Musculoskeletal Disorders Part 2 Bone Infections

Musculoskeletal Disorders Part 2 Bone infections
Maria Carmela L. Domocmat, RN,MSN Instructor School of Nursing Northern Luzon Adventist College Artacho, Sison, Pangasinan
Overview
Part 1: Degenerative & Metabolic bone disorders: Part 2: Bone infections
Osteomyelitis Septic arthritis
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
Osteomyelitis Septic arthritis
BONE INFECTIONS
3/5/2012
Maria Carmela L. Domocmat, RN, MSN
BONE INFECTIONS: OSTEOMYELITIS
3/5/2012
Osteomyelitis
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.
Osteomyelitis
Infection of the bone, most often of the cortex or medullary portion. Is commonly caused by bacteria, fungi, parasites & viruses.
Osteomyelitis
Classified by mode of entry- Contiguous or exogenous is caused by a pathogen from outside the body or the by the spread 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.
Osteomyelitis
Hematogenous- caused by bloodborne pathogens originating from infectious sites within the body. Ex: sinus, ear, dental, respiratory & GU infections. The infection spreads from the bone to the soft tissues & can eventually break through the skin, becoming a draining fistula. Again, Staph aureus is the most common causative organism.
S/s
Acute Osteomyelitis left untreated or unresolved after 10 days is considered chronic. Necrotic bone is the distinguishing feature of chronic osteomyelitis.
Symptoms
Bone pain Fever General discomfort, uneasiness, or ill-feeling (malaise) Local swelling, redness, and warmth Other symptoms that may occur with this disease: Chills Excessive sweating Low back pain Swelling of the ankles, feet, and legs
Pathophysiology
similar to that infectious processes in any other body tissue. Bone inflammation is marked by edema, increased vascularity & leukocyte activity. fever, malaise, anorexia, & headache. affected body may be erythematous, tender, & edematous. There may be fistula draining purulent material. Blood test- increase WBCs, ESR, & C-protein levels.
Causes, incidence, and risk factors

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 occurs under a chronic skin ulcer (sore).
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The infection that causes osteomyelitis can also start in another part of the body and spread to the bone through the blood. A current or past injury may have made the affected bone more likely to develop the infection.
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A bone infection can also start after bone surgery, especially if the surgery is done after an injury or if metal rods or plates are placed in the bone. children -- long bones usually affected. Adults -- feet, vertebrae, and pelvis are most commonly affected.
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Risk factors
Diabetes Hemodialysis Injected drug use Poor blood supply Recent trauma People who have had their spleen removed are also at higher risk for osteomyelitis
Osteomyelitis
Osteomyelitis of diabetic foot Osteomyelitis of T10 secondary to streptococcal disease.
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Osteomyelitis
Osteomyelitis of the great toe Osteomyelitis of index finger metacarpal head secondary to clenched fist injury
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Osteomyelitis
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Osteomyelitis of the elbow.
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Dx tests
A physical examination shows bone tenderness and possibly swelling and redness. Tests may include:
Blood cultures Bone biopsy (which is then cultured) Bone 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
Dx tests
Diagnosis requires 2 of the 4 following criteria:
Purulent material on aspiration of affected bone Positive findings of bone tissue or blood culture Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema Positive radiological imaging study
http://emedicine.medscape.com/article/785020-treatment
Emergency Department Care

