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*MSK-Rheum > Septic Arthritis / Osteomyelitis (1*) > Flashcards

Septic Arthritis / Osteomyelitis (1*) Flashcards

1
Q

What questions should you ask with a PC of arthritis?

A
  • How many joints?
    • e.g. mono (1),
    • oliogo <or>
      </or><li>&gt;5 poly arthritis?</li>
    </or>
  • Symmetrical?
    • (or asymmetrical)
  • Associated symptoms?
  • e.g. systemically unwell?, rash?
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2
Q

What arthritis types can be both mono or oligo arthritis?

A
  1. Crystal
  2. osteo arthritis
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3
Q

what are the monoarthritis?

A

(crystal, OA)

trauma - e.g. haemoarthrosis

septic

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4
Q

What are the oligoarthritis types?

A
  1. psoriatic
  2. reactive
  3. ank spon

(crystal + OA)

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5
Q

What are the polyarthritis types (>5 joints)?

A
  • Symmetrical
    • RA,
    • OA,
    • viral (hep A,B,C and mumps)
    • systemic conditions
  • Asymmetrical
    • Psoriatic
    • reactive arthritis
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6
Q

Which of RA, SLE, Psoriatic arthritis, OA and ank spon dont involve inflammation? (the others do)

A

OA doesnt involve inflamm

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7
Q

what joints are involved in RA?

A

small and large joints

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8
Q

what joints are involved in OA?

A

Weight bearing - PIPs, DIPs and CMC

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9
Q

What joints are involved in SLE arthritis?

(lupus isnt an arthritis but can cause arthritis as a common symptom)

A

Small joints

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10
Q

What joints are involved in psoriatic arthritis?

A

Large and small joints

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11
Q

What joints are involved in ank spon?

A

large joints

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12
Q

Which of RA, OA, SLE, psoriatic, ank spon are symmetrical or variable in symmetry?

A

OA and psoriatic are variable

RA, SLE and ank spon are symmetrical

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13
Q

Which of RA, OA, SLE, Psoriatic and ank spon are axial (head and trunk)? or variabl or no?

A
  • YES
  • RA can be in neck
  • OA neck and lower back
  • ank spon also yes

psoriatic arthritis is variable

SLE = NO

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14
Q

Why is septic arthritis an emergency?

A

will wreck joints in <24hrs - consider in any acutely inflamed joint

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15
Q

What is the definition of septic arthritis?

A

septic arthritis definition:

infection of joint space & its synovium -

  • common in infants & children,
  • rare in adults –> unless immunocompromised or diabetic but always exclude in any acute monoarticulopathy
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16
Q

What are the risk factors for septic arthritis?

A

RF:

  1. IVDU,
  2. immunosuppressed,
  3. pre-existing joint disease (especially RA),
  4. DM,
  5. prosthetic joints,
  6. recent joint surgery,
  7. chronic renal failure (weak immmunity inc liver and DM too),
  8. age >80yrs
  9. (children/infancts)
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17
Q

What are the pathological features of septic arthritis?

A
  • 1o seeding of synovial membrane
    • direct puncture,
    • haematogenous spread
  • 2o infection from adjacent metaphysis or directly from epiphysis (osteomyelitis)
  • LEADS TO
  • Proteolytic enzymes released from synovial cells &
  • proteases from chondrocytes
    • ​–> causing destruction of articular cartilage
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18
Q

What are the SSx of septic arthritis?

A
  • Hot, swollen, tender, restricted joint ; Associated swelling of soft tissue, erythema, hot
    • (rubor, calor, tumour, dolor, functio laesa)
  • Monoarthritis
  • Rapid onset joint pain
  • Significant pain with any movement - pt keeps stil; & rigid
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19
Q

What Ix’s should be done for septic arthritis?

A
  • _Plain X-ray
    Bloods    _
  • USS
    • for effusion detection and
    • to guide–> aspiration
      • Aspiration ​= MC&S and analyse for crystals [rules out gout/psuedogout]
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20
Q

What would blood tests should you look for in septic arthritis?

A
  1. raised
    • WCC
    • Neutrophils
    • CRP
    • ESR
  2. Do blood cultures
  3. check:
    • U&E,
    • LFT,
    • glucose (ic in DM infection)
21
Q

What should you look for on plain X-ray for septic arthritis?

