musculoskeletal disorders part 2 bone infections

8/2/2019 Musculoskeletal Disorders Part 2 Bone Infections

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MMusculoskeletal Disorders Part 2usculoskeletal Disorders Part 2Bone infectionsBone infections

Maria Carmela L. Domocmat, RN,MSN

Instructor

School of NursingNorthern Luzon Adventist College

Artacho, Sison, Pangasinan


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OverviewOverview Part 1: Degenerative & Metabolic bone

disorders: Part 2: Bone infections

Osteomyelitis

ep c ar r s Part 3: Muscular disorders

Part 4: Disorders of the hand

Part 5: Spinal column deformities Part 6 : Disorders of foot

Part 7: Sports Injuries

3/5/2012 Maria Carmela L. Domocmat, RN, MSN 2


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BONE INFECTIONSBONE INFECTIONS

Osteomyelitis

Septic arthritis



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BONE INFECTIONS:BONE INFECTIONS:



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OsteomyelitisOsteomyelitis


Osteomyelitis is infection in the bones. Often, the original site of

infection is elsewhere in the body, and spreads to the bone by the

blood. Bacteria or fungus may sometimes be responsible for

osteomyelitis.


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OsteomyelitisOsteomyelitis Infection of the bone, most often of the

cortex or medullary portion. Is commonly caused by bacteria, fungi,

arasites & viruses.


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OsteomyelitisOsteomyelitis Classified by mode of entry- Contiguous

or exogenous is caused by a pathogenfrom outside the body or the by the

s read of infection from adjacent soft

tissues. The organism is Staph aureus.

Example- pathogens from open fracture. The onset is insidious: initially cellulites

progressing to underlying bone.


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OsteomyelitisOsteomyelitis Hematogenous- caused by bloodborne

pathogens originating from infectious siteswithin the body.

Ex: sinus, ear, dental, respiratory & GUinfections.

The infection spreads from the bone tothe soft tissues & can eventually breakthrough the skin, becoming a draining

fistula. Again, Staph aureus is the most common

causative organism.


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S/sS/s Acute Osteomyelitis left untreated or

unresolved after 10 days is consideredchronic.

Necrotic bone is the distinguishing

eature o c ron c osteomye t s.


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SymptomsSymptoms Bone pain Fever General discomfort, uneasiness, or ill-feeling

(malaise) Other symptoms that may occur with this

disease: Chills Excessive sweating Low back pain Swelling of the ankles, feet, and legs



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PathophysiologyPathophysiology similar to that infectious processes in any

other body tissue.

Bone inflammation is marked by edema,increased vascularity & leukocyte activity.

ever, ma a se, anorex a, ea ac e. affected body may be erythematous, tender,

& edematous. There may be fistula draining

purulent material. Blood test- increase WBCs, ESR, & C-protein

levels.


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Causes, incidence, and riskCauses, incidence, and risk

factorsfactors Bone infection can be caused by bacteria

(more common) or fungi (less common). Infection may spread to a bone from

infected skin muscles or tendons next to

the bone, as in osteomyelitis that occursunder a chronic skin ulcer (sore).



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factorsfactors The infection that causes osteomyelitis

can also start in another part of the bodyand spread to the bone through the

blood.

A current or past injury may have madethe affected bone more likely to develop

the infection.



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factorsfactors A bone infection can also start after bone

surgery, especially if the surgery is doneafter an injury or if metal rods or plates

are laced in the bone.

children -- long bones usually affected.

Adults -- feet, vertebrae, and pelvis are

most commonly affected.



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Risk factorsRisk factors Diabetes

Hemodialysis Injected drug use

Recent trauma

People who have had their spleen

removed are also at higher risk forosteomyelitis



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OsteomyelitisOsteomyelitis Osteomyelitis of

diabetic foot

Osteomyelitis of T10

secondary tostreptococcal

disease.



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OsteomyelitisOsteomyelitis Osteomyelitis of the

great toe

Osteomyelitis of

index fingermetacarpal head

secondary to

c enc e st n ury



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OsteomyelitisOsteomyelitis Osteomyelitis of

index fingermetacarpal head

secondary to

Osteomyelitis of the

elbow.

c enc e st n ury.



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DxDx teststests A physical examination shows bone tenderness

and possibly swelling and redness.