Select the appropriate antibiotics using direct culture results in samples from the infected site, whenever possible. Further surgical management may involve removal of the nidus of infection, implantation of antibiotic beads or pumps, hyperbaric oxygen therapy,or other modalities.
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.
http://emedicine.medscape.com/article/785020-treatment
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Treatment
Treatment is difficult & costly. Goal of treatment
complete removal of necrotic bone & affected soft tissue control of infection & elimination of dead space (after removal of necrotic bone).
Treatment
The primary treatment for osteomyelitis
parenteral (IV) antibiotics that penetrate bone and joint cavities for at least 4-6 weeks. After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis.
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Antibiotics
Nafcillin (Nafcil, Unipen) Ceftriaxone (Rocephin) Cefazolin (Ancef) Ciprofloxacin (Cipro) Ceftazidime (Fortaz, Ceptaz) Clindamycin (Cleocin) Vancomycin (Vancocin) Linezolid (Zyvox)
Treatment
Surgery
to remove dead bone tissue if have an infection 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 new bone tissue.
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Treatment
Infection of an orthopedic prosthesis, such as an artificial joint, may need surgery to remove the prosthesis and infected tissue around the area. If have diabetes- need to be well controlled. If problems with blood supply to the infected area, such as the foot, surgery to improve blood flow may be needed.
Nursing management
use of aseptic technique during dressing changes. Observed for S/S of systemic infection, & administered antibiotic on time. ROM exercises are encouraged to prevent contractures & flexion deformities & participation in ADL to the fullest extent is encouraged.
Expectations (prognosis)
markedly improved with timely diagnosis and aggressive therapeutic intervention. The outlook is worse for those with longterm (chronic) osteomyelitis, even with surgery.
Amputation may be needed, especially in those with diabetes or poor blood circulation.
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Expectations (prognosis)
The outlook for those with an infection of an orthopedic prosthesis depends, in part, on:
The patient's health The type of infection Whether the infected prosthesis can be safely removed
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Complications
Bone abscess Paravertebral/epidural abscess Bacteremia Fracture Loosening of the prosthetic implant Overlying soft-tissue cellulitis Draining soft-tissue sinus tracts
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Complications
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
Prevention
Prompt and complete treatment of infections is helpful. People who are at high risk or who have a compromised immune system should see a health care provider promptly if they have signs of an infection anywhere in the body.
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Deterrence/Prevention
Acute hematogenous osteomyelitis
can potentially be avoided by preventing bacterial seeding of bone from a remote site. This involves the appropriate diagnosis and treatment of primary bacterial infections.
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Deterrence/Prevention
Direct inoculation osteomyelitis
can best be prevented with appropriate wound management and consideration of prophylactic antibiotic use at the time of injury.
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SEPTIC ARTHRITIS
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Septic arthritis
Septic arthritis is inflammation of a joint due to a bacterial or fungal infection. AKA:
infectious arthritis Bacterial arthritis Non-gonococcal bacterial arthritis
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Causes
Septic arthritis develops when bacteria or other tiny disease-causing organisms (microorganisms) spread through the bloodstream to a joint. It may also occur when the joint is directly infected with a microorganism from an injury or during surgery.
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Causes
most common sites - knee and hip. acute septic arthritis
bacteria such as staphylococcus or streptococcus.
chronic septic arthritis

less common caused by organisms such as Mycobacterium tuberculosisand Candida albicans.
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Risk 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
Risk 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 B streptococcus or Haemophilus influenza, if they have not been vaccinated.
Symptoms
Symptoms usually come on quickly. Fever joint swelling - usually just one joint. intense joint pain- gets worse with movement.
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Symptoms in newborns or infants:

Cries when infected joint is moved (example: diaper change causes crying if hip joint is infected) Fever Inability to move the limb with the infected joint (pseudoparalysis) Irritability
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Symptoms in children and adults:

Inability to move the limb with the infected joint (pseudoparalysis) Intense joint pain Joint swelling Joint redness Low fever Chills may occur, but are uncommon
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Exams and Tests

Aspiration of joint fluid for cell count, examination of crystals under the microscope, gram stain, and culture Blood culture X-ray of affected joint
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Treatment
Antibiotics are used to treat the infection. Joint Immobilization and Physical Therapy
Resting, keeping the joint still, raising the joint, and using cool compresses may help relieve pain. Exercising the affected joint helps the recovery process.
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Treatment
Arthrocentesis
If synovial fluid builds up quickly due to the infection, a needle may be inserted into the joint often to aspirate the fluid.
Severe cases may need surgery to drain the infected joint fluid.
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Treatment
Medical management of infective arthritis focuses
adequate and timely drainage of the infected synovial fluid, administration of appropriate antimicrobial therapy immobilization of the joint to control pain.
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Antibiotic 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 weeks IV antibiotic therapy. Orally administered antimicrobial agents are almost never indicated in the treatment of S aureus infections. Gram-negative native joint infections with a pathogen that is sensitive to quinolones can be treated with oral ciprofloxacin for the final 1-2 weeks of treatment. As a rule, a 2-week course of intravenous antibiotics is sufficient to treat gonococcal arthritis.
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Antibiotics
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-negative enteric rods. Monitor sensitivity data.
Ciprofloxacin (Cipro)
alternative antibiotic to ceftriaxone to treat N gonorrhoeae and gram-negative enteric rods.
Antibiotics
Cefixime (Suprax)
a third-generation oral cephalosporin with broad activity against gram-negative bacteria. Oral cefixime is used as a follow-up to intravenous (IV) ceftriaxone to treat N gonorrhoeae.
Oxacillin
useful against methicillin-sensitive S aureus (MSSA).
Antibiotics
Vancomycin (Vancocin)
anti-infective agent used against methicillinsensitive S aureus (MSSA), methicillin-resistant coagulase-negative S aureus (CONS), and ampicillin-resistant enterococci in patients allergic to penicillin.
Linezolid (Zyvox)
an alternative antibiotic that is used in patients allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.
http://emedicine.medscape.com/article/236299medication#showall
Joint Immobilization and Physical Therapy

