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Year 3 - Musculoskeletal > Infections in bone and joints > Flashcards

Infections in bone and joints Flashcards

1
Q

What is osteomyelitis?

A

A bone infection

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2
Q

What is septic arthritis?

A

A joint infection

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3
Q

Who is most commonly effected by acute osteomyelitis?

A
  • Children mostly
  • Boys >girls
  • Those with a history of trauma
  • Diabetics
  • Rheumatic Arthritis
  • Immunocompromised
  • Steroid users
  • Sickle cell
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4
Q

Acute osteomyelitis, source of infection - Haematogenous spread?

A

Children and elderly

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5
Q

Acute osteomyelitis, source of infection - Local spread from infection spread?

A

> Trauma, open fracture
Bone surgery
Joint replacement

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6
Q

Acute osteomyelitis, source of infection?

A

> Haematogenous
Local from contiguous site of infection
Vascular insufficiency

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7
Q

Acute osteomyelitis, source of infection - in infants?

A

Infected umbilical cord

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8
Q

Acute osteomyelitis, source of infection - in children?

A

> Boils
Tonsilitis
Skin abrasions

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9
Q

Acute osteomyelitis, source of infection - in adults?

A

> UTI

> Arterial line

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10
Q

Acute osteomyelitis, causative organism - In infants, <1 year?

A

> S aureus
Group B Strep
E. coli

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11
Q

Acute osteomyelitis, causative organism - In older children?

A

> S aureus
Strep pyogenes
Haemophilus influenzae

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12
Q

Acute osteomyelitis, causative organism - In adults?

A 
> S aureus, most common
> Coagulase negative Strep (Prosthesis)
> Propionibacterium spp (Prosthesis)
> Mycobacterium tuberculosis
> Pseudomonas aeroginosa, especially secondary to penetrating foot injuries, IVDAs
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13
Q

Acute osteomyelitis, causative organism - In diabetic foot and pressure sores?

A

Mixed infection including anaerobes

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14
Q

Acute osteomyelitis, causative organism - In sickle cell disease?

A

Salmonella spp

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15
Q

Acute osteomyelitis, causative organism - In fishermen, filleter?

A

Mycobacterium marnum

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16
Q

Acute osteomyelitis, causative organism - In debilitation, HIV, AIDs, other immunocompromised?

A

Candida

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17
Q

Acute osteomyelitis - where is affected?

A

Long bones - Metaphysis

  • Distal femur
  • Proximal tibia
  • Proximal humerus

Joints with intra-articular metaphysis:

  • Hip
  • Elbow (Radial head)
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18
Q

Acute osteomyelitis - Pathology?

A

1) Start at metaphysis
2) Vascular tasks
3) Acute inflammation
4) Suppuration
5) Release of pressure
6) Necrosis of bone (Sequestrum)
7) New bone formation (Involucrum)
8) Resolution, or not (chronic)

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19
Q

Acute osteomyelitis, clinical features - In infants?

A 
> May be minimal signs, or may be very ill
> Failure to thrive
> Drowsy or irritable
> Metaphyseal tenderness + swelling
> Decrease ROM
> Positional change
> Most common around the knee
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20
Q

Acute osteomyelitis, clinical features - In children?

A

> Severe pain
Reluctant to move (neighbouring joints held flexed); not weight bearing
May be tender fever (swinging pyrexia) + tachycardia
Malaise (fatigue, nausea, vomiting – “nae weel” - fretful
Toxaemia

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21
Q

Primary acute osteomyelitis, clinical features - In adults?

A

> Primary OM seen commonly in thoracolumbar spine
Backache
History of UTI or urological procedure
Elderly, diabetic, immunocompromised

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22
Q

Secondary acute osteomyelitis, clinical features - In adults?

A

> Secondary OM much more common
Often after open fracture, surgery (esp. ORIF)
Mixture of organisms

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23
Q

Causative organism in cellulitis?

A

Group A Strep

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24
Q

Causative organism in Erysipelas?

A

Group A Strep

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25
Q

Causative organism in necrotising fasciitis?

A
  • Group A Strep

- Clostridia

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26
Q

Causative organism in gas gangrene?

