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Flashcards in Infecção Deck (223):
1

Qual o local mais comum do osso de ocorrer osteomielite na criança? Por quê?

The relative absence of phagocytic cells in the metaphyses of bones in children may explain why acute hematogenous osteomyelitis is more common in this location.

2

Quais fatores dependentes do paciente estão relacionados ao desenvolvimento da osteomielite?

Patient-dependent factors include nutrition, immunological status, and infection at a remote site.

3

Quanto de energia um evento traumático ou um processo infeccioso aumenta o metabolismo basal?

Basal energy requirements of a traumatized or infected patient increase from 30% to 55% of normal.

4

Como pode ser avaliado o status nutricional de um paciente?

Nutritional status can be determined preoperatively by (1) anthropometric measurements (height, weight, triceps skin fold thickness, and arm muscle circumference), (2) measurement of serum proteins or cell types (lymphocytes), and (3) antibody reaction to certain antigens in skin testing. Nutritional support is recommended before elective surgery for patients with recent weight losses of more than 10 lb, serum albumin levels less than 3.4 g/dL or lymphocyte counts of less than 1500 cells/mm.

5

Qual a formula do cálculo nutricional?

[(1.2 × serum albumin) + (0.013 × serum transferrin)] − 6.43. If the sum is 0 or a negative number, the patient is nutritionally depleted and is at high risk for sepsis.

6

Quais são os principais mecanismos de defesa do organismo?

The body’s main defense mechanisms are (1) neutrophil response, (2) humoral immunity, (3) cell-mediated immunity, and (4) reticuloendothelial cells.

7

A quais tipos de bacterias está sujeito um paciente com diminuição da imunidade humoral e mediada por células?

Abnormal neutrophils or humoral and cell-mediated immunities have been implicated in infections caused by encapsulated bacteria in infants and elderly patients, in the increased incidence of Pseudomonas infections in heroin addicts, and in Salmonella and Pneumococcus infections in patients with sickle cell anemia.

8

Quais doenças diminuem a contagem de neutrófilos?

Diabetes, alcoholism, hematological malignancy, and cytotoxic therapy are common causes of neutrophil abnormalities.

9

A partir de que niveis de neutrofilos o paciente fica susceptível a infecções? Quais são os germes?

If the neutrophil count decreases to less than 55/mm3 , infections caused by Staphylococcus aureus, gram-negative bacilli, Aspergillus organisms, and Candida organisms become a major threat.

10

Pacientes com hipogamaglobulinemia e esplenectomizados estão sujeitos a infecção por qual tipo de bacterias?

Patients with hypogammaglobulinemia or who have had a splenectomy are at increased risk of infection caused by encapsulated bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria organisms. Septic arthritis caused by unusual organisms such as Mycoplasma pneumoniae and Ureaplasma urealyticum has been reported and should be suspected in patients with hypogamma- globulinemia and culture-negative septic arthritis.

11

Paciente com deficiencia no sistema complemento estão sujeito a infecção por quais organismos?

When a defect in a component of the complement cascade is present, S. aureus and gram-negative bacillus infections are common.

12

Quais fatores podem levar a uma deficiencia secundária da imunidade mediada por células? A quais organismos o paciente está sujeito à infecção?

Corticosteroid therapy, malnutrition, lymphoma, systemic lupus erythematosus, immunodeficiency in elderly patients, and autoimmune deficiency syndrome all can cause a secondary cell-mediated deficiency, which predisposes the host to fungal and mycobacterial infections and also infection with herpesvirus and Pneumocystis jiroveci.

13

Em qual local da pele geralmente as bactérias residem e se reproduzem?

the hair follicles and sebaceous glands where bacteria normally reside and reproduce.

14

Quais dedos geralmente são perfurados durante o ato cirurgico?

Most frequently, the perforation occurs on the index finger or thumb of the nondominant hand.

15

De quanto em quanto tempo as luvas cirurgicas devem ser trocadas durante uma cirurgia?

At a minimum, surgical gloves should be changed every 2 hours.

16

O fluxo de ar laminar na sala de cirurgia diminui em quanto a porcentagem de bactérias suspensas no ar?

Airborne bacterial concentrations in the operating room may be reduced by at least 80% with laminar-airflow systems and even more with personnel-isolator systems.

17

Além do fluxo laminar de ar, qual outro processo também diminui a porcentagem de bactérias suspensas na sala cirúrgica?

Ultraviolet light also has been shown to decrease the incidence of wound infection by reducing the number of airborne bacteria; not recommended by the Hospital Infection Control Practice Advisory Committee.

18

Como reage o organismo do paciente ao procedimento cirurgico ortopédico em relação às bacterias?

During the first 24 hours, infection depends on the number of bacteria present. During the first 2 hours, the host defense mechanism works to decrease the overall number of bacteria. During the next 4 hours, the number of bacteria remains fairly constant, with the bacteria that are multiplying and the bacteria that are being killed by the host defenses being about equal. These first 6 hours are called the “golden period,” after which the bacteria multiply exponentially. The administration of prophy- lactic antibiotics expands the golden period.

19

Qual bacteria mais comum na pele?

S. aureus, although the frequency of Staphylococcus epidermidis is increasing.

20

Em relação a quimioprofilaxia, qual antibiotico deve ser administrado para o paciente alergico a penicilina? Qual antibiotico não deve ser usado de rotina?

Clindamycin can be given if a patient has a history of anaphylaxis to penicillin. Routine use of vancomycin for prophylaxis should be avoided.

21

Em que momento da cirurgia o antibiótico deve ser administrado? Quando deve ser repetido?

Ideally, antibiotic therapy should begin immediately before surgery (ideally 30 minutes before skin incision). Must be repeated every 4 hours intraoperatively or whenever the blood loss exceeds 1000 to 1500 mL.

22

Quanto tempo deve durar a quimioprofilaxia com antibióticos?

Prophylactic antibiotics should not be extended past 24 hours even if drains and catheters are still in place.

23

Comente sobre a colonização de MRSA entre cirurgiões e residentes.

Schwarzkopf et al. prospectively studied the prevalence of S. aureus colonization in orthopaedic surgeons and their patients and found that among surgeons and residents there was a higher prevalence of MRSA compared with a high-risk group of patients.

24

Qual é a tríade clássica da infecção?

he classic triad is fever, swelling, and tenderness (pain).

25

Durante um episódio de infecção aguda, qual porção do diferencial sanguineo aumenta?

The diferential shows increases in neutrophils during acute infections.

26

Em relação ao PCR e VHS, como eles se comportam durante um episódio de infecção aguda?

Peak elevation of the ESR occurs at 3 to 5 days after infection and returns to normal approximately 3 weeks after treatment is begun. CRP, synthesized by the liver in response to infection, is a better way to follow the response of infection to treatment. CRP increases within 6 hours of infection, reaches a peak elevation 2 days after infection, and returns to normal within 1 week ater adequate treatment has begun.

27

Na análise do aspirado articular, quais valores celulares sugerem infecção?

In septic arthritis, the cell count usually is greater than 80,000/mm3, with more than 75% of the cells being neutrophils.

28

No caso de uma biopsia por congelação, quais contagens de células brancas sugerem infecção?

Intraoperative frozen section also should be obtained in cases in which infection is suspected. A white blood cell count greater than 10 per high-power field is considered indicative of infection, whereas a count less than 5 per high-power field all but excludes infection.