Usually, immobilization of the infected joint to control pain is not necessary after the first few days. If the patient's condition responds adequately after 5 days of treatment, begin gentle mobilization of the infected joint. Most patients require aggressive physical therapy to allow maximum postinfection functioning of the joint.
Joint Immobilization and Physical Therapy

Initial physical therapy consists of maintaining the joint in its functional position and providing passive ROM exercises. The joint should bear no weight until the clinical signs and symptoms of synovitis have resolved. Aggressive physical therapy is often required to achieve maximum therapy benefit.
Synovial 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 to prevent significant reaccumulation of fluid. Aspirating the joint 2-3 times a day may be necessary during the first few days. If frequent drainage is necessary, surgical drainage becomes more attractive. Gonococcal-infected joints rarely require surgical drainage.
Synovial Fluid Drainage

Surgical drainage is indicated when one or more of the following occur:
The appropriate choice of antibiotic and vigorous percutaneous drainage fails to clear the infection after 5-7 days The infected joints are difficult to aspirate (eg, hip) Adjacent soft tissue is infected Routine arthroscopic lavage is rarely indicated. However, drainage through the arthroscope is replacing open surgical drainage. With arthroscopic drainage, the operator can visualize the interior of the joint and can drain pus, debride, and lyse adhesions.
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Surgical Intervention in Prosthetic Joint Infection

In cases of prosthetic joint infection (PJI) that require surgery for cure, successful treatment requires appropriate 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 in place. In recent years, evidence has shown that debridement alone could yield a cure rate of 74.5% of patients with a 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.

First, remove the prosthesis and follow with 6 weeks of antibiotic therapy. Then, place the new joint, impregnating the methylmethacrylate cement with an antiinfective agent (ie, gentamicin, tobramycin). Antibiotic diffusion into the surrounding tissues is the goal. The success rate for this approach is approximately 95% for both hip and knee joints.

An intermediate method is to exchange the new joint for the infected joint in a 1stage surgical procedure with concomitant antibiotic therapy. This method, with concurrent use of antibiotic cement, succeeds in 70-90% of cases.
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Outlook (Prognosis)
Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent joint damage may result.
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Possible Complications
Joint degeneration (arthritis)
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Prevention
Strictly adhere to sterile procedures whenever the joint space is invaded (eg, in aspiration or arthroscopic procedures). Antibiotic prophylaxis
with an antistaphylococcal antibiotic has been demonstrated to reduce wound infections in joint replacement surgery. Polymethylmethacrylate cement impregnated with antibiotics may decrease perioperative infections.
Prevention
Treat any infection promptly to lessen the chance of bloodstream invasion. decreasing the incidence of underlying infections best prevents reactive arthritis
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References
Espinoza LR. Infections of bursae, joints, and bones. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 290. Ohl CA. Infectious arthritis of native joints. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2009:chap 102. http://www.nlm.nih.gov/medlineplus/ency/article/0 00430.htm http://emedicine.medscape.com/article/236299medication#showall
REACTIVE ARTHRITIS
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Reactive 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.
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Musculoskeletal Disorders Part 2 Bone Infections

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Musculoskeletal Disorders Part 2 Bone infections

Osteomyelitis Septic arthritis

Maria Carmela L. Domocmat, RN, MSN

BONE INFECTIONS: OSTEOMYELITIS

Maria Carmela L. Domocmat, RN, MSN

Causes, incidence, and risk factors

Maria Carmela L. Domocmat, RN, MSN

Causes, incidence, and risk factors

Maria Carmela L. Domocmat, RN, MSN

Causes, incidence, and risk factors

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Emergency Department Care

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

chronic septic arthritis

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Symptoms in newborns or infants:

Maria Carmela L. Domocmat, RN, MSN

Symptoms in children and adults:

Maria Carmela L. Domocmat, RN, MSN

Exams and Tests

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Joint Immobilization and Physical Therapy

Joint Immobilization and Physical Therapy

Synovial Fluid Drainage

Synovial Fluid Drainage

Maria Carmela L. Domocmat, RN, MSN

Surgical Intervention in Prosthetic Joint Infection

Surgical Intervention in Prosthetic Joint Infection

Surgical Intervention in Prosthetic Joint Infection

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

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