Quiz #5 Flashcards
what is osteomyelitis?
bone inflammation caused by infection
what bones are typically affected by osteomyelitis?
pelvis (from UTIs), or arm (from IV)
what can osteomyelitis lead to?
septicemia or septic infection of a joint
where does osteomyelitis tend to occur in children?
near growth plates of long bones
where does osteomyelitis tend to occur in adults?
lumbar spine (bc of proximity to bladder)
what is the etiology of osteomyelitis?
usually caused by staph aureus infection in acute osteomyelitis
binds to cartilage and releases toxins
what is exogenous osteomyelitis?
invasion of bone from outside (open fx, puncture wound)
absess can infect bone
what is the prognosis for exogenous osteomyelitis in pts with DM, vascular insufficiency, or who are immunocompromised?
poor
what is hematogenous osteomyelitis?
spread of organisms from pre-existing infections through blood
often UTI
who does acute osteomyelitis occur the most in?
children and boys
who does chronic osteomyelitis occur the most in?
adults and the immunocompromised
what in a radiograph will indicate osteomyelitis?
opacity of bone
what are the risk factors for osteomyelitis?
chronic illness, alcohol abuse, diabetes, malignant, malnutrition, renal/hepatic failure, MRSA, large doses of steroids or immunosuppressants
what are some additional risk factors for development of osteomyelitis?
calcaneal or sacral decubiti deeper than 3 mm or >2 cm ^2
SCI w/complete motor or sensory loss
slow healing post-op wound
what does a radiograph show with periprosthetic infection?
periosteal new bone formation, scattered foci of osteomyelitis, subchondral bone resporption (late finding)
what is the gold stand for periprosthetic infection testing?
intra operative cultures
how is periprosthetic infection managed from least to most severe?
irrigation and debridement w/component retention, one or two-stage exchange, antibiotic suppression, resection, arthrodesis (jt fusion), or amputation
what is usually the first cause of prosthetic failure?
mechanical loosening
what is usually the second cause of prosthetic failure?
infection
what is the initial stage of pathogenesis of osteomyelitis?
inflammatory response
vascular loop in growing bone
arterioles form loop and drain in medullary cavity w/o establishing a capillary bed
what is the long bone metaphysis pathogenesis of osteomyelitis?
bone is porous and allows exudate from the infection to speard easily
organism grows and forms pus
increased bone tension in rigid medullary cavity
puss forced in Haversian canals
bacteria proliferates unimpeded
what is the subperiosteal absess formation pathogenesis of osteomyelitis?
bone is denied blood supply and may cause necrosis
necrotic cells are a fertile bed for infectious agents to multiply
no sensory nerve endings in cancellous bone so the process progresses without pain
necrosis stimulates the periosteum to form new bone
what is the last phase of pathogenesis of osteomyelitis?
sheath of new bone (involucrum) forms around sequestrum of necrotic tissue
chronic stage
more common in children, more fx in adults
is the involucrum and sequestrum more common in children or adults?
children
what is vertebral osteomyelitis?
affect the metaphysis or cartilagenous end plates
spreads to IV discs and adjacent tissues
what adjacent tissues does vertebral osteomyelitis spread to?
posteriorly into epidural
anterior into hip flexors like illiospoas
what is often the chief complaint (CC) in adults with osteomyelitis?
back pain, low grade fever once it becomes systemic
t/f: adults with osteomyelitis often have delayed s/s bc the cortex of the bone has no nerve endings
true
what are the clinical manifestions of osteomyelitis in children?
acute, severe symptoms (high fever, intense pain)
locally-edema, erythema, tenderness
t/f: there can be antalgic gait if osteomyelitis is in LEs
true
is it easier to detect osteomyelitis in the extremities or trunk? why?
in the extremities bc there is often unexplained cellulitis
what is a RED FLAG of osteomyelitis?
dactylitis (sausage toes)
what are some additional clinical manifestations of osteomyelitis?
back pain aggravated by motion (may be non mechanical)
radiculopathy
pain with hip extension
meningitis
infected/non-healing ulcers after several weeks of appropriate care
these are all ways to prevent what?
open fx management
screening risk factors
identification of early warning signs
pin site care
s/p jt replacement
proper nutritional health
osteomyelitis
how is osteomyelitis managed?
