Skin, Soft Tissue and Bone

Question 1

What is the basic problem in chronic venous insufficiency?

Answer 1

Prevents wast substances and fluid flowing from lower limbs back to the central circulatory system
Leaks out into tissue of lower limbs causing discolouration, swelling and inflammation.

Question 2

What is lipodermatosclerosis?

Answer 2

Chronic inflammatory condition resulting from venous insufficiency characterised by subcutaneous fibrosis and hardening of skin on the lower legs.
Results in ‘inverted champagne bottle’ appearance.
Associated with immobility and high BMI.

Question 3

In chronic venous insufficiency what causes the brown discolouration of the legs?

Answer 3

Hemosiderin staining - haemoglobin leaking into the skin.

Question 4

What skin changes are commonly seen in chronic venous insufficiency?

Answer 4

1. It mostly commonly affects gaiter area between top of foot and bottom of calf
2. Hemosidering deposits
3. Venous eczema - dry, itchy, flaky skin
4. lipodermatosclerosis - fibrotic subcuteanous tissue - hardening and tightening of skin.
5. Atrophy blanche - porcelain white - surrounded by hyperpigementation

Question 5

What are some complications of chronic venous insufficiency?

Answer 5

Cellulitis
Ulcers
Pain
Poor healing after injury.

Question 6

What factors can help differentiate chronic venous insufficiency from other conditions?

Answer 6

1. Tends to be bilateral whilst cellulitis and DVT are unilateral
2. Tends to be chronic - slower to develop rather than acute onset.
3. Often associated with varicose veins

Question 7

What is osteomyelitis?

Answer 7

Infection of the bone.
Typically acute bacterial, but can become chronic if the infection does not fully resolve.

Question 8

What are the common causative organisms of osteomyelitis?

Answer 8

S. aureus (most common)
Streptococci
Enterobacter spp
H. Influnzae

Question 9

What are the three ways that infection can spread in osteomyelitis?

Answer 9

Hematogenous spread (blood) - norm to metaphysis of bone
Direct inoculation of micro-organism into the bone (following an open fracture)
Direct spread from a nearby infection (adjacent septic arthritis)

Question 10

What bones are most common affected in osteomyelitis?

Answer 10

Adults = vertebrae and great hallus

Question 11

What is the basic process happening in osteomyelitis?

Answer 11

Infection of the bone
Often infection contracted through bloodstream to metaphysics of bone
Once infected, leukocytes migrate to the ear - as engulf infectious organism release enzymes that lyse the bone
Pus spreads into the bones blood vessels - impairing their flow
Areas of devitalised infected bone known as sequestra form the basis of a chronic infection.

Question 12

What organism is most commonly seen in IVDU in osteomyelitis?

Answer 12

Staphylococcus aureus

Question 13

Who is most at risk of developing osteomyelitis?

Answer 13

IVDU
Diabetics (neuropathy and small vessel disease - develops quickly and can go unnoticed - diabetic foot ulcers potential point of spread)
Peripheral arterial disease
Recent trauma - open bone fracture.
Orthopaedic operations
Hematogenous risk increases - with remote sources of infection such as indwelling vascular catheters or intravenous drug use.
Immunosuprresion

Question 14

What are some clinical features of acute osteomyelitis?

Answer 14

Symptoms develop gradually overa few days
Pain - along with warmth, erythema and swelling of soft tissue surrounding the affected bone.
In proximal joints may only have pain
Tenderness in the area.
Systemic symptoms such as fever and malaise may be present.
Generally unwell

Question 15

What are the features of chronic osteomyelitis?

Answer 15

Only with local symptoms such as swelling, erythema and pain
Draining sinus tract may be seen - specific
Present as non-healing fractures
Diabetics with ulcers >2cm

Question 16

What is Potts Disease?

Answer 16

Infection of the vertebral body and intervertebral disc by Mycobacterium TB,
Back pain +/- neurological features
Low grade fever
Non-specific infective symptoms

Question 17

How would you investigate osteomyelitis?

Answer 17

Bedside: Obs, examination, wound swab
Bloods: CRP, WCC, FBC, ESR, LFT, U&Es, FBC, bone profile, blood cultures
Imaging: Bone density scan, X-ray,
Other: Biospy

Question 18

What is the gold standard investigation for osteomyelitis?

Answer 18

Bone biospy with histopathological examination and tissue culture.

Question 19

What is the typical management for osteomyelitis?

Answer 19

Medical = long term IV antibiotics (4-6w) tailored to culture results in available. Flucloxacillin is recommended.
Surgical - if clinically deteriorates, evidence of deterioration or imaging shows progressive bone destruction. Remove necrotic bone and debridement of infected surrounding tissue. Replacement of prosthetic joint if needed.

Question 20

What is septic arthritis?

Answer 20

Infection of a joint (native or prosthetic).
Bacteria seed to joint from bacteremia (e.g recent cellulitis, UTI) or direct inoculation or spreading from adjacent osteomyelitis
Causes irreversible articular cartilage damage leading to severe osteoarthiritis

Question 21

What are the two main causative organisms that lead to septic arthritis?

Answer 21

Staphylococcus aureus
Neisseria gonorrhoeae is more common in young, sexually active individuals.

Question 22

What are the signs and symptoms of septic arthritis?

Answer 22

Red, hot, swollen and painful joint - 80% single joint affected.
Restricted in movement - unable to walk if weight bearing, often held join in position to maximise intraarticular space e.g fully extended
Often has an intra-articular effusion
Most commonly the knee, hips, wrists, shoulder and ankles.
IVDU - sternoclavicular or sacroiliac.
Might feel systematically unwell.

Question 23

What are the key investigations for septic arthritis?

Answer 23

Joint arthrocentesis - synovial fluid analysis, gram staining and culture
Synovial fluid - yellow/green and turbid
Culture pos in 70% of non-gonococcal septic arthritis
Synovial fluid WCC is often raised
Other useful tests = blood cultures, CRP and ESR.

Question 24

What is the Kocher criteria for diagnosis septic arthritis?

Answer 24

Fever >38.5 degrees
Non-weight bearing
Raised ESR
Raised WCC

Question 25

What is the typical management for septic arthritis?

Answer 25

Medical - empirical antibiotics after any planned cultures/aspirates
Norm for 4-6w IV.
Examples: oxacillin, nafcillin or vancomycin.

Surgical - native joints require surgical irrigation and debridement, prosethic joints washout is still required but may also need revision surgery.

Question 26

What is the antibiotic choice surrounding osteomyelitis?

Answer 26

1st line for acute = flucloxacillin 6/52 of which 2w IV
May add rifampicin and fusidic acid
If penicillin allergy consider clindamycin
Is MRSA pos consider teicoplanin or vancomycin
Chronic - extened course of 3months.