A

Clostridium perfringens

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27
Q

Causative organism in toxic shock syndrome?

A

S aureus

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28
Q

What is cellulitis?

A

Soft tissue infection - (deep) infection of subcutaneous tissues (Gp A Strep)

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29
Q

What is Erysipelas?

A

Soft tissue infection - superficial infection with red, raised plaque (Gp A Strep)

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30
Q

What is necrotising fasciitis?

A

Soft tissue infection - aggressive fascial infection (Gp A Strep, Clostridia)

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31
Q

What is gas gangrene?

A

Soft tissue infection - grossly contaminated trauma (Clostridium perfringens)

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32
Q

Acute osteomyelitis, diagnosis?

A

> History and clinical examination (pulse + temp.)

> FBC + diff WBC (neutrophil leucocytosis)

> ESR, CRP

> Blood cultures x3 (at peak of temperature – 60% +ve)

> U&Es – ill, dehydrated

> Aspiration

> Imaging

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33
Q

Acute osteomyelitis, diagnosis - imaging techniques?

A

> X-ray (normal in the first 10-14 days)

> Ultrasound

> Isotope Bone Scan imaging (Technectium-99 labelled siphosphonate, Gallium-67 citrate delayed)

> Labelled white cell scan (Indium-111)

> MRI

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34
Q

What is seen on radiograph in acute osteomyelitis, early on?

A

Minimal changes

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35
Q

What is seen on radiograph in acute osteomyelitis, 10-20days?

A

Periosteal changes

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36
Q

What is seen on radiograph in acute osteomyelitis?

A

> Early radiographs minimal changes

> 10-20 days early periosteal changes

> Medullary changes - lytic areas

> Late osteonecrosis - sequestrum

> Late periosteal new bone - involucrum

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37
Q

What is sequestrum?

A

Late osteonecrosis

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38
Q

What is involucrum?

A

Late periosteal new bone formation

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39
Q

When are blood cultures useful in osteomyelitis?

A
  • Heamatogenous osteomyelitis

- Septic arthritis

40
Q

How do you treat acute osteomyelitis?

A

> Supportive therapy for pain and dehydration

> Rest and splintage

> Abx:

  • Duration = 4-6 weeks, depends on response, monitor ESR
  • Choice = Empirical (Fluclox + Benzylpenicillin) whilst waiting for microbiology

> Surgery

41
Q

Prior to antibiotics what was the mortality in acute osteomyelitis?

A

70%

42
Q

What is important in antibiotic choice in acute osteomyelitis?

A

> Spectrum of activity
Penetration to bone
Safety for long term administration

43
Q

Why may Abx fail in acute osteomyelitis?

A

> Drug resistance – e.g.  lactamases

> Bacterial persistence - ‘dormant’ bacteria in dead bone

> Poor host defences - IDDM, alcoholism…

> Poor drug absorption

> Drug inactivation by host flora

> Poor tissue penetration

> MRSA, etc.!!

44
Q

What are the indications for surgery in acute osteomyelitis?

A

Indications:
> Aspiration of pus for diagnosis & culture
> Abscess drainage (multiple drill-holes, primary closure to avoid sinus)
> Debridement of dead/infected /contaminated tissue
> Refractory to non-operative Rx >24..48 hrs

45
Q

Complications of acute osteomyelitis?

A 
> Septicemia, death
> Metastatic infection
> Pathological fracture
> Septic arthritis
> Altered bone growth
> Chronic osteomyelitis
46
Q

Cause of chronic osteomyelitis?

A

> Acute osteomyelitis

> De novo:

  • Following operation
  • Following open fracture
  • Immunocompromised, diabetics, elderly, drug abusers..

> Repeated breakdown of healed tissue

47
Q

Chronic osteomyelitis, causative organism?

A

> Often mixed
Mostly S aureus, E coli, Strep progenes, Proteus
Flare-up usually contains same organism(s)

48
Q

Chronic osteomyelitis, Pathology?

A

> Cavities, possibly sinus(es)
Dead bone (retained sequestra)
Involucrum
Histological picture is one of chronic inflammation

49
Q

Chronic osteomyelitis, complications?