IV and high dose antibiotics based on culture results
intra-articular surgery for debridement and jt reconstruction once infection is eliminated
radical debridement over serial debridement due to reoccurrence
oral or bead chain antibiotics used prophylactically
when would you normally starting seeing abnormalities in osteomyelitis radiographs?
after 2 weeks
what is the prognosis for osteomyelitis?
small risk of death in immunocompromised
70-90% infection arrest rate
delayed treatment-permanent loss of bone structure
may impact long bone growth in children
excellent w/early antibiotic therapy
what is involved in the PT screening of osteomyelitis?
thorough history and review of systems
fever
unexplained weight loss
h/o cancer
failure to respond to intervention
disturbed sleep
what are the 4 groups of infectious arthritis?
- bacterial (focus for this class)
- fungal
- viral
- reactive
what is bacterial infectious arthritis?
caused by gonococcal, endocarditis, or Lyme
what is fungal infectious arthritis?
caused by candida
what is viral infectious arthritis?
caused by Epstein-Barr, HIV, mumps, or rubella
what is reactive infectious arthritis?
acute rheumatic fever, chlamydial infection
what is the most common etiology of infectious arthritis?
staph aureus, strep, kingella kingae, neisseria, gonorrhea
what is the most common way infectious arthritis spreads?
hematogenous (through the blood)
what are the primary risk factors for infectious arthritis?
OA, RA, ETOH, IV drug use, HIV
who is at the greatest risk for infectious arthritis?
older adults and children
what are the 6 mechanisms of infectious arthritis?
- direct inoculation
- direct extension
- hematogenous
- bacterial products
- phagocytosis of bacteria
- bacterial toxins
what mechanism of infectious arthritis is being described?
bacteria rapidly multiplies in liquid culture of jts
killed by phagocytes of synovial cells from micro-abcesses in synovial membrane
direct inoculation
what mechanism of infectious arthritis is being described?
periarticular osteomyelitis
contagious ST injuries
direct extension
what mechanism of infectious arthritis is being described?
multiply in enlarging abcsesses of synovial lining until they break into jt cavity
hematogenous
what mechanism of infectious arthritis is being described?
endotoxins and cell wall fragments
release of tumor necrosis factor and interleukin 1
leads to inflammation
bacterial products
what mechanism of infectious arthritis is being described?
autolysis of neutrophils
release of lysosomal enzymes into jt
leads to synovial, ligament, and cartilage damage
phagocytosis of bacteria
what mechanism of infectious arthritis is being described?
activation of the coagulation system
causes intervascular thrombosis in sub-synovial vessels and fibrin deposition on the surface of synovium and articular cartilage
provides gelatinous nidus for bacterial replacement
microvascular disruption leads to ischemia and necrosis, permitting further abscess formation which destroys cartilage matrix
synovial membrane proliferation–> pannus (inflammatory exudate)
bacterial toxins
what are the classic signs of infection?
acute onset of pain, swelling, tenderness, loss of motion, and sometimes drainage
what are the manifestations of infectious arthritis?
classic signs of infection
jt destruction, pathological fxs, growth deficits, deformity, dislocation, septic shock, multi-organ disease, pericarditis, pyelonephritis (kidney infection)
WBCs release enzymes that destroy cartilage
monoarticular sepsis
what is the most common spot for monoarticular sepsis from infectious arthritis in adults?
hips or knees
what is the most common spot for monoarticular sepsis from infectious arthritis in children?
ankles or elbows
what most often causes monoarticular sepsis in children and adults?
staph aureus
what are some ways that infectious arthritis is managed?
needle aspiration (assisted by fluoroscopy and live x-ray)
antibiotic therapy
IV antibiotics w/follow-up oral meds with corticosteroids
tidal irrigation, arthroscopy, arthrotomy, open drainage
jt rest
what is antibiotic therapy for infectious arthritis based on?