29

Por que a avaliação radiológica não é um bom método para avaliar infeção aguda?

Bone destruction is not apparent on radiographs, however, until an infection has been present for 10 to 21 days. In addition, 30% to 50% of the bone matrix must be lost to show a lytic lesion on radiographs.

30

Como o processo infeccioso altera a imagem na TC?

CT can help determine the extent of medullary involvement. Pus within the medullary cavity replaces the marrow fat, causing an increased density on the CT scan. CT diagnosis of acute osteomyelitis is based on detection of intraosseous gas, osteolysis, sot tissue masses, abscesses, or foreign bodies.

31

Quais são os 3 radioisotopos mais utilizados nas cintilografias?

The three most commonly used radioisotopes are technetium, gallium and indium.

32

Como diferenciar uma celulite, osteomielite e um processo degenerativo pela cintilografia?

Cellulitis causes increased activity during the low and equilibrium phases and a decreased or normal uptake in the delayed phase. Osteomyelitis causes increased uptake in all three phases. Increased uptake in the delayed phase but not in the low or equilibrium phase suggests 99m degenerative joint disease.

33

Quais são os achados clássicos da osteomielite na RNM?

The classic findings of osteomyelitis on MRI are a decrease in the normally high marrow signal on T1 images and a normal or increased signal on T2 images. Although MRI is good for detailing marrow involvement and discitis, it does little to detect early cortical bone involvement.

34

Qual o momento ideal para se colher material para cultura?

Every efort should be made to obtain a culture specimen before antibiotic therapy is begun.

35

Quais os materiais preferidos para realizarem cultura?

The preferred specimen in most bacterial and yeast infections is aspirated fluid (joint or purulent luid). A deep wound biopsy or a curetted specimen ater cleaning the wound is acceptable. In certain bacterial and fungal infections, a tissue biopsy specimen from the edge of the wound is preferable. Aerobic and anaerobic swabs are more commonly used, but aspirated fluid or a tissue biopsy specimen is preferable.

36

O que é o MIC?

The lowest concentration of an antibiotic that inhibits growth of the patient’s isolate is designated the minimal inhibitory concentration (MIC).

37

O que é minimal bactericidal concentration?

The lowest concentration of antimicrobial agent that allows survival of less than 0.1% of the original cultured inoculum.

38

O que é serum bactericidal concentration (SBC)?

The lowest dilution of the patient’s serum that kills 99.9% of a standard inoculum is called the SBC.

39

Quais são os organismos mais comumente isolados? E nas proteses?

S. aureus is most frequently isolated in infectious arthritis. After this, N. gonorrhoeae is more common in adults younger than 30 years, and H. inluenzae type B is more common in children younger than 2 years. These three bacteria, along with various Streptococcus species, constitute most known isolates in joint infections. In contrast, prosthetic joint infections most often are caused by skin lora, such as S. epidermidis and other coagulase-negative Staphylococcus and gram-negative bacilli that are transient skin colonizers.

40

Qual organismo tem sua incidencia aumentando em osteomielite em neonatos e portadores de anemia falciforme?

S. aureus is the most frequent isolate in osteomyelitis, but Salmonella organisms have an increased incidence in patients with sickle cell anemia or neonatal osteomyelitis.

41

Qual a função do desbridamento na osteomielite?

Débridement reduces the inoculum and removes necrotic and avascular bone, bacteria, and harmful bacterial products.

42

Se um paciente não responder a antibioticoterapia entre 36 e 48h o que pode estar acontecendo?

If the patient does not respond to antibiotic treatment in 36 to 48 hours, the wrong antibiotic has been chosen or an abscess has formed.

43

Quais são os antibioticos geralmente associados ao cimento ósseo?

tobramycin, vancomycin, and gentamicin

44

Com o uso de tobramicina e vancomicina no cimento osseo, em que momento ocorre o pico de concentração desses antibioticos e quanto tempo esse pico ocorre?

With tobramycin and vancomycin, the peak concentration of antibiotic delivered to local tissue occurs on the first day and lasts for only approximately 1 week.

45

Quais efeitos o uso de quinolonas e tobramicina podem trazer ao organismo?

Quinolones have shown detrimental efects on chondrocytes and fracture healing; and tobramycin at intermediate levels of concentration (400 μg/mL) can decrease cell replication.

46

Quantas linhagens de HIV foram identificadas até hoje?

Two strains of HIV have been identified: HIV-1, which is the strain most common in the United States, and HIV-2, which has been reported primarily in Europeans, Africans, and rarely in the United States.

47

Qual célula humana o HIV parasita?

The HIV retrovirus is trophic for the CD4 surface receptors of T lymphocytes. The virus causes deregulation and destruction of these T lymphocytes, ultimately resulting in an immunodeicient state.

48

Quando ocorre a osteomielite?

Osteomyelitis occurs when an adequate number of a suficiently virulent organism overcomes the host’s natural defenses (inlammatory and immune responses) and establishes a focus of infection.

49

A partir de qual valor de CD4 as infecções oportunistas podem ocorrer?

When the CD4 cell count is less than 200/mm3 , opportunistic infections occur and clinical manifestations of AIDS begin.

50

Quais são as doenças oportunistas mais comuns nos pacientes com HIV?

P. jiroveci pneumonia and malignancies such as Kaposi sarcoma are the most common opportunistic diseases associated with AIDS in the United States.

51

Quais são os 4 estagios da infecção pelo HIV?

The stages are (1) acute primary HIV infection, (2) chronic asymptomatic HIV infection, (3) symptomatic HIV infection, and (4) advanced HIV-associated opportunistic disease or AIDS.

52

Quais são as manifestações musculoesqueleticas mais comuns nos pacientes com HIV?

The most common musculoskeletal syndromes in HIV-infected patients are manifestations of drug toxicity, reactive arthritis, infectious arthritis, myositis, tendinitis, and bursitis.

53

Quais são os principios gerais na avaliação de um paciente com HIV?

(1) Any musculoskeletal syndrome that occurs in non–HIV-infected patients can occur in HIV-infected patients; (2) HIV infection can alter the clinical presentation, severity, and course of musculoskeletal problems; and (3) early diagnosis of infections is especially important to prevent their spread in an immunocompromised patient.

54

Quais são os organismos mais isolados em artrite septica e bursite em pacientes com HIV?

Gram-positive bacteria, such as S. aureus and S. pneumoniae, commonly found in noninfected patients with septic arthritis and bursitis, also are the most frequently reported organisms causing septic arthritis and bursitis in HIV-infected individuals. Primary osteomyelitis has been reported in HIV-infected patients, but usually it is the result of direct extension from a septic joint.

55

Quais as possiveis causas de miosite nos pacientes com HIV?

Muscle pain or myositis is a common complaint in HIV- infected patients, including idiopathic polymyositis, poly-myositis secondary to zidovudine toxicity, and pyomyositis.

56

Quais são os 3 fatores que devem ser reconhecidos no risco de transmissão de HIV de um paciente para um cirurgião?

Three factors that must be known to calculate an orthopaedic surgeon’s risk of incurring HIV from punctures in the operating room are (1) the frequency of punctures, (2) the percentage of surgical patients who are HIV positive, and (3) the risk of HIV transmission per needle stick from known HIV-positive patients.

57

Quais a formas de transmissão de HIV são de grande risco?

Greatest risk for occupational transmission of HIV involved parenteral injection of blood through orthopaedic pins or hollow-core needles.