Tests may include: Blood cultures

Bone biopsy (which is then cultured)

one scan

Bone x-ray

Complete blood count (CBC)

C-reactive protein (CRP)

Erythrocyte sedimentation rate (ESR)

MRI of the bone

Needle aspiration of the area around affected bones



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DxDx teststests Diagnosis requires 2 of the 4 following

criteria: Purulent material on aspiration of affected

bone

Positive findings of bone tissue or bloodculture

Localized classic physical findings of bony

tenderness, with overlying soft-tissueerythema or edema

Positive radiological imaging study


http://emedicine.medscape.com/article/785020-treatment


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Emergency Department CareEmergency Department Care Select the appropriate antibiotics using direct

culture results in samples from the infected site,

whenever possible.

Further surgical management may involve

remova o t e n us o n ect on, mp antat onof antibiotic beads or pumps, hyperbaric oxygen

therapy,or other modalities.


http://emedicine.medscape.com/article/785020-treatment

Nidus: a nest; A central point or focus of bacterial growth in a living organism.

the point of origin or focus of a disease process.


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TreatmentTreatment Treatment is difficult & costly.

Goal of treatment complete removal of necrotic bone & affected

soft tissue

control of infection & elimination of deadspace (after removal of necrotic bone).


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TreatmentTreatment The primary treatment for osteomyelitis

parenteral (IV) antibiotics that penetratebone and joint cavities for at least 4-6 weeks.

After intravenous antibiotics are initiated on

an inpatient basis, therapy may be continuedwith intravenous or oral antibiotics, depending

on the type and location of the infection, on

an outpatient basis.



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AntibioticsAntibiotics Nafcillin (Nafcil, Unipen)

Ceftriaxone (Rocephin) Cefazolin (Ancef)

Ceftazidime (Fortaz, Ceptaz)

Clindamycin (Cleocin)

Vancomycin (Vancocin)

Linezolid (Zyvox)



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TreatmentTreatment Surgery

to remove dead bone tissue if have aninfection that does not go away.

If there are metal plates near the infection,

they may need to be removed. The open space left by the removed bone

tissue may be filled with bone graft or packing

material that promotes the growth of newbone tissue.



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TreatmentTreatment Infection of an orthopedic prosthesis,

such as an artificial joint, may needsurgery to remove the prosthesis and

infected tissue around the area.

If have diabetes- need to be wellcontrolled.

If problems with blood supply to theinfected area, such as the foot, surgery to

improve blood flow may be needed.



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Nursing managementNursing management use of aseptic technique during dressing

changes. Observed for S/S of systemic infection, &

.

ROM exercises are encouraged to

prevent contractures & flexion

deformities & participation in ADL to thefullest extent is encouraged.


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Expectations (prognosis)Expectations (prognosis) markedly improved with timely diagnosis

and aggressive therapeutic intervention. The outlook is worse for those with long-

term chronic osteom elitis even with

surgery. Amputation may be needed, especially in

those with diabetes or poor blood circulation.



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Expectations (prognosis)Expectations (prognosis) The outlook for those with an infection

of an orthopedic prosthesis depends, inpart, on:

The atient's health

The type of infection Whether the infected prosthesis can be safely

removed



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ComplicationsComplications Bone abscess

Paravertebral/epidural abscess Bacteremia

Loosening of the prosthetic implant

Overlying soft-tissue cellulitis

Draining soft-tissue sinus tracts



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ComplicationsComplications When the bone is infected, pus is produced

in the bone, which may result in an abscess. The abscess steals the bone's blood supply.

The lost blood supply can result in a

complication called chronic osteomyelitis. Other complications include:

Need for amputation

Reduced limb or joint function

Spread of infection to surrounding tissues or the

bloodstream



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PreventionPrevention Prompt and complete treatment of

infections is helpful. People who are athigh risk or who have a compromised

immune s stem should see a health care

provider promptly if they have signs of aninfection anywhere in the body.



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Deterrence/PreventionDeterrence/Prevention Acute hematogenous osteomyelitis

can potentially be avoided by preventingbacterial seeding of bone from a remote site.

This involves the appropriate diagnosis and

treatment of primary bacterial infections.



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Deterrence/PreventionDeterrence/Prevention Direct inoculation osteomyelitis

can best be prevented with appropriatewound management and consideration of

prophylactic antibiotic use at the time of

injury.



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SEPTIC ARTHRITISSEPTIC ARTHRITIS



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Septic arthritisSeptic arthritis Septic arthritis is inflammation of a

joint due to a bacterial or fungal infection. AKA:

Bacterial arthritis

Non-gonococcal bacterial arthritis



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CausesCauses Septic arthritis develops when bacteria or

other tiny disease-causing organisms(microorganisms) spread through the

bloodstream to a joint. It ma also occur

when the joint is directly infected with amicroorganism from an injury or during

surgery.