cultures, stains, WBC count, ESR or sedimentation rate, c-reactive protein (CRP)
how is jt rest provided for infectious arthritis?
splinting/casting w/intermittent ROM exercises to prevent jt contractures
what is ESR or sedimentation rate?
measure of inflammatory activity in the body
t/f: the ESR is a stand alone test
false
how does the ESR monitor progress of inflammatory diseases in the body?
it measures the distance RBCs fall in a hour
the further down they fall the more inflammation bc inflammation causes cell clumping, making the RBCs more dense so that they fall quicker
what is the prognosis for infectious arthritis if treatment is initiated w/in 5-7 days of its onset?
excellent
t/f: there are long term functional deficits in infectious arthritis based on jt damage
true
what is the mortality rate of infectious arthritis?
10-25%
what % of survivors of infectious arthritis have permanent jt disability?
25-50%
is the knee, hip, or shoulder associated with better outcomes in infectious arthritis?
the knee
what are the PT implications for infectious arthritis?
early recognition is key!!!
be aware of pt history, risk factors, and s/s of infection
can result in residual impairments like ankylosis (self-fusion of a jt)
what is myositis?
muscles inflammation from an autoimmune or viral bacterial, parasitic infection
what are the 3 ways myositis is most commonly manifested as?
- dermatomyositis (DM)
- polymyositis (PM)
- inclusion body myositis (IBM)
who is DM more common in?
children and older adults
what are the common parasitic causes of myositis?
staph aureus, triconella, tapeworm larvae
what is the most acquired muscles disease in populations over 50 y/o?
IBM
what is the etiology of myositis?
intramuscular fiber degeneration–>fiber destruction and severe weakness
what is the primary cause of muscle damage in myositis?
inflammation
t/f: myositis can result from drug therapy
true
what is usually the first sign of malignancy?
myositis
why may myositis be a good sign in ca?
it shows that there is an immune rxn against the tumor
what are clinical manifestations of myositis?
nonspecific symptoms of inflammation
tissue necrosis and extensive muscles damage, atrophy, and weakness
dysphagia, Raynauds, cardiomyopathy, pulmonary fibrosis, purple rash, and eyelid edema (may want to ask about visual disturbances)
frequent falls, trouble w/transfers and stairs, drop foot, weak grip
what is the gold standard for dx of myositis?
muscle biopsy
how can myositis be diagnosed?
biopsy, EMG, and lab values
what differentiates between DM, PM, and IBM myositis?
a muscle biopsy
what lab value would indicate the presence of myositis?
increased creatinine kinase in the blood (5-10x higher w/PM)
how are PM and DM myositis managed?
immunosuppressive therapy and corticosteroids
is there a successful intervention for IBM?
no:(
what are the PT implications for myositis?
recognition of symptoms
thorough hx including meds
submax exercise is effective
eccentric and intense exercise should be avoided
watch exercises in persons w/symptomatic myotoxicity
what tendons or bursae are more susceptible to infection?
tendons and bursae closer to the surface bc they can have direct contact with microorganisms
what population is more susceptible to tendon and bursa infections by direct contact with microorganisms?
wrestlers
how else can tendons and bursae become infected?
big bites and diabetes
direct inoculations via abrasion and corticosteroid injections into inflamed bursa/tendon
staph aureus
what is the most common way tendons and bursae become infected?
staph aureus
who is at greater risk for tendon and bursa infection other than wrestlers?
diabetics and immunocompromised
what is the pathogenesis of tendon and bursa infections?
hands: spread along synovial sheaths, fascial planes, and lymphatic channels
bursa: membrane similar to synovium in infectious arthritis
what are the clinical manifestations of tendon and bursa infection?
olecranon or prepatellar bursitis
tendon sheaths
infectious tenosynovitis
what are the s/s of olecranon or prepatellar bursitis?
pain, swelling, and decreased ROM and function
possible cellulitis
what are the most commonly infected bursae?
olecranon and prepatellar bursae
what are commonly affected tendon sheaths?
