic renal dz 
IV drug use
22
Q

Clinical presentation - Adults (vascular insufficiency with DM)

A 
Chronic pain
Persistent sinus tract or wound drainage
Poor wound healing
Malaise
Sometimes fever
23
Q

Clinical presentation - Adults (Typical s/s)

A 
Fever
Pain
Lethargy
Malaise
Swelling of infected site
24
Q

Clinical presentation - Adults (hx of fx)

A

Drainage or delay in fx healing

25
Q

Clinical presentation - Classic signs

A 
Fever
Erythema
Soft tissue swelling
Bone pain
Decreased ROM
Ulcers
26
Q

Dx work-up - labs in general

A

CBC
CRP
ESR

27
Q

CBC

A

Leukocytosis acutely

Chronically WBC may be normal

28
Q

CRP

A

Marker of inflammation

Elevated in both acute and chronic osteomyelitis

29
Q

ESR

A

Marker of inflammation

Elevated in both acute and chronic osteomyelitis

30
Q

Dx work-up - imaging in general

A

Plain radiographs
MRI
Bone scan
CT

31
Q

Dx work-up - plain radiographs

A 
Focal osteopenia
Soft tissue swelling
Loss of tissue planes
Erosion of bone
Alteration of cancellous bone
Periosteal elevation
Focal lucency around sx implants
Sensitivity 14%
Takes about 2 weeks to show up
32
Q

Dx work-up - MRI

A

Marrow changes associated with osteomyelitis
Determines extent of soft tissue involvement
Can detect osteomyelitis within 3-5d

33
Q

Dx work-up - Bone scan

A

Three-phase technetium-99 bone scintigraphy with leukocyte scintigraphy positive within a few days
High sensitivity
Low specificity

34
Q

Dx work-up - CT

A

Cortical bony details

Detects presence of early cortical erosions associated with osteomyelitis

35
Q

Dx work-up - Gold standard

A

Open bx or aspiration prior to abx administration

Exception - those with hematogenous osteomyelitis and positive blood cultures

36
Q

Dx work-up is not enough, so

A

Look for soft tissue or wound culture typically polymicrobial involvement

37
Q

Chronic osteomyelitis - imaging

A

Plain radiography
MRI
Bone scintigraphy
Demonstrating contiguous soft tissue infection or bony destruction

38
Q

Chronic osteomyelitis - clinical s/s

A 
Exposed bone
Persistent sinus tract
Tissue necrosis overlying bone
Chronic wound overlying sx hardware
Chronic wound overlying fx
39
Q

Chronic osteomyelitis - lab eval

A

Positive blood cultures
Elevated C-reactive protein level
Elevated erythrocyte sed rate

40
Q

Chronic osteomyelitis - definitive dx

A

Bone bx with bacterial culture

41
Q

DDX

A 
Neuropathic arthropathy - Charcot arthropathy
Tumors
Fx and other lytic lesions
Suppurative arthritis
Rheumatic fever
Cellulitis
Gout
Bursitis
42
Q

Tx - in general

A

Refer to ortho & infectious dz
Sx debridement
Abx therapy

43
Q

Tx - sx debridement

A

Sx removal of necrotic tissue
Abx impregnated beads
Vertebral body osteo and epidural abscess - urgent neuro-sx decompression

44
Q

Tx - abx therapy

A

Based on results of cultures and sensitivity
If clinically possible - DELAY ABX UNTIL CULTURES OBTAINED
Typically IV abx followed by oral abx

45
Q

Tx - chronic osteomyelitis

A

IV abx for 2-6 weeks with transition to oral abx for total tx of 4-8 weeks

46
Q

Tx - empiric tx of acute osteomyelitis

A

Beta-lactam abx
If MRSA suspected, then IV vancomycin
In DM foot infections or PCN allergy - Fluroquinolone
Oral therapy with quinolone (Cipro 750 mg BID for 6-8w) has been shown as effective as parenteral.
- if S. aureus quinolones are combined with rifampin 30 mg PO BID

47
Q

Prognosis

A

Most pts can be tx successfully with sx and abx therapy

48
Q

Complications

A

5-33% refractory to tx
Usually due to pt’s overall medical status, comorbidities
May need long-term suppressive abx therapy
Amputation in some cases
Extension to surrounding bone can complicate acute osteomyelitis
Recurrence redsults in anemia, elevated ESR, wight loss, weakness and rarely amyloidosis or nephrotic syndrome
Squamous cell carcinoma or fibrosarcoma may arise in persistently infected tissues

Clin Med II - Ortho (13 decks)

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