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CausesCauses most common sites - knee and hip.

acute septic arthritis bacteria such as staphylococcus or

stre tococcus.

chronic septic arthritis less common

caused by organisms such asMycobacterium

tuberculosisand Candida albicans.



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Risk factorsRisk factors Artificial joint implants Bacterial infection somewhere else in your

body Chronic illness or disease (such as

diabetes, rheumatoid arthritis, and sickle cell

disease) Intravenous (IV) or injection drug use Medications that suppress your immune

system Recent joint injury Recent joint arthroscopy or other surgery



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Risk factorsRisk factors seen at any age.

Children occurs most often in those younger than 3

years.

The hip is often the site of infection in infants.

uncommon from age 3 to adolescence.

Children - more likely than adults infected

with Group Bstreptococcus or Haemophilus influenza, ifthey have not been vaccinated.



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SymptomsSymptoms Symptoms usually come on quickly.

Feverjoint swelling - usually just one joint.

-

movement.



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Symptoms in newborns or infants:Symptoms in newborns or infants: Cries when infected joint is moved

(example: diaper change causes crying ifhip joint is infected)

Fever

Inability to move the limb with theinfected joint (pseudoparalysis)

Irritability



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Symptoms in children and adults:Symptoms in children and adults: Inability to move the limb with the

infected joint (pseudoparalysis) Intense joint pain

Joint redness

Low fever

Chills may occur, but are uncommon



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Exams and TestsExams and Tests Aspiration of joint fluid for cell count,

examination of crystals under themicroscope, gram stain, and culture

Blood culture

X-ray of affected joint



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TreatmentTreatment Antibiotics are used to treat the infection.

Joint Immobilization and Physical Therapy Resting, keeping the joint still, raising the joint,

and usin cool com resses ma hel relieve

pain. Exercising the affected joint helps the

recovery process.



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TreatmentTreatment Arthrocentesis

If synovial fluid builds up quickly due to theinfection, a needle may be inserted into the

joint often to aspirate the fluid.

Severe cases may need surgery to drainthe infected joint fluid.



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TreatmentTreatment Medical management of infective arthritis

focuses adequate and timely drainage of the infected

synovial fluid,

administration of appropriate antimicrobialtherapy

immobilization of the joint to control pain.



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Antibiotic TherapyAntibiotic Therapy In native joint infections, parenteral antibiotics - at least 2

weeks.

Infection with either methicillin-resistant S aureus (MRSA) or

methicillin-susceptible S aureus (MSSA) - at least 4 full weeksIV antibiotic therapy.

Orally administered antimicrobial agents are almost never.

Gram-negative native joint infections with a pathogen that issensitive to quinolones can be treated with oral ciprofloxacinfor the final 1-2 weeks of treatment.

As a rule, a 2-week course of intravenous antibiotics issufficient to treat gonococcal arthritis.



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AntibioticsAntibiotics linezolid with or without rifampin - for

staphylococcal prosthetic joint infection (PJI).

Ceftriaxone (Rocephin)

drug of choice (DOC) against N gonorrhoeae.

This agent is effective against gram-negativeenteric rods.

Monitor sensitivity data.

Ciprofloxacin (Cipro) alternative antibiotic to ceftriaxone to treat N

gonorrhoeae and gram-negative enteric rods.



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AntibioticsAntibiotics Cefixime (Suprax)

a third-generation oral cephalosporin withbroad activity against gram-negative bacteria.

Oral cefixime is used as a follow-up to

intravenous (IV) ceftriaxone to treat Ngonorrhoeae.

Oxacillin

useful against methicillin-sensitive S aureus(MSSA).



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AntibioticsAntibiotics Vancomycin (Vancocin)

anti-infective agent used against methicillin-

sensitive S aureus (MSSA), methicillin-resistantcoagulase-negative S aureus (CONS), and

-

allergic to penicillin. Linezolid (Zyvox)

an alternative antibiotic that is used in

patients allergic to vancomycin and for thetreatment of vancomycin-resistantenterococci.


http://emedicine.medscape.com/article/236299-

medication#showall

Joint Immobilization andJoint Immobilization and


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Physical TherapyPhysical Therapy Usually, immobilization of the infectedjoint to control pain is not necessary after

the first few days. If the patient's condition responds

a equate y a ter ays o treatment,begin gentle mobilization of the infected

joint.

Most patients require aggressive physicaltherapy to allow maximum postinfectionfunctioning of the joint.