hands
what are the s/s of infectious tenosynovitis?
finger maintains slight flexion
fusiform swelling
pain w/passive or active extension
tenderness along the sheath into the palm
how are tendon/bursa infections diagnosed?
examination w/identified local swelling
aspiration for cultures
what is the treatment of tendon and bursa infection?
antibiotics are typically adequate
surgical incision and drainage necessary sometimes
bursectomy occationally
prompt Rx is crucial
what is the purpose of a bursectomy in bursa infections?
removal of the bursa and then regrowth of a normal bursa
what are the PT implications for tendon and bursa infections?
immobilization an delevation
early and aggressive rehab typically necessary
careful monitoring
frequent Rx adjustments based on status
splinting for protection but w/eventual recovery and function in mind
early ROM as soon as infection begins to subside
how is the hand often immobilized and why?
in flexion bc it lengthens the collateral ligaments
how is the wrist often immobilized?
30-50 deg ext
how are the MCPs often immbolized?
75-90 deg flex
how are the IPs often immobilized?
in full ext
what is juvenile idiopathic arthritis (JIA) ?
several chronic inflammatory disorder affecting jts
what is the most common arthritis affecting children?
JIA
most forms of JIA are more common in…
girls
entheses JIA is more common in…
boys
t/f: JIA is an autoimmune disease
true
what is the pathogenesis of JIA?
imbalance of regulatory T cells stimulates release of inflammatory cytokines that lead to jt damage
abnormal bone growth possible due to interleukin-16 released from T cells
persistent activation of immune cells (monocytes, macrophages)
t/f: JIA can be remitting or unremitting
true
what are the 5 types of JIA?
- oligoarthritis
- polyarthritis
- psoriatic arthritis
- enthesis-related “spondyloarthritis”
- undifferentiated
what is the oligoarthritis type JIA?
affects 4 or fewer joints
usually knee, ankle, shoulder, or elbow
what is the most common subtype of JIA?
oligoarthritis
what is the polyarthritis type of JIA?
affects 5 or fewer jts often bilaterally
25% in children with JIA
what is the psoriatic arthritis type of JIA?
jt symptoms paired with scaly rash that presents b4 or after onset of jt symptoms
what is the enthesis-related “spondyloarthritis” type of JIA?
inflammation targeting the entheses
only subtype more common in boys
what is undifferentiated JIA?
symptoms that don’t match any subtype
what are the s/s of JIA?
joint pain/stiffness
fatigue
blurry vision/dry eyes
appetite loss
limited ROM
rash
red, tender, swollen joints
high fever
what are the risk factors for JIA?
children ages 2-3 are at highest risk
girls are twice as likely to develop JIA
exposure to infections
genetic/family factors may be involved (not enough research)
t/f: JIA is a diagnosis of exclusion
true
what a some common differential diagnosed with JIA?
Lyme arthritis
sickle cell arthritis
osteomyelitis
post strep reactive arthritis
acute rheumatic fever
how is JIA diagnosed?
ESR
CRP
antinuclear antibodies
rheumatoid factor and anti-cyclic citrullinated peptide antibodies
HLA-B27
CBC
arthrocentesis
x-ray
US
MRI
what is the medical management of JIA?
NSAIDS
DMARDs
biological response modifiers (methotrexate)
corticosteroids
for advanced arthritis: osteotomy, synovectomy, arthrodesis, total jt replacement (last resort)
what is the prognosis for JIA?
1/2 of children fully recover
some have continued symptoms or develop advanced arthritis
what should be looked for in an exam of JIA?
joint pain, swelling, stiffness
eye inflammation
reduced ROM
muscle weakness
anemia
fatigue
what are red flags that require a referral in JIA?
unremitting pain that disturbs sleep
fever, malaise, weight loss, excessive sweating
bone/joint pain accompanied by fever
what are the tests and measures for JIA?
JADAS and JAMAR outcome measures15
MMT
functional testing
measure ROM and joint mobilization
measure aerobic capacity
vitals
what are the PT interventions for JIA?
regular exercise
ROM
modalities
pt education