A

Plain X-ray -

  • joint space widening,
  • joint subluxation or dislocation,
  • soft tissue swelling
22
Q

What should you look for in aspiration / arthrocentesis?

A

[as well as crystal analysis for gout/psuedogout - not if prosthetic joint]

MC&S

G +ve

  • Staph aureus - IVDUs, floxacillin
  • Strep pyogenes

G-ve bacilli

  • E-coli
  • N gonococcus
  • Pseudomonas (can cause lung infections)

If HIV +ve, look for atypical mycobacteria & fungi

23
Q

What is the treatment for septic arthritis?

A
  1. broad spectrum abx then specific based on MC&S (IV 2weeks, oral 4weeks),
    • Flucloxacillin IV (staph aureus - g+ve ones)
    • Vancomycin IV if MRSA
    • Cefotaxime IV if gonococcal or G-ve (e.coli, psuedomonas)
  2. open or arthroscopic drainage of affected joint,
  3. lavage & debridement (especially if prosthetic joint involved)
24
Q

What is the pathophysiology of acute haematogenous osteomyelitis?

A
  1. INFLAMMATION D0: End branches of nutrient artery have acute inflammatory response to infection
  2. Supparation D2-3: pus formation in medulla pushes way out to periosteium
  3. NECROSIS D7: infective thrombosis compromises blood supply (obstruction).
  4. avascular necrosis of bone
  5. sequestra (necrosed bone formation) / bone breakdown
  • REPAIR -
  • OR
  • ==> chronic osteomyelitis
25
Q

What is acute haematogenous osteomyelitis?

A

organisms settle near metaphysis at growing end of long bone

26
Q

What a likely cause of acute haematogenous osteomyelitis in infants, children and adults?

A

staph aureus

27
Q

What are the likely causes of acute haematogenous osteomyelitis in infants e.g. <1y/o?

A
  • GBS
  • E.Coli

(& S.aureus)

28
Q

What are the likely causes of acute haematogenous osteomyelitis in children e.g. <16y/o?

A
  • Strep pyogenes
  • H.influenzae (its g-ve)

(& S.aureus)

29
Q

What is the likely cause of acute haematogenous osteomyelitis in adults?

A

Staph epidermis

(& Staph aureus)

30
Q

What is a likely cause of acute haematogenous osteomyelitis in sickle cell patients?

A

salmonella

(NB: reactive arthritis maybe caused by salmonella/campylobacter: GI stuff too)

31
Q

What are RARE causes of acute haematogenous osteomyelitis?

A
  1. brucella (a bacterium)
  2. TB
  3. spirochetes (spiral bacterium family e.g. one type is syphilis, e.g. syphilistic osteomyelitis of skull)
  4. fungi
32
Q

What are the signs and symptoms of osteomyelitis?

A

General SSx:

  • limping/ refusing to weight bear
  • after a few days (e.g. suppuration) develops: fever, pain, malaise

O/E: localised swelling or redness of a long bone

Usually:

Infants: failure to thrive, drowsiness or irritability

Children: preceding hx of trauma or infection (skin, respiratory)

33
Q

What are the blood investigations for osteomyelitis?

A

Bloods -

  1. raised WCC & neutrophils, ESR & CRP,
  2. blood cultures +ve in 50%,
  3. also do U&Es, LFTs, glucose

(same as septic arthritis)

34
Q

What imaging is done for septic arthritis?

A

Images -

  • plain X-ray
    • may be normal for ~10d
  • technetium-99 scan
    • ​e.g. bone nuclear medicine
  • MRI
    • Sensitive but not specific
    • e.g. less false positives but more false negatives (if there = condition, if not = dont know)
  • CT
    • define extent of bone sequestration & cavitation
35
Q

What does CT scans of osteomyelitic bones show?

A
  • Soft tissue swelling, displacement of fat planes
  • Patchy lucencies in the metaphysis ~10d (pus, infective thrombosis, necrosis etc)
  • Periosteal new bone = Involucrum formation (new layer of outside bone) ~3wks
  • Sequestration (dead bone) is radiodense (surrounding bone is osteopenic)
36
Q

What is the treatment procedure for osteomyelitis?

