Other Flashcards
Osteomyelitis
Sx? Risk Factors? PE? Imaging? Labs? Ddx? Complications? Tx?
Bone infection causing bone destruction and inflammation. Can occur by hematogenous spread, contiguous spread, or can be associated with vascular insufficiency.
Signs: Pain, fever, erythema, inability to BW
Risk factors: trauma, immunocompromised, vascular compromise.
PE: Infants- Irritable, not feeding well, will not want to move.
Older child- Very ill. High fever (103-104). Refusal to walk. Swelling and warmth at the site. Tenderness to palpation.
Adults- Pain in the extremity, fever, erythema and inability to BW.
Imaging: X-ray, US, MRI, CT, Nuclear medicine.
Labs: CBC with diff, ESR, CRP. Blood culture. Bone biopsy.
Ddx: Acute hematogenous osteomyelitis. Supprative arthritis. Rheumatic fever. Cellulitis. TB. Ewing sarcoma. Metastatic cancer.
Complications: Incomplete treatment (chronic osteomyelitis), recurrence (anemia, wt loss, amyloidosis, or nephrotic syndrome), Persistent (cancer- squamous cell or fibrosarcoma).
Tx: Irrigation and debridement. Biopsy and culture of lesion followed by prolonged antibiotic treatment. Antibiotic (Quinalones… add Rifampin with S. Aureus)
Septic Arthritis/ Infectious Arthritis
PE? Imaging? Labs? Special tests? Ddx? Tx?
ACUTE! Underlying abnormality causing a bacteremia (MCC S. aureus). Large effusion. Knee is most common.
PE: Large effusion, warm, tender, decreased ROM.
Imaging: Not very useful. Can be used to confirm swelling.
Labs: Synovial fluid to check for WBC and crystals. (Crystals =gout). WBC >50,000.
Special Tests: FABER position (flexion, abduction, external rotation of the hip). This position would decrease pressure at the hip.
Ddx: Gout/pseudo gout, lymph disease, acute rheumatic fever, pseudo septic acute inflammatory mono arthritis.
Tx: Surgical lovage and debridement of joint. Synovial fluid gram stain. IV antibiotics broad spectrum until organism is identified.
Septic Arthritis in Pediatrics
Osteomyelitis? Labs? US? Tx?
** In children under 18 months with osteomyelitis, co-existing septic arthritis of the joint can occur easily.
Bacteremia or septicemia by infection. Bacterial emboli lodge in the vessels of the capsule and cause an infection to accumulate within the joint.
Labs: WBC and diff. ESR. Aspiration of the joint for gram stain and culture.
US: for the hips
Tx: Surgical incision and drainage. Antibiotics. PT.
Transient/Toxic Synovitis
Sx? PE? Ddx? Imaging? Labs? Tx?
MCC hip pain/limp in 3-5yo.
Sx: Reluctance to walk, low grade temperature.
PE: Limited hip internal rotation on affected side.
Ddx: Septic arthritis, osteomyelitis, acute rheum fever, JRA (usually in knee or ankle not hip)
Imaging: X-rays (normal), US (variable amount of fluid)
Labs: WBC (may be normal), ESR (may be elevated), Aspirate (If labs are high + high fever + limited ROM of hips)
Tx: Rest (resolved 3-5 days without long term sequelae)
Osteochondroma
Sx? Imaging? Tx?
Solitary lesion. Arise in metaphysis and with child’s growth will move away from joint. 1% chance of malignant degeneration. (If multiple lesions: autosomal dominant)
Sx: +/- pain, bump
Imaging: X-ray (AP/lat)
Tx: Observation vs. surgical excision
Echondroma/ Ollier’s Disease
Imaging? Tx?
Cartilage cyst that appears on hands and feet (10-20 yo). It grows inside the bone marrow.
X-ray: Intramedullary lesions.
Multiple lesions = Ollier’s disease
Tx: Surgery (depends on severity)
Fibrous Dysplasia
Sx? Imaging? Dx? Ddx?
Gene mutation that makes bone fibrous and vulnerable to fracture. Affects the metaphysics and diaphysis. Monostotic or polyostotic.
Sx: Pain. Endocrine abnormalities in polyostotic.
Imaging: X-RAY (Expansile lesion sparing the epiphysis)
Dx: Cafe au lait spots (Coast of Maine) and X-RAY
Ddx: Bone cysts, enchondromas, osteoblastoma, and osteofibrous dysplasia.
McCune-Albright Syndrome
Combination of:
1) cafe au lait spots
2) polyostotic fibrous dysplasia
3) endocrine dysfunction
Unicameral Bone Cyst (UBC)
Sx? Imaging? Tx? Pathognomonic sign?
