Musculoskeletal Disorders Part 2 Bone and joint infections: Osteomyelitis, Septic Arthritis

1. Musculoskeletal Disorders Part 2
Bone infections
Maria Carmela L. Domocmat, RN,MSN
Instructor
School of Nursing
Northern Luzon Adventist College
Artacho, Sison, Pangasinan

2. 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
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3. Osteomyelitis
Septic arthritis
BONE INFECTIONS
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4. BONE INFECTIONS:
OSTEOMYELITIS
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5. 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.
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6. Osteomyelitis
Infection of the bone, most often of the
cortex or medullary portion.
Is commonly caused by bacteria, fungi,
parasites & viruses.

7. 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.

8. 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.

9. S/s
Acute Osteomyelitis left untreated or
unresolved after 10 days is considered
chronic.
Necrotic bone is the distinguishing
feature of chronic osteomyelitis.

10. 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
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11. 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.

12. 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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13. Causes, incidence, and risk
factors
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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14. Causes, incidence, and risk
factors
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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15. 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
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16. Osteomyelitis
Osteomyelitis of Osteomyelitis of T10
diabetic foot secondary to
streptococcal
disease.
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17. Osteomyelitis
Osteomyelitis of the Osteomyelitis of
great toe index finger
metacarpal head
secondary to
clenched fist injury
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18. Osteomyelitis
Osteomyelitis of Osteomyelitis of the
index finger elbow.
metacarpal head
secondary to
clenched fist injury.
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19. 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
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20. 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
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21. 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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22. 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).

23. 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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24. Antibiotics
Nafcillin (Nafcil, Unipen)
Ceftriaxone (Rocephin)
Cefazolin (Ancef)
Ciprofloxacin (Cipro)
Ceftazidime (Fortaz, Ceptaz)
Clindamycin (Cleocin)
Vancomycin (Vancocin)
Linezolid (Zyvox)
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25. 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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26. 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.
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27. 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.

28. Expectations (prognosis)
markedly improved with timely diagnosis
and aggressive therapeutic intervention.
The outlook is worse for those with long-
term (chronic) osteomyelitis, even with
surgery.
◦ Amputation may be needed, especially in
those with diabetes or poor blood circulation.
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29. 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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30. 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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31. 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
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32. 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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33. 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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34. 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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35. SEPTIC ARTHRITIS
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36. 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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37. 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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38. 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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39. 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
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40. 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.
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41. Symptoms
Symptoms usually come on quickly.
Fever
joint swelling - usually just one joint.
intense joint pain- gets worse with
movement.
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43. 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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44. 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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45. 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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47. 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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48. 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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49. 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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50. 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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51. 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.
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52. 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).
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53. Antibiotics
Vancomycin (Vancocin)
◦ anti-infective agent used against methicillin-
sensitive 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/236299-
medication#showall
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54. 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.
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55. 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.
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56. 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.
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57. 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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59. 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.
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60. Surgical Intervention in
Prosthetic Joint Infection
First, remove the prosthesis and follow with
6 weeks of antibiotic therapy.
Then, place the new joint, impregnating the
methylmethacrylate cement with an anti-
infective 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.
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61. Surgical Intervention in
Prosthetic Joint Infection
An intermediate method is to exchange
the new joint for the infected joint in a 1-
stage surgical procedure with
concomitant antibiotic therapy.
This method, with concurrent use of
antibiotic cement, succeeds in 70-90% of
cases.
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62. Outlook (Prognosis)
Recovery is good with prompt antibiotic
treatment. If treatment is delayed,
permanent joint damage may result.
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63. Possible Complications
Joint degeneration (arthritis)
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64. 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.
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65. 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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66. 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/236299-
medication#showall
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67. REACTIVE ARTHRITIS
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68. 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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