58

Quis são as chances de um ortopedista ser contaminado por HIV?

These figures put the annual risk to the orthopaedic surgeon between 0.025% and 0.5%, acumulative (>40 years of practice) risk of 0.6%.

59

O uso de duas luvas durante procedimentos diminui a chance de contato com sangue do paciente em qual porcentagem?

Double gloving reduces the risk of blood contact from 29% to 13%; however, the gloves must be changed at least every 2 hours or every hour for trauma cases.

60

O uso de quimioprofilaxia após o contato com sangue contaminado diminui em qual porcentagem o chance de soroconversão pelo HIV?

A decrease in seroconversion rates of 79% has been shown with the use of chemoprophylaxis ater exposure using zidovudine and lamivudine, chain terminators for reverse transcriptase. Adding a protease inhibitor, indinavir, further decreases antiretroviral activity. hese drugs should be started within 2 hours of exposure and generally are recommended for at least a 4-week course.

61

Qual a população mais acometida por osteomielite aguda hematológica?

Acute hematogenous osteomyelitis is more common in males in all age groups afected.

62

Como é a distribuição da osteomielite aguda hematogênica nas crianças?

The age distri­bution of acute hematogenous osteomyelitis in children is bimodal, generally afecting children younger than age 2 years and children aged 8 to 12 years. Half of all children with osteomyelitis are younger than 5 years of age.

63

Por que crianças menores que 2 anos estão susceptiveis a diminuição do membro e deformidade angular após osteomielite?

In children younger than 2 years, some blood vessels cross the physis and may allow the spread of infection into the epiphysis. For this reason, infants are susceptible to limb shortening or angular deformity if the physis or epiphysis is damaged from the infection. Otherwise, the physis acts as a barrier that prevents the direct spread of a metaphyseal abscess into the epiphysis.

64

Por que a região metafisária é mais susceptivel à osteomielite aguda na criança?

The metaphysis has relatively fewer phagocytic cells than the physis or diaphysis, allowing infec­tion to occur more easily in this area.

65

Osteomielite na região diafisária ocorre com que frequencia?

The diaphysis rarely is involved, and exten­sive sequestration occurs infrequently except in the most severe cases.

66

Como funciona a fise na criança acima de 2 anos em relação a osteomielite aguda?

In children older than 2 years, the physis efectively acts as a barrier to the spread of a metaphyseal abscess. Because the metaphyseal cortex in older children is thicker, however, the diaphysis is at greater risk in these patients. If the infec­tion spreads into the diaphysis, the endosteal blood supply may be jeopardized.

67

Em pacientes esqueleticamente maduros, qual o local mais comum de desenvolvimento de osteomielite hematologica aguda?

Although it can occur anywhere and in any part of the bone, generally the vertebral bodies are afected.

68

Como ocorre a pioartrite na criança abaixo de 2 anos? Qual é articulação mais acometida?

In children younger than 2 years, the common blood supply of the metaphysis and epiphysis crosses the physis and can allow spread of a metaphyseal abscess into the epiphysis and eventually into the joint. The hip joint is the most commonly afected in young patients; however, the physes of the proximal humerus, radial neck, and distal fibula also are intraarticular, and infection in these areas can lead to septic arthritis as well.

69

Qual patógeno é mais comum nas osteomielites em pacientes usuários de drogas injetáveis?

Pseudomonas is the most common infecting organism found in intravenous drug abusers with osteomyelitis.

70

Osteomielite fúngica é mais comum em qual tipo de paciente?

Fungal osteo­myelitis is seen increasingly in chronically ill patients receiv­ing long­term intravenous therapy or parenteral nutrition.

71

Qual patogeno é mais comum em pacientes com hemoglobinopatias?

Salmonella osteomyelitis has long been associated with SS or SC hemoglobinopathies. This infection tends to be diaphyseal rather than metaphyseal.

72

Qual é o patogeno mais comum em crianças saudáveis de 2 a 4 semanas de vida?

Group B Streptococcus is the most likely infecting organism found in otherwise healthy infants 2 to 4 weeks old.

73

Qual o patogeno mais comum nas osteomielites em crianças de 6 meses a 4 anos de idade?

Haemophilus influenzae infections occur primarily in children 6 months to 4 years old.

74

Quais doenças podem mimetizar osteomielite na radiografia? Qual exame pode ser utilizado para diferenciar?

Conditions that may be mistaken for osteomyelitis on plain radiographs include septic arthritis, Ewing sarcoma, osteosarcoma, juvenile arthritis, sickle cell crises, Gaucher disease, and stress fractures. Technetium­ 99m bone scans can conirm the diagnosis 24 to 48 hours after onset in 90% to 95% of patients; a negative technetium­bone scan efectively rules out the diagnosis of osteomyelitis.

75

Qual a aparência da osteomielite na RNM?

On T1­-weighted MR images, osteomyelitis typi­cally has low signal intensity; on T2­-weighted and short-­tau inversion recovery (STIR) images, it has a high marrow signal intensity.

76

Quais são os principios de Nade para o tratamento de osteomielite aguda hematogenica?

In 1983, Nade proposed five principles for the treat­ment of acute hematogenous osteomyelitis that are still appli­cable today: (1) an appropriate antibiotic is efective before abscess formation; (2) antibiotics do not sterilize avascular tissues or abscesses, and such areas require surgical removal; (3) if such removal is efective, antibiotics should prevent their re­formation, and primary wound closure should be safe; (4) surgery should not damage further already ischemic bone and sot tissue; and (5) antibiotics should be continued ater surgery.

77

Quais são as duas indicações cirurgicas para a osteomielite aguda?

The two main indications for surgery in acute hematogenous osteomyelitis are (1) the presence of an abscess requiring drainage and (2) failure of the patient to improve despite appropriate intravenous antibiotic treatment.

78

Qual procedimento deve ser realizado na limpeza de um abscesso na criança?

When a subperi­osteal abscess is found in an infant, several small holes should be drilled through the cortex into the medullary canal. If intramedullary pus is found, a small window of bone is removed.

79

Torniquete pode ser utilizado na limpeza de um abscesso?

Use a tourniquet whenever possible. Elevate the extremity for a few minutes before inlating the tourniquet. Do not exsanguinate the limb with an elastic bandage if infection is present.

80

Como deve ser imobilizada a tibia apos a drenagem de um abscesso?

A long-leg posterior plaster splint is applied with the foot in a neutral position, the ankle at 90 degrees, and the knee at 20 degrees of flexion.

81

Geralmente quanto tempo de antibiotico endovenoso é dado para uma criança com osteomielite aguda?

Generally, a 6-week course of intravenous antibiotics is given.

82

Qual porcentagem de pacientes com infecção primária desenvolvem osteomielite subaguda?

Subacute osteomyelitis is relatively common, reported to occur in over a third of patients with primary bone infections.

83

Como é a contagem da série branca nos pacientes com osteomielite subaguda?

White blood cell counts generally are normal. The erythrocyte sedimentation rate is elevated in only 50% of patients, and blood cultures usually are negative. Even with an adequate bone aspirate or biopsy specimen, a pathogen is identiied only 60% of the time. Plain radiographs and bone scans generally are positive

84

Como é a classificação de osteomielite subaguda de Gledhill e modificada por Roberts et al.?

