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HCR240-Chapter39InfectionandInflammatoryDisordersofMusculoskeletalSystem.pptx

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Chapter 39

Infection and Inflammatory Disorders of the

Musculoskeletal System

Bone Structure and Infection

Bone

Normally resistant to infection

Bacterial infections most common

Infection due to break in bone

Infection from bloodstream

Bacteria invade cortex via Haversian and Volkmann canals

Bone Structure and Infection (continued)

Risk for bone infections

Immunosuppression

Comorbid diseases (diabetes mellitus)

Nutritional deficiency

Prosthetic material

Joints and Synovial Fluid

Cartilage covers the articular surfaces of bone

Avascular, with limited ability to repair and heal

Synovial fluid

Found in synovial joints

Amount of this fluid may increase in disease states

Joint effusion: edema of joint

Limited blood supply: difficulty in delivering medications (use intra-articular injection)

Overview

Common inflammatory disorders of musculoskeletal system

Gout

Rheumatoid arthritis

Rheumatology

Inflammation of muscle, bone, and joints

Myositis

Inflammation of muscle

Osteomyelitis

Inflammation of bone, usually due to infection

Bone Infection and Inflammation

Contiguous spread

Invasion of microorganism via puncture or wound

S. aureus

Hematogenous spread

Spread via bloodstream, Group A streptococci, or S. pneumoniae

Five Stages of Bone Infection

Inflammation

Vascular congestion and increased pressure within the interior bone

Suppuration

Infectious material enters Haversian system and abscess formed

Sequestrum

Increased pressure, vascular obstruction, and thrombi compromise blood supply, causing bone necrosis in approximately 7 days

Five Stages of Bone Infection

4. Involucrum

New bone formation from surface of periosteum

5. Resolution or progression to complications:

With antibiotics and surgical treatment early in disease process: osteomyelitis resolves

If no resolution: gangrene, necrotic tissue can develop

Joint Infection and Inflammation

Routes of infection

Via injection

Direct contact with infected neighboring tissue

Hematogenous or lymphogenous spread

Bacterial arthritis

Acute, chronic, or reactive

Reactive arthritis (ReA)

Post-infectious complication, no need of pathogen presence in joint

Often affects several joints

Bacterial infection rarely affects more than one joint

Joint Infection

AKA: infectious arthritis

Common sites for joint infection

Knee – 1st

Hip – 2nd

Increased infection risk in predamaged joints or joints with prosthesis

Surgery for implantation of prosthesis increases risk

Prosthesis surface may serve as binding site for bacteria

Assessment

Local signs of inflammation, erythema, discharge

Compare affected area with opposing area for symmetry

Aggravating factors, alleviating factors

ROM, past musculoskeletal injuries

Systemic symptoms

Surgeries, prosthesis

Presence of skin rashes

Check gait, posture

Increased Susceptibility to Joint Infection

Medical disorders that increase susceptibility to joint infection

Diabetes

Sickle cell anemia

Immune disease

Lyme disease

Peripheral arterial disease

Osteomyelitis

Infection of bone

Normally bacterial (S. aureus)

Sickle-cell anemia: Salmonellae

Three categories

Hematogenous, contiguous, chronic

Presentation

Assess for recent infections

Chills, fever, malaise

Localized tenderness, erythema, edema, reduced ROM in affected area

Osteomyelitis (continued_1)

Hematogenous

Rapid onset of symptoms

Most cases in children (increased vascularity in growing bone)

Contiguous

Trauma and surgery are common causes, as well as decubitus ulcers

Individuals with DM, PVD are at increased risk

Osteomyelitis (continued_2)

Chronic

Defined by length of time (longer than 6–8 weeks), lack of response to medications

Necrotic bone

Increased gangrene risk

Osteomyelitis Diagnosis

CBC, ESR, C-RP

Blood cultures

Positive only 50% of patients

Culture and aspiration may fail to identify pathogen

X-ray (may be normal at first), CT scan, MRI

Treatment of Osteomyelitis

Antibiotic therapy

IV for 2 to 6 weeks

Oral therapy follows IV therapy

Debridement of necrotic tissue

Surgical drainage of abscess

Reevaluate patient every 3 months for 2 years

Complications can develop

Removal of infected prosthesis may be needed

Lyme Disease

Bacterial disease: Borrelia burgdorferi

Transmitted by ticks

Northeastern and north-central U.S.

Deer tick (Ixodes scapularis)

Incubation period: 7 to 14 days

Fewer than 50% of individuals recall tick bite

Disease manifestation due to infection and immune response

Lyme Disease (continued)

Erythema migrans (“bull’s-eye rash”) may develop

Bacteria disseminated throughout body

Infect the skin, heart, joints, eyes, central nervous system, peripheral nerves

Patient presentation

Arthralgia, myalgias, fatigue, and headache

Stages of Lyme Disease

Early localized

Most common stage of presentation (3–30 days post-bite)

Fever, myalgias, erythema migrans

Early disseminated

3 to 12 weeks post-bite

Vague, generalized symptoms, lymphocytic meningitis, cranial neuritis, carditis ocular involvement

Stages of Lyme Disease (continued)

Late disseminated

Months to years after bite

Severe joint pain and swelling of large joints, central nervous system involvement, polyradiculopathy symptoms

Lyme Disease Diagnosis

Diagnosis

Symptoms

Tick exposure

Lab test commonly shows false negative

CDC

2-step process, ELISA and Western blot

Lyme Disease Treatment

Treatment

Single prophylactic dose of doxycycline for those with tick bite living in area with endemic Lyme disease

10- to 21-day course of doxycycline

Post-Lyme syndrome may be reported

May be due to prolonged immune response

Gout

Hyperuricemia triggers inflammation

Affects specific joints (first metatarsal)

Podagra: acute inflammation of metatarsophalangeal joint of great toe

Primary and secondary forms

Uric acid crystals may be deposited in subcutaneous tissue (“tophi”)

Patient presents with redness, warmth, swelling of joint

Discomfort onsets during night or early morning

Risk Factors for Gout

Diet high in meat

Purines: uric acid

High alcohol consumption

Obesity; yo-yo dieting

Family history

Chemotherapy resulting in cellular destruction

Medications

Gout (continued)

Chronic gout may involve several joints

May be confused with OA and RA

Hyperuricemia can lead to kidney stones

Diagnosis

Rule out other joint inflammatory conditions

24-hour urine uric acid

Hyperuricemia may not be present and should not be used for as sole diagnostic criteria

Aspiration of joint showing urate crystals is gold standard for diagnosis

Gout Treatment

Manage acute attacks and prevent future attacks

Begin medication early to prevent joint damage and lessen pain

NSAID’s, colchicine, allopurinol

asignment 6

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