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Ortho/Rheumatology > Septic Arthritis & Osteomyelitis > Flashcards

Septic Arthritis & Osteomyelitis Flashcards

1
Q

Infectious arthritis that is a medical emergency?

A

Septic Arthritis.

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2
Q

Pathogenesis of Septic Arthritis?

A

Organisms invade the joint space.

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3
Q

What is the most common way that an organism invades the joint space in Septic Arthritis?

A

Hematogenous spread of bacteremia.

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4
Q

Name the other ways that organisms invade the joint spaces in Septic Arthritis?

A
  • Periarticular osteomyelitis (near a joint).

- Direct inoculation via diagnostic or therapeutic procedure, such as an intra-articular joint injection.

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5
Q

Affects one joint 90% of the time? MC joint?

A

Bacterial septic arthritis.

-Knee is MC, followed by hip, shoulder, elbow, ankle, wrist.

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6
Q

What is the most common pathogen that causes Septic Arthritis?

A

Staphylococcus Aureus, >50% (Gram + Cocci).

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7
Q

What is a common cause of Septic Arthritis in young, sexually active patient’s?

A

Neisseria Gonorrhea, 20% of cases.

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8
Q

Pathophysiology of Septic Arthritis?

A

Organisms invade the joint space causing inflammation of the synovial membrane and purulent effusion in the joint – bacteria load damages articular cartilage, which can occur as quickly as 8hrs after Sx onset.

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9
Q

Risk factors associated with Septic Arthritis?

A

Elderly, medical comorbidities, “Immunosuppressed,” Hx of Gout, “IVDU,” Hx of Open Fx, Hx of joint surgery.

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10
Q

How does bacteria load damage the articular cartilage?

A

Release of proteolytic enzymes from inflammatory cells (PMNs) in synovial fluid.

-50% of adult pt’s have sequelae of decreased ROM, Chronic pain, even if treated properly.

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11
Q

Other pathogens that cause Septic Arthritis?

A
  1. Gram + Cocci are causes in 75-80% of cases:
    - Staph, Beta-Hemolytic strep, Strep Pneumonia, Staph Epidermis.
  2. Gram - Bacilli occur in 15-20% of cases:
    - Pseudomonas aeruginosa, E. Coli, Pasteurella Multocida.
  3. Neisseria Gonorrhea.
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12
Q

Clinical presentation of Septic Arthritis?

A
  1. Acute onset.
  2. Hot, swollen joint**
  3. Large joints (knees and hips MC).
  4. Fevers +/-
  5. Pain, Erythema, Effusion.
  6. Unable to tolerate passive ROM, unable to bear weight**
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13
Q

DDx of Septic Arthritis?

A
  1. Crystal arthropathy – Gout or Pseudogout.
  2. Cellulitis.
  3. Bursitis
    - -commonly see prepatellar bursitis in knee; differentiate if the swelling is superficial vs effusion, ROM not as painful.
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14
Q

Lab diagnostics of Septic Arthritis?

A
  1. Basic labs will show elevation of infection markers.
    - -WBC >10k w/Left Shift.
    - -ESR >30, rises w/in 2 days of infection.
    - -CRP >5, most helpful, judges efficacy of treatment.
  2. ARTHROCENTESIS is the GOLD STANDARD.
    - -BEFORE initiation of antibiotics.
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15
Q

Diagnostic imaging of Septic Arthritis?

A
  1. XRs are unrevealing early on, may see soft tissue swelling or joint effusion.
    - -always obtain to r/o any other pathology.
  2. U/S useful in superficial joints and children.
  3. CT Scan may show joint effusion, fat-fluid level.
  4. **MRI – most sensitive and specific, infected joint fluid will “light up.”
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16
Q

Treatment for Septic Arthritis?

A
  1. IV Abx***
    - -Initiate empiric Abx AFTER aspiration of possible.
  2. Operative I and D w/irrigation and debridement***
    - -Open vs Arthroscopic, obtain deep cultures.
    - -If additional drainage or Sx persist, may require a repeat I and D.
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17
Q

Abx coverage in Septic Arthritis?

A
  1. Young and Healthy – coverage for Staph and N. Gonorrhea (Vanco + Ceftriaxone).
  2. Older, immunocompromised – coverage for Staph and Pseudomonas aeruginosa (Vanco + Cefepime).
  3. ID consult, narrow coverage after culture results obtained (1-4 days).
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18
Q

Prognosis for Septic Arthritis?