Classification of subacute osteomyelitis: type 1, central metaphyseal lesion; type 2, eccentric metaphyseal lesion with cortical erosion; type 3, diaphyseal cortical lesion; type 4, diaphyseal lesion with periosteal new bone formation, but without deinite bony lesion; type 5, primary subacute epiphyseal osteomyelitis; and type 6, subacute osteomyelitis crossing physis to involve metaphysis and epiphysis.

85

Quais são os organismos predominatemente isolados nas osteomielites subagudas?

S. aureus and Staphylococcus epidermidis are the predominant organisms identified in subacute osteomyelitis.

86

Qual o tratamento geral para a osteomielite subaguda?

Biopsy and curettage followed by treatment with appro­priate antibiotics generally are recommended for all lesions that seem to be aggressive: “biopsy all cultures and culture all biopsies.” For lesions that seem to be a simple abscess in the epiphysis or metaphysis, biopsy is not recommended. These lesions, which are characteristic of subacute hematogenous osteomyelitis, should be treated with intravenous antibiotics for 48 hours followed by a 6 ­week course of oral antibiotics.

87

O que é o abscesso de Brodie?

A Brodie abscess is a localized form of subacute osteomyelitis that occurs most oten in the long bones of the lower extremi­ties of young adults.

88

Qual a queixa comum do paciente com abscesso de Brodie?

Intermittent pain of long duration is the presenting complaint, along with local tenderness over the afected area.

89

Qual a aparencia radiografica do abscesso de Brodie na radiografia?

On plain radiographs, a Brodie abscess gener­ally appears as a lytic lesion with a rim of sclerotic bone, but it can have a markedly varied appearance.

90

Quais organismos geralmente são isolados nos abscessos de Brodie?

Organisms of low virulence are believed to cause the lesion. S. aureus is cultured in 50% of patients; in 20%, the culture is negative.

91

Geralmente como é a cultura da osteomielite cronica?

In chronic osteomyelitis, secondary infections are common, and sinus track cultures usually do not correlate with cultures obtained at bone biopsy. Multiple organisms may grow from cultures taken from sinus tracks and from open biopsy specimens of surrounding soft tissue and bone.

92

Como é a classificacão fisiológica de Cierny and Mader para osteomielite crônica?

Class A hosts have a normal response to infection and surgery. Class B hosts are compromised and have deficient wound healing capabilities. When the results of treatment are potentially more damaging than the presenting condition, the patient is considered a class C host.

93

Como é a classificação anatomica de Cierny and Mader para osteomielite cronica?

Type I, a med­ullary lesion, is characterized by endosteal disease. In type II, supericial osteomyelitis is limited to the surface of the bone and infection is secondary to a coverage defect. Type III is a localized infection involving a stable, well­demarcated lesion characterized by full­thickness cortical sequestration and cavitation (in this type, complete débridement of the area would not lead to instability). Type IV is a difuse osteomy­elitic lesion that creates mechanical instability, either at pre­ sentation or ater appropriate treatment, and requires complex reconstruction.

94

Como é descrita a classificação de Jones para osteomielite cronica hematogenica na criança?

Three main types are identiied based on radiographic appear­ance: type A, Brodie abscess; type B, sequestrum involucrum; and type C, sclerotic. Type B, sequestrum involucrum, has four subtypes: B1, localized cortical sequestrum; B2, seques­trum with structural involucrum; B3, sequestrum with scle­rotic involucrum; and B4, sequestrum without structural involucrum. Physeal damage is indicated by the addition of “P” (proximal) or “D” (distal) to the classification.

95

Qual é o exame padrão-ouro para diagnóstico de ostemielite crônica?

The “gold standard” is to obtain a biopsy specimen for histological and microbiological evaluation of the infected bone.

96

Qual é o melhor radiofármaco para diferenciar osteomielite cronica e artropatia neuropática no pé diabético?

Indium­–la­beled leukocyte scans are more sensitive than technetium or gallium scans and are especially useful in diferentiating chronic osteomyelitis from neuropathic arthropathy in the diabetic foot.

97

O que é o sinal da paprica?

Puntate bleeding bone is achieved, indicating healthy tissue. (quando realizado curetagem)

98

A tecnica de Papineau é dividida em quantas fases?

The operation is divided into three stages and usually requires several surgeries: (1) débridement and stabilization, (2) cancellous autografting, and (3) skin closure.

99

Quais são os métodos descritos para preenchimento de defeito osseo após curetagem do osso com osteomielite?

The methods described to eliminate this dead space are (1) bone grafting with primary or secondary closure; (2) use of antibiotic PMMA beads as a temporary filler of the dead space before reconstruction; (3) local muscle flaps and skin grating with or without bone grating; (4) microvascular transfer of muscle, myocutaneous, osseous, and osteocutaneous flaps; and (5) the use of bone transport (Ilizarov technique).

100

Na tecnica de Papineau, quais métodos podem ser utilizados para estabilização da região curetada?

Stabilize the bone with an external ixator or intramedullary nail if needed.

101

Na tecnica de Papineau, de quanto em quanto tempo deve ser realizado o debridamento seriado?

Repeat débridement and irrigation with VAC change every 48 to 96 hours until a healthy viable tissue bed is obtained.

102

Qual a concentração local do antibiótico quando usado associado ao cimento ósseo em relação a concentração quando utilizado antibiótico sistemico?

Pharmacokinetic studies have shown that the local concen­trations of antibiotic achieved are 200 times higher than levels achieved with systemic antibiotic administration.

103

Como preparar a mistura antibiotico/cimento ósseo em relação a quantidade de cada produto?

Currently, most commercially available bone cements have a prepackaged form available with gentamicin (500 mg/40­g pack). We generally add 2 to 4 g of vancomy­cin, with or without 1 g of tobramycin, to each 40­g pack before adding the monomer.

104

Quais são as categorias das substâncias absorvíveis usadas com antibióticos para preenchimento de defeitos ósseos?

The biodegradable substances used as antibiotic delivery systems can be classified into three main categories: proteins, bone grat materials and substitutes, and synthetic polymers.

105

Em relação aos flaps musculares utilizados na perna, quais são os musculos utilizados em cada segmento?

The gastrocnemius muscle is used for defects around the proximal third of the tibia, and the soleus muscle is used for defects around the middle third. A microvascular free muscle transfer is required for defects around the distal third of the tibia.

106

O que é uma transferência microvascular?

A microvascular transfer of tissue may consist of muscle that is covered with a skin graft or a myo­cutaneous, osseous, or osteocutaneous flap.

107

O uso de fixador externo circular sobre uma haste para alongamento ósseo é utilizado para que tamanho de defeito segmentar?

Use of distraction osteogenesis with ring fixation over an intramedullary rod has been used for the treatment of segmental defects of up to 13 cm.

108

O que é a osteomielite esclarosante de Garré?

Sclerosing osteomyelitis is a chronic form of disease in which the bone is thickened and distended but abscesses and seques­tra are absent.

109

Qual a causa da osteomielite esclerosante de Garré?

Its cause is unknown, but it is thought to be an infection caused by a low­grade, possibly anaerobic bacterium.

110

Qual tratamento para osteomielite esclerosante de Garré? Quais são os diagnósticos diferenciais?

No treatment has been predictably helpful, but fenestration of the sclerotic bone and antibiotics are advisable. The condition must be distinguished from osteoid osteoma and Paget disease.

111

Nas fraturas por osteomielite, quais métodos de estabilização são preferencialmente utilizados?

