Osteomyelitis, Arthritis Flashcards
Acute Osteomyelitis
def, risk factors, causes
Infection of bone. Often seen in children (femur & tibia)
Vertebrae in adults (IV drug use)
Risk Factors
● Sickle Cell
● DM
● Immunocompromised
● Joint diseases
● Indwelling catheters
Infection comes from:
● Hematogenous spread
● Direct Inoculation (in close proximity to
bone, prosthetic joints, open fractures &
wounds).
● Contiguous spread with vascular
insufficiency (DM, Peripheral Vascular Disease)
Causes:
● Staph aureus -most common**
● Staph epidermis (PJI)
● Salmonella (sickle cell)
● Group B streptococcus (neonates)
● Pseudomonas aeruginosa (puncture
wounds- dirty shoes)
MCC acute osteomyelitis and definitive dx
Staph aureus -most common**
definitive dx: BONE BX
acute osteomyelitis: sx, dx, tx
Signs & Symptoms
● Fever, chills, malaise
● Bone pain, warmth, swelling, tenderness
● Decreased ROM, limp, refusal to bear weight
Diagnosis
● Blood work -Increased
■ ESR/CRP,
■ WBC
○ +blood cultures (50%)
● X-rays
○ EARLY: soft tissue
swelling, periosteal reaction.
○ LATE: cortical destruction
● MRI: Most sensitive
● Bone Scans: may detect other sites
● Bone Bx: definitive
Treatment
● IV ABX 2 weeks, followed by oral
ABX another 4 weeks
● May need debridement
● Treat the offending the organism with the appropriate ABX (infectious disease often involved)
Chronic Osteomyelitis: onset, what type of pt, where does the infection come from (Test)
overview:
- over Months to years
- Often seen with prostetic joint infections (Staph epidermis), IV drug users (Pseudomonas)
Infection comes from:
● DIRECT INOCULATION (in close proximity to bone, prosthetic joints, open fractures & wounds) *****
● Contiguous spread with vascular insufficiency (DM, Peripheral Vascular Disease)
● Hematogenous spread (more common in children)
Chronic Osteomyelitis: sx, dx, tx
Signs & Symptoms
● SINUS TRACT DRAINAGE*
● Edema, warmth, tenderness,
decreased ROM
Diagnosis: Often clinical and with a good history
● ESR&CRP may or may not be elevated
● X-Rays: Soft tissue swelling, periosteal reaction, osteopenia, bone destruction
○ Sequestrum: necrotic bone that is separated from normal bone.
○ Involucrum: new periosteal bone surrounding necrotic bone.
● MRI or CT: Most sensitive
● Bone Bx: Needed to identify pathogen & direct tx
Treatment:
Surgical debridement & cultures with ABX based on culture
Septic Arthritis: most common organisms
STAPH AUREUS MC
Neisseria GONORRHEAE MC IN SEXUALLY ACTIVE YOUNG ADUCTS (ceftriaxone)
ORTHOPEDIC EMERGENCY!!!
Organisms
● The Staphs (S. aureus m.c)**
● Neisseria gonorrhoeae (sexually active young adults) **
● The Streps (especially @ extremes of age, <3mo & elderly)
● Pseudomonas (immunocompromised)
- If no organism: Vancomycin + Ceftriaxone.
- Gram+ Cocci = Vancomycin
- Gram- Cocci or Gonococcus = Ceftriaxone
septic arthritis:
- overview, what location mc - and with age/IV drug user,
- where does the infection come from
- RF
- organisms
Bacterial infection of joint cavity
Orthopedic Emergency!
- Knee most common overall.
- Hip most common in children
- SternoClavicular joint in IV drug users
Infection comes from:
● Hematogenous infection (75%)
● Contiguous spread. Penetrating trauma, orthopedic fixation, arthroscopy
Risks
● Pre-existing joint disease (RA, OA, TJR)
● Immunocompromised, HIV, IVDU, DM)
Organisms
● The Staphs (S. aureus m.c)**
● Neisseria gonorrhoeae (sexually active
young adults) **
● The Streps (especially @ extremes of age, <3mo & elderly)
● Pseudomonas (immunocompromised)
Septic Arthritis sx and dx
Signs & Symptoms
● Acute monoarthritis: swollen, warm, painful joint. Decreased ROM.
● Fever, chills, malaise myalgias.
● Guarding on exam
Diagnosis
●ASPIRATION with fluid sent for culture, cell count, gram stain & cultures**
■ WBC>50,000, WBC>1,100 in PJI (primarily neutrophils)
■ Incr. ESR, CRP
■ Blood cultures positive in 50%
○ MRI/CT to assess joint damage**
Septic Arthritis tx
- Joint drainage 2. Debridement 3. IV ABX
Treat the organism
- If no organism: Vancomycin + Ceftriaxone.
- Gram+ Cocci = Vancomycin
- Gram- Cocci or Gonococcus = Ceftriaxone
Compartment Syndrome - definition, etiology
Occur when the closed muscle compartment pressure is > perfusion pressure due to limited space.
The circulation is compromised leading to muscle & nerve ischemia.