A

> Chronically discharging sinus + flare-ups

> Ongoing (metastatic) infection (abscesses)

> Pathological fracture
growth disturbance + deformities

> Squamous cell carcinoma (0.07%)

50
Q

Chronic osteomyelitis, treatment?

A

> Long-term antibiotics:

  • Local (gentamicin cement/beads, collatamp)
  • Systemic (orally/ IV/ home AB)

> Eradicate bone infection- surgically

> Treat soft tissue

> Deformity/reconstruction

> Amputation

51
Q

Acute Septic Arthritis - Route of infection?

A

> Haematogenous

> Eruption of bone abscess

> Direct invasion:

  • Penetrating wound (iatrogenic? – joint injection)
  • Intra-articular injury
  • Arthroscopy
52
Q

What can a bone abscess lead to?

A

1) Acute septic arthritis

2) Acute osteomyelitis

53
Q

Acute Septic Arthritis -

Organisms?

A 
Common:
> Staphylococus aureus
> Haemophilus influenzae
> Streptococcus  pyogenes
> E. coli
54
Q

Acute Septic Arthritis - Pathology?

A

1) Acute synovitis with purulent joint effusion
2) Articular cartilage attacked by bacterial toxin and cellular enzyme
3) Complete destruction of the articular cartilage

4) then, either:
> Complete recovery

or

> Partial loss of the articular cartilage and subsequent OA

or

> Fibrous or bony ankylosis

55
Q

End result of acute septic arthritis?

A

Either:
> Complete recovery

or

> Partial loss of the articular cartilage and subsequent OA

or

> Fibrous or bony ankylosis

56
Q

Acute Septic Arthritis, clinical presentation - Neonate?

A

Picture of septicaemia
> irritability
> resistant to movement
> ill

57
Q

Acute Septic Arthritis, clinical presentation - Child/adult?

A

Acute pain in single large joint:
> Reluctant to move the joint (any movement – c.f. bursitis where RoM OK)

> Increase temp. and pulse

> Increase tenderness

58
Q

Most common site(s) of acute septic arthritis in an adults?

A

Often involves superficial joint - Knee, ankle, wrist

59
Q

Investigation in acute septic arthritis in an adult?

A 
Investigation:
> FBC, WBC, ESR, CRP, blood cultures
> X ray
> Ultrasound
> Aspiration
60
Q

What is the most common cause of acute septic arthritis in an adult?

A

Injected joint replacement

  • Rare, only 1-1.5%
  • Disaster = Amputation, death etc
  • S aureus still most common
61
Q

Differential diagnosis in acute septic arthritis?

A 
> Acute osteomyelitis
> Trauma
> Irritable joint
> Haemophilia
> Rheumatic fever
> Gout 
> Gaucher’s disease
62
Q

Treatment in acute septic arthritis?

A

> General supportive measures

> Antibiotics (3-4 weeks)

> Surgical drainage & lavage - emergency (“never let the sun set on pus” ); open or arthroscopic lavage;

> Infected joint replacements - one stage revision, two stage revision, antibiotics only?

63
Q

Classification of tuberculosis in bone and joints?

A

Classification:
> Extra-articular (epiphyseal / bones with haemodynamic marrow)
> Intra-articular (large joints)
> Vertebral body

64
Q

Tuberculosis, bone and joints - clinical features?

A

> Insidious onset & general ill health

> Contact with TB

> Pain (esp. at night), swelling

> Loss of weight

> Low grade pyrexia

> Joint swelling

> Decrease ROM

> Ankylosis

> Deformity

65
Q

Tuberculosis, bone and joints - pathology?

A

> Primary complex (in the lung or the gut)

> Secondary spread

> Tuberculous granuloma

> n.b. role of nutrition/ other disease (e.g. HIV AIDS)

66
Q

Tuberculosis, bone and joints - pathology?

A

> Primary complex (in the lung or the gut)

> Secondary spread

> Tuberculous granuloma

> n.b. role of nutrition/ other disease (e.g. HIV AIDS)

67
Q

Tuberculosis, bone and joints - Diagnosis?