Plates and medullary nails have been used to fix infected fractures, but they should be avoided if possible. External fixation or cast immobilization usually is preferred.

112

Qual população mais acometida pela osteomielite cronica multifocal?

The disease is most common in children, with a peak age of 10 years.

113

Quais são os locais mais comumente afetados pela osteomielite cronica multifocal?

It most often affects the metaphysis of long bones, especially the tibia, femur, and clavicle.

114

Qual é o achado radiografico comum em pacientes com osteomielite cronica multifocal com acometimento na coluna?

Vertebra plana is frequent in patients with this disease.

115

Qual condição pode estar associada a osteomielite cronica multifocal?

Another associated condi­tion is palmar-­plantar pustulosis, which manifests as a pus­tular rash on the soles of the feet and palms of the hands.

116

Quais são os critérios diagnósticos para infecção cronica multifocal?

The following have been proposed as criteria for the diagnosis of CRMO: two or more bone lesions mim­icking osteomyelitis, radiographic and bone scan indings consistent with osteomyelitis, 6 months or more of chronic and relapsing symptoms, failure of response to at least 1 month of appropriate therapy, and a lack of other identifiable cause.

117

Qual o tratamento para osteomielite cronica multifocal?

No efective treatment for CRMO has been found, and if the results of cultures are negative, antibiotic treatment is not indicated.

118

Qual é o germe associado a osteomielite do pé após perfuração?

The association of Pseudomonas osteomyelitis with puncture wounds to the foot is well documented in the literature;

119

Quais são as caracteristicas da osteomielite por anaerobico?

Anaerobic soft tissue infections usually start in injured or ischemic tissue. Frequently, a putrid discharge and gas production are present, and extensive tissue necrosis tends to burrow through subcutaneous and fascial planes. Ana­erobic infections have been frequently associated with diabetic gangrene.

120

Qual é a abordagem cirurgica para osteomielite cronica do calcaneo?

Gaenslen approach through the plantar surface of the heel is indicated for resecting the diseased bone of chronic osteomyelitis.

121

Na abordagem de Gaenslen, a incisão na fascia plantar deve ser realizada entre quais músculos?

Incise the plantar aponeurosis in the plane between the abductor digiti quinti and flexor digitorum brevis muscles.

122

Na osteomielite do ilio, quais doenças os sintomas iniciais podem mimetizar?

Early symptoms may suggest acute appendicitis or pyogenic arthritis of the hip joint.

123

Qual a região de formação de abscesso na osteomielite do pubis e do isquio?

In osteomyelitis of the ischium and pubis, an abscess develops either beneath the external or internal obturator muscles or in the ischiorectal fossa.

124

Osteomielite da tuberosidade isquiática é comum em quais pacientes?

Osteomyelitis of the ischial tuberosity is common in bedridden and paraplegic patients who develop pressure sores with secondary infection, necro­sis, and osteomyelitis.

125

Na osteomielite de metatarso, qual região do osso deve ser preservada na criança?

Resect the entire shaft, but preserve the physis whenever possible in children.

126

Quais cuidados devem ser tomados na ressecção da fibula devido a osteomielite?

The entire fibula can be resected if necessary, but the distal fourth contributes to ankle stability and should be retained whenever possible. If the proximal end is resected, the lateral collateral ligament of the knee and the biceps femoris tendon should be firmly anchored to the tibia.

127

Qual a tecnica utilizada para ressecção da asa do iliaco?

Técnica de Badgley

128

Qual é a porcentagem de malignização secundária de um foco de osteomielite crônica e quais são os tipos histológicos descritos?

The prevalence of malignancy arising from chronic osteomyelitis has been reported to be 0.2% to 1.6%. Most of these are squamous cell carcinoma arising from a sinus track, but reticulum cell carcinoma, fibrosarcoma, and other malig­nancies have been reported.

129

Quais são os fatores de risco para o desenvolvimento de pioartrite?

The risk factors for developing joint sepsis included rheumatoid arthritis, osteoarthritis, a prosthetic joint, low socioeconomic status, intravenous drug abuse, alcoholism, diabetes, previous intraarticular corticosteroid injection, and cutaneous ulcers.

130

Em qual população a pioartrite é mais prevalente? Em qual população a pioartrite é mais sequelante?

Septic arthritis occurs most frequently in adults; however, the most serious sequelae from infection occur in children, especially if a hip joint is involved and treatment has been delayed.

131

Quais são as articulações mais acometidas por pioartrite?

The lower extremity weight-bearing joints are predominantly afected (61% to 79%);

132

Qual metodo diagnostico pode ser utilizado para detecção de coleções intra-articulares?

Ultrasonography, in contrast to radiographs, can be used to detect even small collections of fluid deep in the joints. Non–echo-free efusions from clotted hemorrhagic collections are characteristic of a septic joint.

133

Quais são os organismos comumente isolados, por idade e fator de risco?

CLINICAL FACTOR
PATIENT AGE
Neonate = SA
2 yr = SA
Young adults (healthy, sexually active) = NG
Elderly adults = SA (50%), strepto, bacilo-GN

STRUCTURAL ABNORMALITIES
Aspiration or injection Trauma = SA

PROSTHESIS
Early infection = S. epidermidis
Late infection = cocco-GP, anaerobios

MEDICAL CONDITIONS
Injecting drug use = bacilo GN atipico (pseudomonas)
Rheumatoid arthritis = SA
Systemic lupus erythematosus, sickle cell anemia = Salmonela
Hemophilia = SA (50%), strepto, bacilo-GN
Immunosuppression = SA, micobacteria, fungos

134

Como é a patogenese da pioartrite?

Why joints are afected and other vulnerable organs are not is unclear; however, collagen receptors found on Staphylococcus aureus (the most common nongonococcal infecting cause of hematogenous septic arthritis) may play a role. Also, the lack of a limiting basement membrane in the capillaries of synovium may allow intravascular bacteria to reach the extravascular space of synovial tissue through gaps between capillary endothelial cells. In addition, synovial fibroblasts inhibit phagocytosis of bacteria.

135

Na pioartrite, em quanto tempo ocorre a destruição articular total?

Complete destruction of articular cartilage occurs at approximately 4 weeks.

136

Como é a pioartrite por N. gonorrhea?

Often the infection is polyarticular and may be associated with a papular rash. Gonococcal arthritis generally has a favorable outcome if treated with appropriate antibiotics, and drainage usually is unnecessary.

137

Quais são os princípios de manejo das pioartrites?

The principles in the management of acute septic arthritis include (1) adequate drainage of the joint, (2) antibiotics to diminish the systemic efects of sepsis, and (3) resting the joint in a stable position.

138

Quais valores de leucócitos e porcentagem de PMN presente no aspirado articular indicam pioartrite?

Typically, synovial leukocyte counts greater than 50,000/mm3 indicate infectious arthritis; leukocyte counts of 28,000/mm3 or less have been implicated, especially in immunocompromised patients. In addition to the total leukocyte count, the proportion of polymorphonuclear neutrophils, if greater than 90%, indicates infection.

139

Quais pioartrites devem ser abordadas cirurgicamente?

Except for gonococcal arthritis, which usually can be treated efectively with antibiotics, drainage should be performed for all other infectious arthritis.

140

Após a resolução do quadro infeccioso, como deve ser realizado a reabilitação do paciente com pioartrite?

As the infection resolves, therapy to restore normal joint function is begun, including functional splinting initially to prevent deformity, isometric muscle strengthening, and active range-of-motion exercises.