A
  • If timely recognition and treatment, 90% recover with minimal effects.
  • If left untreated, can cause irreversible joint damage within 48 hrs.
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19
Q

Septic Arthritis in Children…

A
  1. Peaks in the first few years of life, 50% <2 yrs.
  2. Most often “hip and knee.”
  3. “Group B Strep - Neonates,” S. Aureus >2 yrs.
  4. Acute onset pain, systemic Sx (fever), refusal to bear weight.
  5. Localized swelling, tenderness, warmth, effusion.
  6. Severe pain w/Passive ROM, hip rest in FABER.
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20
Q

What is FABER?

A

Flexion, ABDuction, Ext. rotation – maximizes capsular volume and relieves pain.

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21
Q

Diagnosis of Septic Arthritis in children?

A
  1. XR, ‘ULTRASOUND,’ (both hips if any septic joint identified).
  2. WBC, ESR, ‘CRP,’ (rises in 6-8 hrs after infx), blood cultures if febrile.
  3. ‘ASPIRATE’ - typically done in IR w/sedation.
    - -cell count: ‘WBC >50k’ w/ >75% PMNs.
22
Q

Complication in Septic Arthritis in children?

A

High risk for AVN and deformity.

23
Q

Treatment for septic arthritis in children?

A

Urgent ‘Surgical I and D, Abx.”

–Cephalosporin, typically.

24
Q

Diagnostic indication for Arthrocentesis?

A

Need to analyze joint fluid for etiology of arthritis

  • -Inflammatory vs Infectious.
  • -Gout, RA, Septic, Fx.
25
Q

Therapeutic indications for Arthrocentesis?

A
  1. Large, painful joint effusion – aspirate for pain relief.
  2. Intra-articular injections (Steroids, anesthetic).
26
Q

Contraindications for Arthrocentesis?

A
  1. No absolute.
  2. Overlying Cellulitis (seed the joint w/bacteria).
  3. Joint prosthesis.
  4. Bleeding disorders.
  5. Fx.
  6. Adjacent osteomyelitis.
  7. Uncooperative patient.
27
Q

Complications of Arthrocentesis?

A
  1. Puncture tendons, blood vessels, nerves.
  2. Infection.
  3. Reaccumulation of effusion.
  4. Hemarthrosis – traumatic tap, large needle punctures blood vessels, typically if multiple attempts.
    - -presents within a few hours, self-limiting usually, resolves in a couple of weeks.
28
Q

What do you do after collecting the fluid from an Arthrocentesis?

A
  1. Always send it for cell count w/diff, grain stain, culture, glucose, crystals.
    - -cell count comes back first, usually WBC >50k (prosthetic joints WBC >1100); in septic arthritis.
  2. Consult orthopedic surgery, if you haven’t already.

**Pg. 26 of notes.

29
Q

Inflammation and infection of the bone due to bacteria (occasionally fungus) that leads to progressive inflammatory destruction?

A

Osteomyelitis.

30
Q

Pathogenesis of Osteomyelitis?

A
  1. Hematogenous – from the blood stream.

2. Direct Colonization – trauma, surgery, FB, prosthesis)

31
Q

A few characteristics of Osteomyelitis?

A
  1. Can be present in any bone in the body – location depends on the pt’s specifics.
  2. Can by polymicrobial.
  3. Acute (<2 wks), Subacute (1-4 months), Chronic (>4 months, often post-traumatic).
32
Q

Pathophysiology of Osteomyelitis?

A

Bacteria creates ‘biofilm’ (dormant phase, does not replicate as quickly) making it more resistant to Abx – Abx has difficulty penetrating biofilm – resistant strains of bacteria develop – INFX that spreads into SOFT tissues as well can affect the blood supply to the bone leading to necrotic bone – forms sequestrum.

33
Q

What is required when resistant strains of bacteria develop?

A

They require prolonged IV Abx and multiple surgical debridements.

34
Q

What is a bone sequestrum?

A

A piece of dead bone that has become separated in the process of necrosis; complication of Osteomyelitis.

35
Q

Risk factors associated with Osteomyelitis?

A
  1. DM, ESRD, Vascular compromise.
  2. Trauma – open Fx, large wounds, surgery.
  3. IVDU.
36
Q

Presentation of Acute Osteomyelitis?