Etiology
● LONG BONE FRACTURES (tibia, supracondylar in children)
● Crush injuries
● Constriction (casts, splints, burns)
Compartment Syndrome sx, PE (test)
Signs & Symptoms
● Pain out of proportion to injury & paresthesias**
- ex: Pt comes in w tibia fracture - IN TOO MUCH/LOTS OF PAIN
Physical Exam:
● Pain with passive stretching of the affected muscles and limb**
● Tense firm feeling
● Pulselessness, Palor, Decreased sensation. Capillary pressure preserved **
Compartment Syndrome: dx and tx
Diagnosis
● Increased intracompartmental pressure (>30mm Hg)
● Labs: Increased creatinine kinase & myoglobin (muscle is dying - enzymes leak)
Treatment
● Urgent decompression with emergent fasciotomy
● Place limb at level of heart while awaiting surgery
Exertional Compartment Syndrome: def, tx
Pain with exertion/exercise that is relieved with rest (NOT emergency) **
def: ignore the numbers
● A resting pressure of greater than or equal to 15 mmHg and/or a pressure of greater than or equal to 30 mmHg at 1 min post-exercise in any compartment, and/or;
● Post-exercise pressure greater than 20 mmHg at 5 minutes post-exercis
Treatment:
● NSAIDs
● Botox
● Gait training
● Fasciotomy
Osteoarthritis (long card, everything)
Loss of articular cartilage and joint degeneration.
- Most common in weight-bearing joints
- MC in hand: thumb basal joint (saddle joint)
Chondrocytes in arthritis
1. Proliferation and cell death
2. Changes in synthetic activity
3. Degradation of chondrocytes
4. Phenotypic modulation of chondrocytes
5. Formation of osteophytes
Risk factors
- Obesity Trauma Heavy labor Age
- F>M Family History
Signs & Symptoms
● Pain with use, relieved with rest.
● Worse @ night
● Joint stiffness worse in am and at night
Physical Exam
● Joint tenderness, decreased ROM, crepitus
● Hand involvement
● Bouchard Nodes (PIP enlargement)
● Heberden Nodes (DIP enlargement)
X-rays:
● Asymmetric joint space narrowing
● Marginal osteophytes
● Subcondral sclerosis &/or cysts
Management: EXERCISE AND WT LOSS
● Weight management
● Exercise
● Braces, assistive devices to off load joint.
● Acetaminophen
● NSAIDs (Topical preferred)
● Topical analgesics
● Intra-articular steroid and visco-supplement ation injections (last resort, will cause hyperglycemia)
● Bouchard Nodes (PIP
enlargement)
● Heberden Nodes (DIP
enlargement)
= osteoarthritis with hand invovlement
Complex Regional Pain Syndrome
● Autonomic dysfunction following bone or soft tissue injury.
● Upper extremities most common**
● Women > Males
● Approx. age >30y/o
Signs & Symptoms
● Sensory - pain (hyperalgesia) out of proportion to injury.
● Motor & Trophic changes. Decreased ROM, motor dysfunction, Increased hair & nail growth, then decreased growth.
● Edema
● Vasomotor - Temp. & skin color asymmetry (Autonomic dysfunction)
Diagnosis: Clinical
● hx: An initiating event - fracture, sprain
● Persistent pain or hyperalgesia
● Symptoms of edema & blood flow
● R/O other causes
Treatment
● NSAIDs
● P.T. & O.T.
● CBT
● Anesthetic blocks
● Antidepressants
● Transcutaneous electrical nerve stimulation
Shiny and solid left hand
- 8-12 wks post injury
complex regional pain syndrome
Fibromyalgia: def, sx, dx, tx
how long does pain last, where is the pain
- Chronic; Generalized pain, fatigue, and diffuse tenderness
- Joints are spared
- Women > Men, 20-60 y/o
- Cause unknown
Signs & Symptoms
● Pain > 3 months**
● Widespread pain - pain on both sides of the body, above & below waist, axial skeletal pain **
● Pain & tenderness at 11 or more trigger points. ***
Diagnosis of EXCLUSION:
- Can result in depression, anxiety, inactivity.
Treatment
● NSAIDs
● Antidepressants
● Topical NSAIDs, analgesics
● Exercise program
● Support group
Knee Joint Effusion
Excess fluid accumulation in the joint.
Causes
● Trauma
● Overuse
● Osteoarthritis
● Rheumatoid arthritis
● Gout
● Infection
Signs & Symptoms
● Swelling
● Pain
● Stiffness
● Warm to touch
Treatment
● RICE
● NSAIDs
● Physical Therapy
● Steroid injection
● Aspiration (both diagnostic & therapeutic)
Different from septic:
- NOT INFECTED: not red, warm, tender
- Just a swollen and lose bony contour
Corticosteroid Injections: overview, MOA
● Strongest class of anti-inflammatories.
● Decrease inflammation and improve function.
● Decrease collagenase, prostaglandin formation & formation of granulation tissue.
● Block glucose uptake in the tissues.
Corticosteroid Injections: Fast acting vs Long Acting (dont memorize)
○ Hydrocortisone (Cortisol) = Fast acting, short duration
○ Methylprednisolone (Depo-Medrol) = Fast acting, intermediate duration
○ Triamcinolone acetonide (Kenalog) = Mod onset, intermediate duration
○ Betamethasone (Celestone) = Fast acting, long duration
Corticosteroid Injections: uses and when to avoid
Uses
○ RA
○ OA
○ Crystal induced arthritis (gout, pseudogout)
○ Tenosynovitis & bursitis
○ Entrapment neuropathies
○ Ganglion cysts
AVOID:
- OLECRANON AND PREPATELLAR BURSITIS - increased risk of infection*****
○ Acute trauma
○ Tendons and nerves
○ Infected joints, tendon or bursa
○ Multiple long-term use
Corticosteroid Injections: adrs
○ Transient hyperglycemia
○ DM carries increased risk of infection
○ Postinjection infectious arthritis
○ Olecranon & prepatellar bursitis increased risk for infection (Avoid) **
○ Local side effects:
■ Lipodystrophy
■ Loss of skin pigmentation
■ Accelerated joint degeneration
■ Transient flare or increased pain