141

Qual a região para puncionar a articulação do tornozelo?

To avoid injuring important structures, the needle is inserted 2.5 cm proximal and 1.3 cm anterior to the tip of the lateral malleolus. This is just lateral to the peroneus tertius tendon.

142

Quais são as vias de acesso para drenagem da articulação do tornozelo? Qual delas é a mais segura?

Anterolateral, anteromedial, posterolateral, and posteromedial. The posterolateral approach has proved safer and more efective than any other approach.

143

Qual é a articulação mais acometida por pioartrite?

The knee joint is the most frequently afected.

144

Qual a região de punção da articulação do joelho?

The needle is inserted on the lateral side at the level of the superior pole of the patella. It is advanced through the lateral retinaculum and into the joint.

145

Quais são as vias de acesso para drenagem da articulação do joelho?

In acute septic arthritis, usually anteromedial arthrotomy or arthroscopic drainage and antibiotic treatment are adequate. If the posterior compartment of the knee is distended, and a popliteal abscess is well established, parallel anterior incisions combined with posterolateral and posteromedial (Henderson) incisions usually are best. If possible, posterior drainage should be avoided because the infection may spread through the fascial planes of the thigh and leg. A posterior midline approach should not be used to drain an infected knee because it exposes the popliteal vessels to pus and to pressure from the drain and creates a potentially contracting scar across the joint.

146

Qual é o metodo de escolha para debridamento do joelho em adultos?

Arthroscopic drainage is the preferred treatment for acute septic arthritis of the knee in adults.

147

Qual é a vantagem da via de Klein para drenagem do compartimento posterior do joelho?

Klein’s approach to the posteromedial aspect of the joint takes advantage of the fact that the bursae between the semimembranosus tendon and the medial head of the gastrocnemius muscle often communicate with the knee joint. Consequently, an incision into these bursae often leads directly into that joint.

148

Qual é a posição que o quadril deve ser imobilizado após drenagem?

After an infected hip in an infant or child has been surgically drained, the hip should be supported in abduction to reduce the risk of pathological dislocation.

149

Qual articulação mais comumente desenvolve pioartrite bilateral?

Bilateral septic arthritis is seen more oten in the hip than in other joints and occasionally is associated with spinal infection.

150

Quais são as vias para puncionar o quadril?

A lateral, anterior, or medial approach can be used to aspirate the hip joint.

151

Como é descrita a tecnica para punção lateral do quadril?

Insert the needle at a 45-degree angle with the surface of the thigh just inferior and anterior to the greater trochanter. Advance the needle medially and proximally close to the bone for 5 to 10 cm, depending on the size of the patient, and into the joint.

152

Como é descrita a tecnica de punção anterior do quadril?

Palpate the femoral artery in line with the inguinal ligament. Insert the needle 2.5 cm lateral and 2.5 cm distal to this point at a 45-degree angle to the skin surface. Advance the needle 5 to 7.5 cm medially and proximally into the joint.

153

Como é a tecnica de punção medial do quadril?

Flex and abduct the leg; this is usually a more comfortable position for patients with septic arthritis. Place the needle inferior to the adductor longus tendon, and using image intensification, advance it in a plane below the palpated femoral artery until the femoral head or neck is reached. Aspirate the joint.

154

Quais são as vias de acesso para drenagem do quadril? Qual é a preferível nas crianças? Qual é a preferível nos adultos?

Drainage of the hip may be accomplished through a posterior, medial, lateral, or anterior approach. The anterior approach is preferred in small children for several reasons: (1) damage to the major blood supply to the femoral head is avoided, (2) the chance of postoperative dislocation is reduced, and (3) the landmarks for the surgical approach are much clearer in a small child. In an adult, the posterior approach allows dependent drainage and is a more familiar approach for most orthopaedic surgeons.

155

Como é chamada a tecnica de drenagem por via posterior do quadril?

Ober

156

Como é chamada a via de drenagem medial do quadril?

Ludloff

157

A via anterior de drenagem do quadril é desenvolvida entre quais músculos?

Expose the sartorius muscle on the medial side and the tensor fasciae latae and vastus lateralis muscles on the lateral side. Use blunt dissection to separate these muscles.

158

A luxação patológica do quadril após pioartrite ocorre geralmente em qual população?

Pathological dislocation occurs predominantly in children.

159

Qual movimento deve ser realizado para reduzir um quadril patológico por pioartrite?

The dislocation is reduced by abduction and gentle rotation;

160

Quais desfechos pode ter a cabeça femoral de um paciente com pioartrite de quadril em crianças

If osteomyelitis results in sequestration of the femoral head in children younger than 12 years old, however, the head may be totally reabsorbed, or it may be replaced by new bone after its circulation is restored.

161

O que pode ocorrer se um abscesso pélvico for drenado por baixo do ligamento inguinal?

Drainage above the inguinal ligament is not advised because a fecal istula may result, and the abscess cannot be thoroughly evacuated.

162

Quais são os resultados da ressecção do quadril pela tecnica de Girdlestone?

This operation may result in a nearly useless pseudarthrosis or ankylosis. Marked shortening of the afected extremity results. For these reasons, this operation is a last resort.

163

Como é a via de acesso na ressecção do quadril pela técnica de Girdlestone?

Begin a transverse incision 2.5 cm posterior and distal to the anterior superior iliac spine, and extend it laterally until the center of the incision is about 2.5 cm proximal to the greater trochanter.

164

Como é a técnica de Klein para tratamento de osteomielite do quadril em pacientes paraplégicos?

Klein et al. described a technique for the treatment of chronic sepsis of the hip in paraplegic patients; it consists of three separate measures to control the infection: (1) a Girdlestone procedure, (2) transposition of the vastus lateralis muscle into the void let by the removal of the femoral head and neck and acetabular wall, and (3) external fixation to prevent unrestrained motion of the femoral shaft that might damage the transposed muscle. The external fixator spans the hip joint with a posterior pelvic-femoral frame.

165

Qual é o exame mais sensível para diagnóstico de pioartrite da sacroiliaca?

The most sensitive diagnostic study is CT.

166

Como é realizado a punção da articulação sacroiliaca?

An 18-gauge spinal needle is introduced in the midline at the level of the sacroiliac joint at a 45-degree angle with the transverse plane and at a 30-degree angle with the sagittal plane. The needle is passed laterally and distally at these angles, and image intensification is used to guide it into the sacroiliac joint 0.5 cm from its most inferior margin.

167

A pioartrite esternoclavicular e acromioclavicular geralmente está associada a quais eventos?

Usually the sternoclavicular and acromioclavicular joints are afected only when acute septic arthritis involves other joints or in heroin addicts.

168

Como é realizada a punção articular do ombro?

he shoulder may be aspirated anteriorly, posteriorly, or later- ally. Because the luctuant area usually is palpable anteriorly, and the bony landmarks can be identiied more easily, the needle is inserted here most often. The aspiration site is located half the distance between the coracoid process and the anterolateral edge of the acromion. The needle is directed posteriorly through the joint capsule, and the joint is aspirated.

169

Quais são as vias de acesso para drenagem do ombro?

The shoulder may be drained through an anterior incision or a posterior incision, but the anterior incision is preferable.

170

Como é a via de acesso para a drenagem anterior do ombro?

Begin an anterior longitudinal incision at the anterior border of the acromion, and extend it 5 to 7.5 cm over the center of the humeral head.