A
  • Rx:
  • pain relief by bed rest, splinting & analgesia
  • Take cultures
  • IV abx according to local guidelines e.g. flucloxacillin IV then PO qds for 6wks
  • Surgical drainage of mature suboperiosteal abscess
    • with debridement,
    • obliteration of dead space,
    • soft tissue coverage &
    • blood supply resotration
37
Q

What treatment do you give for osteomyelitis if the person is allergic to penicillin?

A

clindamycin (e.g. not fluclox) if penicillin allergic,

38
Q

Staph aureus is a cause of osteomyelitis across infants, children and adults. What antibiotic is used to treat MRSA?

A

vancomycin if MRSA, (if just staph, look at local guidelines/fluclox)

39
Q

What is the treatment for osteomyelitis if Haem. Influenzae is the cause

A

ampicillin for Haemophilus

40
Q

What are the complications of osteomyelitis?

A

Complications:

  1. disseminated infection (septicaemia, cerebral abscess),
  2. chronic osteomyelitis,
  3. septic arthritis,
  4. deformity due to epiphyseal involvement
41
Q

What causes of chronic osteomyelitis are there?

A
  1. most common = contaminated trauma and open fractures
  2. haematogenous osteomyelitis
  3. 1ry chronic infections of bone
  4. Joint replacement surgery (rare)
42
Q

How do you prevent acute haematogenous osteomyelitis causing chronic myelitis?

A

Acute haematogenous osteomyelitis -

  • sinus formation due to sequestra or resistant bacteria
  • (prevent –> chronic with adequate Rx of initial acute attack)

Rx:

  • simple dressings,
  • drain/debride abscesses,
  • involve plastics for tissue over & blood supply restoration,
  • closed suction drainage/irrigation systems, (reduce infection e.g. open drains like stoma)
  • abx (gentamicin)-impregnated beads or sponges, amputation
43
Q

How do you treat contaminated trauma/open fractures (to prevent becoming chronic osteomyelitis)?

A

Contaminated trauma & open fractures (most commonly) -

  • try to prevent with aggressive approach to compound fractures
    • “the solution to pollution is dilution”

Rx:

  • remove foreign bodies e.g. internal metalwork,
  • excise dead tissue,
  • copious lavage,
  • skeletal stabilisation,
  • IV antibiotics
    • (cefuroxime +/0 metronidazole if anaerobes involved e.g. from soil)
44
Q

How do you prevent osteomyelitis in joint replacement surgeries?

A

Joint replacement surgery - rare, prevention better than cure, 50% need surgical intervention

Rx:

  • prosthesis removal if grossly infected,
  • surfaces debrided,
  • antibiotic cement spacer onto raw bone ends to allow soft tissue envelope to settle,
    • –>once infection resolved new prosthetic can go ahead (may take 12months or not be possible at all)
  • If joint still solid & not “loose”- irrigation, debridement, tissue sampling attempted
45
Q

What are the 4 different types of primary chronic infections of bones?

A
  • Brodies abscess
  • TB
  • syphilitic
  • mycotic
46
Q

What is brodies abscess (a primary chronic infection of the bone)?

A

isolated, well-contained chronic abscess - operative drainage with excision of abscess wall, abx

47
Q

What is potts paraplegia caused by?

A

TB osteomyelitis may present acutely:

  • muscle atrophy develops &
    • can lead to sinus formation (destruction of bone / dead space which –> abscess formation)

“Pott’s paraplegia” = spinal TB may cause vertebral collapse leading to acute neurology

48
Q

What occurs in syphilitic osteomyelitis?

A

Syphilitic osteomyelitis: 3o disease, pathological fractures, X-rays show periosteal thickening with “punched out” areas in sclerotic bone

49
Q

What is mycotic [fungal infection] osteomyelitis?

A

Mycotic osteomyelitis:

  • immunocompromised patients,
  • bone granulomas,
  • necrosis & suppuration present without worsening acute illness
    • usually occurs as spread from 1o lung infections
      • e.g. coccidiomycosis, cryptococcosis, blastomycosis, histoplasmosis -
    • Rx: amphotericin B (antifungal medication) +/- surgical exicion

*MSK-Rheum (6 decks)

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