A
  1. Localized pain, swelling, erythema.
  2. Nonspecific ‘fever, chills, fatigue/lethargy.’
  3. Decreased ROM and Fxn of affected area.
  4. Slow healing of surgical incisions w/signs of localized infection.
  5. Draining sinus tract.
  6. Immunocompromised??
  7. Septic? – ‘fever, tachy, hypotension.
37
Q

Presentation of Chronic Osteomyelitis?

A
  1. Need detailed history of initial event, surgeries, trauma, previous Abx regimens.
  2. Often draining sinus, commonly ‘purulent’ but not always.
  3. Increasing localized pain, swelling, erythema.
38
Q

Differential Diagnosis for Osteomyelitis?

A
  1. Septic arthritis.
  2. Tumor, benign or malignant.
  3. Gout, Pseudogout.
  4. Healing Fx.
  5. Superficial Cellulitis.
  6. Vaso-Occlusive crisis in Sickle cell pt’s.
  7. Mid-Low back pain – high index of suspicion in IVDU.
39
Q

Imaging Diagnostics for Osteomyelitis?

A
  1. XR! – 2 view; compare to old images or similar area.

–Acute Osteo: typically normal XRs, need up to 50% bone loss before visible on XR.

–Chronic Osteo: lucency, periosteal reaction/thickening lysis or lucency around hardware that is loosening, disuse osteopenia.

  1. “MRI” to Dx early infx and assess extent of involvement, surgical planning.
  2. CT to help delineate bone structure involvement and surgical planning.
  3. Bone scan if unable to get MRI, infection lights up.
40
Q

What is an Involucrum?

A

Formation of a new bone around a necrotic area (Sequestrum).

41
Q

Gold standard lab for diagnosis of Osteomyelitis?

A

Deep Bone Culture – usually obtained intra-operatively.

42
Q

Other labs for diagnosis of Osteomyelitis?

A
  1. CBC – WBC elevated (>15k) only in 1/3 cases, often normal in Chronic Osto.
  2. ESR – elevated in both acute and chronic, decreases after initiation of Tx.
  3. CRP – elevated 97% of time, decreases faster than ESR after Tx.
  4. Blood cultures if hematogenous spread; r/o systemic infection/sepsis.
  5. Wound culture – sinus tract.
  6. Deep Bone Culture.
43
Q

Treatment of Osteomyelitis?

A
  1. Hold abx if not systemically ill until cultures obtained, then start empiric Abx.
  2. ‘Surgical I and D’; often multiple times.
  3. Consult ID to help guide Abx therapy (f/u levels, lab work, etc).
    - -Abx regimen narrowed after culture results obtained.
  4. ‘Long term IV Abx,’ typically 6 wk minimum, sometimes followed by course of PO Abx.
44
Q

Pathogenesis of Osteomyelitis in children?

A

Typically, ‘Hematogenous Spread.’

  • -Often ‘starts in the metaphysis due to high vascularity of the growth plate, but can extend to the epiphysis’ (which can lead to septic arthritis).
  • -Extends to the epiphysis because of communicating blood vessels b/t the metaphysis and epiphysis.
45
Q

Osteomyelitis in children is most common in what age?

A

Preterm infants and immunocompromised infants.

46
Q

MC pathogen involved in Osteomyelitis in children?

A
  1. <2 months – group B strep, E. Coli, Klebsiella, S. aureus.
  2. <5 y/o – Staph, Strep pyogenes, Strep Pneumoniae.
  3. > 5 y/o – Staph, Strep pyogenes, N. Gonorrhea.
47
Q

Strep or Staph. Aureus, which causes higher fevers and WBC?

A

Strep.

48
Q

Presentation of Osteomyelitis in children?

A
  • Can be very nonspecific.
  • FEVER, malaise, IRRITABILITY.
  • +/- swelling and erythema over affected area.
  • DECREASED MOVEMENT OF THE AFFECTED LIMB.
49
Q

Treatment for Osteomyelitis in children?

A
  1. IV Abx alone if caught early; if no subperiosteal abscess or bone abscess.
  2. Surgery not indicated if clinical improvement w/in 48 hrs.
50
Q

Complications of Osteomyelitis?

A
  1. Chronic Osteo can be debilitating w/recurring infx, resistant bacteria more difficult to treat.
  2. Sepsis…life over limb if overwhelming infection.
  3. Amputation if unable to cure.
  4. Common – DEFORMITY AND CHRONIC PAIN.
  5. Osteoporosis of affected bone due to inflammatory reaction and disuse atrophy until function returns.
    - -disuse osteopenia.

Ortho/Rheumatology (15 decks)

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