A 
> Long history
> Involvement of single joint
> Marked thickening of the synovium
> Marked muscle wasting
> Periarticular osteoporosis
68
Q

Tuberculosis, bone and joints - Investigations?

A

> FBC , ESR

> Mantoux test*

> Sputum/ urine culture

> Xray:

  • soft tissue swelling
  • periarticular osteopaenia
  • articular space narrowing

> Joint aspiration and biopsy

  • AAFB identified in 10-20%
  • culture +ve in 50% of cases
69
Q

Tuberculosis, bone and joints - Differential diagnosis?

A 
> Transient synovitis
> Monoarticular RA
> Haemorrhagic arthritis
> Pyogenic arthritis
> Tumour
70
Q

Tuberculosis, bone and joints - Differential diagnosis?

A 
> Transient synovitis
> Monoarticular RA
> Haemorrhagic arthritis
> Pyogenic arthritis
> Tumour
71
Q

Tuberculosis, bone and joints - Treatment?

A 
chemotherapy
1) Initial:
- rifampicin = 8 weeks    
- isoniazid = 8 weeks
- ethambutol = 8 weeks
then:
- rifampicin and isoniazid for 6-12 months

2) Rest and splintage
3) Operative drainage rarely necessary

72
Q

Tuberculosis, bone and joints - Treatment, chemotherapy first 8 weeks?

A
  • rifampicin = 8 weeks
  • isoniazid = 8 weeks
  • ethambutol = 8 weeks
73
Q

Tuberculosis, bone and joints - Treatment, chemotherapy after the first 8 weeks?

A

Rifampicin and isoniazid for 6-12 months

74
Q

When does acute osteomyelitis most commonly occur in adults?

A

In those immunocompromised, sickle cell, diabetes etc

75
Q

Where is Propionibacternirm spp found on the body?

A

In the axilla

76
Q

If someone was to step on a nail which organism is likely to cause acute osteomyelitis?

A

Pseudomonas aeroginosa

77
Q

Which age group is most likely to have acute osteomyelitis caused by H influenzae?

A

4-8 yrs of age

78
Q

When do you see acute osteomyelitis caused by fungal infections?

A

In those who are immunocompromised

79
Q

If the released into the joint within acute osteomyelitis what is likely to occur?

A

Septic arthritis

80
Q

Who is more likely to be affected by multi-site acute osteomyelitis?

A

Infants

81
Q

What is the most common site of primary acute osteomyelitis in adults?

A

The spine

82
Q

What are the most common organisms which cause acute osteomyelitis in adults?

A

UTI –> E. coli

83
Q

What is lost in septic arthritis?

A

Mobility of the joint

84
Q

What can viral infection lead to within children?

A

Transient synovitis (Effusion into the hip)

85
Q

What can you see if using ultrasound in acute osteomyelitis?

A

Periosteal swelling from pus

86
Q

Which imaging modality is more commonly used in acute osteomyelitis now?

A

MRI

87
Q

What is the big complication risk of chronic osteomyelitis?

A

Squamous cell carcinoma

88
Q

If there is a penetrating wound near a joint how is this managed?

A

They are taken to theatre and the wound and joint is washed out

89
Q

What is the risk of a deeper joint being affected by acute septic arthritis?

A

Deeper joint is harder to recognise and is less tender and often leads to late diagnosis as a consequence

90
Q

Which organism is more likely to cause acute septic arthritis in an adult who has received a joint replacement?

A

Staph epidermis

91
Q

If there is acute inflammation of a joint with a loss of ROM which pathology should be considered?

A

Acute septic arthritis

92
Q

How is acute septic arthritis managed?

A

> Early = Aggressive ABx prior to pus
Once there is pus surgical drainage and lavage is required
Infected joint replacement = One stage/ two stage revisions

93
Q

Which site is most common in bone/joint related TB?

A

The vertebral bodies

94
Q

Which site is most common in intra-articular TB?

A

The knee

95
Q

When does pain typically occur in bone/joint TB?

A

Pain at night

96
Q

If there is a decreased ROM in bone/joint TB what is this suggestive of?

A

Fibrosis

Year 3 - Musculoskeletal (30 decks)

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