171

Como é a via de acesso para a drenagem posterior do ombro?

Begin the incision at the base of the spine of the scapula, and extend it distally and laterally for 7.5 cm in line with the fibers of the deltoid muscle.

172

Para quais casos a drenagem de pioartrite do ombro por artroscopia está indicada?

Arthroscopic drainage should be reserved for treatment of septic arthritis early in the disease process, particularly before 2 weeks of onset of Gächter stage I or II infections. Loculations and adhesions can be débrided, and a synovectomy can be done.

173

Como Gächter definiu os estágios de infecção?

Stage I: Opacity of fluid, redness of the synovial membrane, possible petechial bleeding, no radiographic alterations.

Stage II: Severe inflammation, fibrinous deposition, pus, no radiological alterations.

Stage III: Thickening of the synovial membrane, compartment formation, no radiological alterations.

Stage IV: Aggressive pannus with infiltration of the cartilage, undermining the cartilage, radiological signs of subchondral osteolysis, possible osseous erosions and cysts.

174

Como é realizado a punção articular do cotovelo?

For elbow aspiration, the physician flexes the elbow and inserts the needle on its posterior aspect just lateral to the olecranon. The needle is advanced through the skin and joint capsule, and the joint is aspirated.

175

Quais são os locais de punção articular do punho?

Aspiration is performed on the dorsal side of the wrist. Several aspiration sites on the dorsum of the wrist can be used. The most common site of aspiration is between the first and second extensor compartments at the radiocarpal level, immediately adjacent to the point where the extensor pollicis longus crosses the extensor carpi radialis longus. Other aspiration sites are between the third and fourth extensor compartments or between the fourth and ith extensor compartments.

176

A drenagem do punho por uma via lateral é feita entre quais músculos?

Make a longitudinal incision 5 cm long between the abductor pollicis longus and extensor pollicis brevis tendons volarly and the extensor pollicis longus tendon dorsally.

177

A drenagem do punho por uma via medial é realizada entre quais músculos?

Make an incision 5 cm long over the ulnar head between the tendons of the flexor and extensor carpi ulnaris. Avoid injuring the dorsal branch of the ulnar nerve.

178

A drenagem da articulação do punho por via dorsal pode ser realizada entre quais músculos?

Make a dorsal longitudinal incision 5 cm long between the extensor pollicis longus and extensor indicis proprius tendons or between the extensor carpi ulnaris and extensor digiti quinti proprius tendons.

179

Como tratar as deformidades do tornozelo após infecção?

When the ankle is fixed in equinus by soft tissue contracture, treatment by Quengel casting or serial wedged casts or by operations such as lengthening of the Achilles tendon with or without posterior capsulotomy generally are efective in restoring plantigrade position of the foot. When fixed equinus is caused by bony ankylosis, cuneiform osteotomy through the joint is indicated.

180

Como corrigir as deformidades do joelho após quadro de infecção?

Soft tissue flexion contractures of the knee can be managed by Quengel or serial wedged casts or may require soft tissue operations. A flexion deformity can be corrected indirectly by a supracondylar osteotomy that causes a compensatory deformity in the opposite direction. This operation should be considered when the flexion deformity is not severe but the joint is unsuitable for manipulation or soft tissue release. In children, the osteotomy should be made well proximal to the physis.

181

Quando está indicada alongamento dos tendões do jarrete nas cirurgias de correção de deformidades do joelho?

If the flexion contracture is greater than 45 degrees, the hamstring tendons should be lengthened before the osteotomy.

182

Quais são os tipos de osteotomias supracondilares do femur usadas para correção da contratura em flexão do joelho?

Tranversa, V-osteotomy (Thompson), cuneiforme (base anterior) e controlled rotational osteotomy (Osgood).

183

Quando está indicada a osteotomia para correção do joelho contraturado em flexo?

Femoral osteotomy is indicated when a functional range of flexion remains beyond the flexion contracture. The osteotomy should be made as near the joint as possible. Full extension can be regained by this operation, but the preoperative range of lexion may be reduced.

184

Quais são os fatores de pior prognóstico para pioartrite do quadril em crianças? Qual deles é o mais importante?

Poor prognostic factors related to septic arthritis of the hip in infants, including (1) an infection that occurred before 22 weeks of age, (2) prematurity, and (3) symptoms that lasted longer than 4 days. The most important factor was delay in diagnosis.

185

A morbidade de um quadril que sofreu de pioartrite está relacionado a quais fatores?

Dor, rigidez, deformidade e instabilidade.

186

Quais são os motivos para atrasar a correção de deformidade do quadril pós pioartrite?

The reasons for this delay are as follows: (1) the danger of reactivating the old infection is reduced; (2) the status of the proximal femur and femoral head should be deinitely determined in children because early radiographs may show what appears to be destruction of the proximal femur with separation and osteonecrosis of the femoral head epiphysis, only to show satisfactory reconstitution on later films; and (3) the strength and general character of the bone improve with time, especially in children, as necrotic bone is revascularized, and abscess cavities are filled in, increasing the likelihood of success after reconstructive surgery.

187

Quais artroplastias podem ser realizadas em pacientes pós piorartrite de quadril com anquilose?

Interposition or cup arthroplasty still may be useful in younger patients with an ankylosed hip. Total hip arthroplasty should be considered only for older patients.

188

Quais procedimentos podem ser realizados para estabilização do quadril?

The hip may be stabilized after acute septic arthritis by (1) arthrodesis, (2) pelvic osteotomy, (3) proximal femoral osteotomy, (4) trochanteric arthroplasty (Colonna) combined with proximal femoral osteotomy, and (5) Harmon or L’Episcopo reconstruction.

189

Qual a proposta da reconstrução L’Episcopo ou Harmon?

In the L’Episcopo or Harmon reconstruction, a new femoral neck is fashioned to articulate with the acetabulum. These operations are useful for young children in whom the femoral head and neck have been absorbed.

190

Como tratar uma contratura em flexão e adução do quadril? E em casos de anquilose?

A flexion and adduction contracture is treated by transferring the crest of the ilium and, when necessary, by an adductor tenotomy. A hip ankylosed in flexion and adduction is treated by intertrochanteric osteotomy, as described here, fixing the hip in neutral rotation, 0 degrees of flexion, and 20 to 30 degrees of abduction (in children). In adults, 25 degrees of flexion and neutral abduction is the best position.

191

Quais são os tipos de osteotomias intertrocantericas para anquilose em flexão e adução do quadril?

a transverse opening wedge osteotomy, a transverse closing wedge osteotomy, or the Brackett ball-and- socket osteotomy.

192

Quais são os prós e contras da osteotomia de abertura intertrocantérica?

The transverse opening wedge osteotomy is simple, and it lengthens the extremity; however, bony apposition is limited, union is delayed in adults, and it is initially unstable.

193

Quais são os prós e contras da osteotomia intertrocantérica de fechamento?

The transverse closing wedge osteotomy provides good bony apposition and is stable; however, it shortens the extremity.

194

Quais são os prós e contras da osteotomia intertrocantérica de Brackett (bola e soquete)?

The Brackett osteotomy achieves stability without shortening the extremity; however, extensive dissection is required. In severe biplane deformities, an accurate and stable osteotomy is difficult to perform.

195

Quais são as populações com risco de contaminação por tuberculose?