Metaphysical cyst. Present for years before diagnosis.
Sx: Pain.
Imaging: X-RAYS (Poss. Fx. Or is incidental finding).
“Fallen lead sign”- pathognomonic
Tx: Aspiration, surgery, injection with corticosteroids. RESOLVE BY ADULT
Aneurysmal Bone Cyst
Risks? Tests?
Expansive hemorrhagic tumor that can affect any bone in the body. Metaphysical, eccentric, building, and fluid filled.
Risks: Bone destruction (needs surgical stabilization)
Tests: Biopsy (Mandatory to r/o telangiectatic sarcoma). Pre-op embolization.
Osteoid Osteoma
PE? Imaging? Tx?
Nidus that causes pain worse at night and often absent during the day. NSAIDS get rid of pain. Diagnosis delayed because people assume it to be psychotic or “growing pains”
PE: No findings. (Possibility for some atrophy of affected leg, and stiffness and hamstring tightness if pain is in the back).
Imaging: X-RAYS (Thickening of the cortex. Bone scan (identify source of pain). CT scan.
Tx: Surgical resection of the nidus. Radio ablation.
Giant Cell Tumors
Epid? Sx? Dx? Imaging? Tx?
Benign tumor near epiphysis (usually near knee). Can destroy the surrounding bone so removed. Rarely can cause metastasis to lung.
Epid: Young adults (20-40), females, rare.
Sx: Pain with activity, better with rest. Swelling.
Microscopically/Dx: Many unusual large or “giant cells” seen among a background of other abnormal cells.
Imaging: CT of chest to r/o mets.
Tx: Surgery with curettage and bone grafting. Removal of any lung mets.
Osteosarcoma
Epid? Sx? Labs? Imaging? Special X-ray finding? Tx?
Malignant. Around knee.
Epid: Teenager and children. 2nd most common primary bone cancer.
Sx: Pain. Soft tissue mass. Fever. RAPID PROGRESSION.
Labs: ALK phos. Biopsy
Imaging: X-RAYS, Bone scan (hot), CT chest (for mets).
Special X-ray findings:
1) Sunburst-aggressive periostitis. Ray type of appearance.
2) Codman Triangle. Only the edge of the raised periosteum will ossify.
Tx: Surgery (amputation or wide surgical resection/limb salvage) & Chemo (before and after surgery).
Ewing Sarcoma
Epid? Sx? Labs? Imaging? Ddx? Tx?
Malignant. Can develop in any bone, and metastasize to other parts of the body.
(Extraosseous Ewing’s sarcoma when it begins in the muscles and soft tissues.)
Epid: Children and young adults.
Sx: Pain with fever.
Labs: LDH, ESR, WBC
Imaging: X-ray (moth-eaten), Bone scan (hot = mets). CT chest (mets). MRI (soft tissue involvement). Biopsy (need or surgical)
Ddx: <5yo: Neuroblastoma or leukemia 5-10: Eosinophilic granuloma 5-30: Most likely Ewing's >30: Lymphoma >50: Myeloma
Tx: Shrink the tumor with chemotherapy or radiation. Surgery (wide resection of tumor). Rotationplasty (ankle as the knee joint).
Multiple Myeloma
Epid? Sx? PE? Labs? Imaging? Tx? Supportive Care?
Most common primary bone cancer.
Epid: Older adults >40. Men. African Americans.
Sx: Fatigue, feeling ill, fever, night sweats. If high calcium (nausea, fatigue, confusion, constipation, and urination). If anemia (fatigue, weakness, and dyspnea with exercise). If advanced (recurrent infections and kidney failure). May also have anemia, leukopenia, thrombocytopenia, and hypercalcemia.
PE: Pale with diffuse bone tenderness. Pathologic fractures (spine, ribs, pelvis). Compression of spinal cord.
Labs: Blood (SPEP- abnormal antibodies) and urine (Bence Jones protein).
Imaging: X-RAY (decreased bone density and “punched out” holes). Bone scan. Skeletal survey. Bone marrow biopsy (abnormal plasma cells)
Tx: NO TREATMENT. ANY SURGERY IS TO HELP IMPROVE QUALITY OF LIFE. Chemotherapy and stem cell transplant (harvesting pt’s own blood cells). Radiation therapy (to decrease size).
Supportive Care: (Bisphosphonates- prevent destructive bone lesions, Erythropoetin, Antibody infusions and vaccinations, Corticosteroids and hydration- treat high calcium and dehydration, Narcotics)