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Physical TherapyPhysical Therapy Initial physical therapy consists of

maintaining the joint in its functional

position and providing passive ROMexercises.

e o nt s ou ear no we g t unt t eclinical signs and symptoms of synovitishave resolved.

Aggressive physical therapy is oftenrequired to achieve maximum therapybenefit.



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Synovial Fluid DrainageSynovial Fluid Drainage The choice of the type of drainage, whether

percutaneous or surgical, has not been

resolved completely. In general, use a needle aspirate initially,

repeating joint taps frequently enough toprevent signi icant reaccumu ation o ui .

Aspirating the joint 2-3 times a day may benecessary during the first few days.

If frequent drainage is necessary, surgical

drainage becomes more attractive. Gonococcal-infected joints rarely require

surgical drainage.



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Synovial Fluid DrainageSynovial Fluid Drainage Surgical drainage is indicated when one or more

of the following occur:

The appropriate choice of antibiotic and vigorouspercutaneous drainage fails to clear the infection after5-7 days

e in ecte joints are i icu t to aspirate eg, ip

Adjacent soft tissue is infected

Routine arthroscopic lavage is rarely indicated.However, drainage through the arthroscope is

replacing open surgical drainage. With arthroscopicdrainage, the operator can visualize the interior of thejoint and can drain pus, debride, and lyse adhesions.



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Surgical Intervention inSurgical Intervention in


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Prosthetic Joint InfectionProsthetic Joint Infection In cases of prosthetic joint infection (PJI) that require

surgery for cure, successful treatment requiresappropriate antibiotic therapy combined with removal

of the hardware. Despite appropriate antibiotic use, the success rate

has been only about 20% if the prosthesis is left inp ace.

In recent years, evidence has shown that debridementalone could yield a cure rate of 74.5% of patients witha prosthetic joint infection and a C-reactive protein(CRP) level of 15 mg/dL or less who are treated with

a fluoroquinolone. For the time being, a 2-stage approach should be

regarded as the most effective technique.




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gg

Prosthetic Joint InfectionProsthetic Joint Infection First, remove the prosthesis and follow with

6 weeks of antibiotic therapy.

Then, place the new joint, impregnating themethylmethacrylate cement with an anti-

, , .

Antibiotic diffusion into the surroundingtissues is the goal.

The success rate for this approach is

approximately 95% for both hip and kneejoints.




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Prosthetic Joint InfectionProsthetic Joint Infection An intermediate method is to exchange

the new joint for the infected joint in a 1-

stage surgical procedure with

concomitant antibiotic thera .

This method, with concurrent use ofantibiotic cement, succeeds in 70-90% of

cases.


Outlook (Prognosis)Outlook (Prognosis)


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Outlook (Prognosis)Outlook (Prognosis)

Recovery is good with prompt antibiotic

treatment. If treatment is delayed,

permanent joint damage may result.


Possible ComplicationsPossible Complications


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Possible ComplicationsPossible Complications

Joint degeneration (arthritis)


PreventionPrevention


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Strictly adhere to sterile procedureswhenever the joint space is invaded (eg, in

aspiration or arthroscopic procedures). Antibiotic prophylaxis

with an antistaphylococcal antibiotic has beendemonstrated to reduce wound infections injoint replacement surgery.

Polymethylmethacrylate cement impregnated

with antibiotics may decrease perioperativeinfections.




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Treat any infection promptly to lessen the

chance of bloodstream invasion.

decreasing the incidence of underlying

infections best revents reactive arthritis


ReferencesReferences


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ReferencesReferences

Espinoza LR. Infections of bursae, joints, andbones. In: Goldman L, Ausiello D, eds. CecilMedicine. 23rd ed. Philadelphia, Pa: SaundersElsevier; 2007:chap 290.

Ohl CA. Infectious arthritis of native joints. In:,

Douglas, and Bennett's Principles and Practice ofInfectious Disease. 7th ed. Philadelphia, Pa: SaundersElsevier; 2009:chap 102.

http://www.nlm.nih.gov/medlineplus/ency/article/0

00430.htm http://emedicine.medscape.com/article/236299-

medication#showall



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REACTIVE ARTHRITISREACTIVE ARTHRITIS


Reactive arthritisReactive arthritis


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Reactive arthritisReactive arthritis

AKA: Reiter syndrome; Post-infectious

arthritis

a sterile inflammatory process that usually

results from an extra-articular infectious

process. Bacteria are the most significant

pathogens because of their rapidly

destructive nature.


musculoskeletal disorders part 2 bone infections

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