Populations most at risk include individuals with acquired immunodeficiency syndrome (AIDS) or other immunodeficiencies, patients with chronic renal failure, substance abusers, homeless or incarcerated individuals, and immigrants from developing countries.

196

Qual a porcentagem de TB extra-pulmonar? Desses, quantos % são de comprometimento osseo?

Extra­ pulmonary involvement is noted in approximately 14% of patients, with 1% to 8% having osseous disease.

197

Qual a taxa de TB vertebral nos pacientes com TB óssea?

Approxi­mately 50% of patients with osseous tuberculosis have pulmonary involvement, and 30% to 50% of patients with osseous disease have vertebral involvement, most often in the lower thoracic spine.

198

Quais são as regiões do esqueleto apendicular geralmente afetadas por TB?

Less frequently observed appendicular involvement usually afects major weight-­bearing joints of the lower extremity, most commonly the hip and knee, followed in frequency by the foot, elbow, and hand.

199

Como é envolvimento regional da TB vertebral?

Usually, active spinal lesions involve a particular segment: two vertebral bodies and the corresponding disc. Some authors have speculated that these areas are afected most oten because of the generous arterial and venous supply and the high oxygen pressure requirement of the tuberculosis bacilli.

200

Como é geralmente a apresentação ossea da TB no corpo vertebral?

A peridiscal presentation occurs in approximately 80% of patients, with the anterior vertebral body afected and contiguous progression through subligamentous burrowing (anterior longitudinal ligament) and eventual extension to the adjacent vertebrae. Less frequently, lesions occur centrally in the vertebral body.

201

Quais são as manifestações clinicas da TB na coluna vertebral?

Patients may have intramedullary granu­lomas, arachnoiditis, segmental collapse with anterior wedging, and gibbus formation (Pott disease). The posterior elements of the spine are rarely the only sites afected.

202

Quais são as características da TB na tomografia?

Calcifications (best seen on CT) within paraspinous abscesses indicate bone destruction and are characteristic of spinal tuberculosis.

203

Quais são os ossos mais envolvidos nos casos de TB do pé?

When present, isolated lesions usually involve the cal­caneus or talus.

204

Quais são os tratamentos propostos para TB nos pés?

When several bones are involved, especially in adults, amputation is the procedure of choice. Curettage is indicated for isolated lesions even when sinuses are present. When lesions involve the subtalar or midtarsal joints, a triple arthrodesis is indicated. When the subtalar and the ankle joints are afected, posterior arthrod­esis of these joints can be done. Involvement of a phalanx or metatarsal often is best treated by excision.

205

Como é o tratamento para TB no joelho?

A knee with a normal­ appearing radiograph or with mildly confined osteomyelitic changes frequently responds to multidrug chemotherapy. These patients usually tolerate early range­-of-­motion and mobiliza­tion procedures. If a patient does not respond adequately to chemotherapy alone, a synovectomy (at times performed arthroscopically), sequestrectomy, or both or curettage of the bony lesion may be required.

206

Como tratar TB no quadril?

If tuberculosis of the hip is diagnosed early, and the disease is limited to the synovium, rest and chemotherapy may be suficient treatment. This situation is more common in chil­dren. If the lesion extends to articular cartilage and bone, and is not extensive, partial synovectomy and curettage oten are successful. If articular cartilage and adjacent bone are extensively involved, arthrod­esis is indicated.

207

Qual região do cotovelo é mais acometida por TB?

The proximal segment of the ulna (olecranon) is more typically afected, which can result in a progressive degenerative process and a significant elbow flexion contracture. Functional positioning becomes paramount in such cases.

208

Qual o aspecto radiológico da TB nos ossos longos e qual o tratamento de escolha?

Radiographs may show a solitary irregular cavity, a series of confluent cavities, or occasionally fusiform enlargement of the shaft. Multiple bones may be involved simultaneously. Effective treatment requires chemotherapy plus evacua­tion of abscesses and sequestrectomies, an operative treat­ment similar to that for chronic pyogenic osteomyelitis. Wounds in tuberculous osteomyelitis can be closed primarily, however, unless secondary pyogenic infection is present.

209

Qual animal está associado à brucelose?

Cabra

210

Qual o local de comprometimento de brucelose ossea?

The worldwide literature indicates that the axial skeleton is the most likely site of osteoarticular involvement, normally occurring as sacroiliitis, spondylitis, or spondylodiscitis. The frequency of a lumbar pathological process was significantly higher than thoracic or cervical ones, with cervical disorders the least frequent.

211

Qual é o tratamento para brucelose ossea?

A 6­-month three-­drug course of rifampin, doxycycline, and streptomycin is recommended for patients with osteo­ articular involvement.

212

Qual região do esqueleto é mais frequentemente afetada pela febre tifóide?

More frequently, the thoracolumbar junction is afected, with accompanying disc involvement.

213

Quais são as alterações músculo-esqueléticas encontradas na sífilis congênita?

In congenital syphilis, periostitis of the temporal bone and palate and cortical thickening of the upper one half of the tibia (“saber shins”) may be seen. Chronic arthralgias may develop and because of neuropathic or vascular involve­ment may lead to the development of a “Charcot joint.”

214

Quais são os picos de incidencia da doença de Lyme?

Two peak age groups are more commonly afected with the disease: children ages 5 to 14 years and adults ages 55 to 70 years.

215

Como é a apresentação clinica da doença de Lyme?

Most patients with Lyme disease present with a charac­teristic bull’s­ eye rash (erythema migrans) within 1 month of the tick bite, although up to 20% of patients may not display this associated rash. Normally, the rash is accompanied by viral­-like symptoms of fever, chills, fatigue, and headaches. Arthralgia, usually polyarthralgia involving both large and small joints and potentially the neck and back, typically accompanies the viral­-like symptoms and characteristic bull’s ­eye rash.

216

Quais são as articulações mais envolvidas na doença de Lyme?

The knee is the most commonly involved joint, fol­lowed by the ankle and wrist.

217

Qual fator está relacionado ao desenvolvimento da doença de Lyme crônica?

Having the alloantigen HLA­-DR4 increases the risk of developing chronic arthritis.

218

Qual local do sistema musculo-esqueletico é mais acometido pela coccidioidomicose?

The axial skeleton is more commonly afected than the appendicular skeleton, and the vertebral column is the most susceptible location of bony involvement for the disease. Joint infections are more likely to be seen in the lower extremities, especially the knee.

219

Qual é a característica da blastomicose ossea?

In a long bone, the infection tends to localize in the epiphysis and extend into the adjacent joint. Lesions in vertebrae mimic tuberculosis.

220

Como é a apresentação clínica da esporotricose?

While a suppurative granulomatous lesion with an ulcerated appearance develops on the skin, there may be lymph, hematoge­nous, or contiguous spread to other structures. This disease can afect the bones, joints, and periarticular soft tissues. Joint spaces may narrow, and eventual subchondral bone demise may occur. Serological tests are useful, as are fungal cultures; however, they are not that sensitive.

221

Qual é o tratamento de escolha para doença de Lyme?

doxycycline

222

Qual é o tratamento de escolha para esporotricose?

Operative intervention may include débridement and chemotherapy with amphotericin.

223

Quais são os ossos mais comumente afetados pela equinococose?

The most commonly afected areas in bone are the vertebrae, pelvis, and the skull. The best treatment for a bone infection resulting from echinococcosis is to resect the involved bone or to amputate. In suspected cases of echinococcosis, diagnostic biopsy or aspiration is contraindicated.