CASE CONFERENCE ORTHOPEDIC

By Poonperm Sucharitpong Medical student

PATIENT PROFILE • Case ผปวยหญงไทย• อาย 67 ป• ภมลำาเนา จงหวด นครราชสมา• อาชพ คาขาย

CHIEF COMPLAINT• ปวดสะโพกขวา 2 วน กอนมาโรงพยาบาล

PRESENT ILLNESS2 d PTA • ผปวยเรมปวดสะโพกดานขวา ปวดแบบแสบๆ ไมมปวด

ราวไปตำาแหนงอน ปวดจนเดนไมได ไมมแขนขาออน แรง ไมมชา ทานยาแกปวดเอง อาการปวดลดลงเลก นอย

• มไขตำาๆตลอด ปสสาวะไมแสบขด ไมไอ ไมมนำ.ามก ไมม ปวดทอง ไมมคลนไสอาเจยน ไมมถายเหลว

• ไมเคยปวดบรเวณสะโพกขวามากอน• ปฏเสธประวตอบตเหต

PAST HISTORY• Underlying disease – DM , Hypertension

on Amlodipine(5) 1x2 po pcHydralazine(50) 1x2 po pcGlipizide(5) 2x2 po acPioglitazone(30) 1/2x1 po ac

• S/P I&D gluteal abscess Lt.• No history of accident

PERSONAL HISTORY• No history alcohol drinking and smoking• No herbal medication• No drug and food allergy

PHYSICAL EXAMINATION• Vital signs – BT 37.3 C HR 98 /min

RR 16 /min BP 153/72 mmHg• General appearance – An elderly Thai female,

hypersthenic build, good consciousness, not pale, no jaundice

• HEENT – not pale conjuctivae, anicteric sclerae

• Cardiovascular – pulse full and regular, normal s1&s2 sound, no murmur

PHYSICAL EXAMINATION• Lungs and chest – clear, equal breath sound

• Abdomen – soft, not tender, no distension

• Extremities – tender and warmth at right hip, no swelling, no erythema, limit ROM due to pain, Rolling positive, Anvil negative

PROBLEM LIST

• Acute monoarthitis

• Underlying disease – DM , Hypertension

MANAGEMENT AT ED• Septic work-up

CBCH/C x IIUACXR

• Arthrocentesis for fluid profile, gram stain, culture• Basic lab: BUN/Cr, Electrolyte, Anti-HIV,Coagulogram• ESR, CRP, Uric level• Ultrasound Emergency

LABORATORY• CBC

Hb 9.7 g/dL Hct 29.4%WBC 12,000 /uL Neutrophil

75.8%Lymphocyte 15.4% Monocyte 8.2%Eosinophil 0.3% Basophil

0.3%Platelet 455,000 /uL MCV 82.3 fl

• ESR 117• CRP 36.3

LABORATORY• Electrolyte

Sodium 133.4 mmol/LPotassium 3.95 mmol/LChloride 97.9 mmol/LBicarbonate 23.9 mmol/L

• BUN = 19.2 mg/dL• Creatinine = 1.89 mg/dL• Uric level

LABORATORY• Joint fluid profile

Color: slightly red Crystal: not foundTransparency: cloudy Sp.gr. 1.015RBC: 26,500 cell/mm3PMN: 97 %

• UAY/C Nitrite negpH 8.0 RBC negProtein trace WBC 0-1Sugar neg sq.epi 2-3

LABORATORY• Joint fluid culture : pending• Joint fluid gram stain

Many WBCNot seen organism

• Ultrasound : x-ray suggest CT

DIFFERENTIAL DIAGNOSIS

• Septic arthritis• Crystal-induced arthritis• Reactive arthritis• Rheumatoid arthritis• Acute traumatic arthritis

FILM PELVIS AP

CHEST X-RAY

PLAN FOR MANAGEMENT

• Admit • ATB prophylaxis: cefazolin 1 gm IV q 6 hr• Pain control : MO 4 mg IV prn q 6 hr,

Paracetamol(500) 1 tab po prn q 4-6 hr

Septic arthritis

Arthritis that caused by any infectious organism

DEFINITION

EPIDEMIOLOGY

Incidence (per 100,000/year)

0 10 20 30 40 50

Prostheticjoint

Rheumatoidarthritis

Children

Generalpopulation

• Age : elderly>60 yr , Newborn

• Systemic disorders: DM ,RA ,H/D, immunosuppressive drug , HIV infect

• Local factors : Prosthetic joint, OA ,RA ,recent joint surgery, direct joint trauma

PREDISPOSING FACTOR

ORGANISM

60% - S.aureous20% - Streptococcus spp.13% - Gram – negative bacilli4% - Polymicrobial3% - Anaerobes

ORGANISM

Age Organism1 Neonates Streptococcus

Gram-negative organisms2 Infants Staphylococcus aureus

Hemophilus influenza3 Children Staphylococcus aureus

Salmonella4 Adolescent Staphylococcus aureus

Neisseria gonorrhea5 Adults Staphylococcus aureus

Streptococcus Gram-negative organisms

6 IV drug abusers Suspect Pseudomonas and atypical organisms

• Route of infection• Hematogenous spreading• Direct inoculation• Adjacent focal infection

PATHOGENESIS

• Onset of the joint pain• monoarticular or polyarticular • The presence of extra-articular symptoms• Previous history of joint disease or trauma, accidental

or iatrogenic• STD• Intravenous drug abuse

HISTORY

CLINICAL FEATURES

• Fever (high grade fever ~ 50%)• Acute monoarticular arthritis (~80-90%)

Abrupt onset of hot, painful, and swollen jointObvious joint effusionLimitation of passive and active motion

• Polyarticular (~10-20% :- IVDU, DM, RA)

DIFFERENTIAL DIAGNOSIS OF ACUTE MONOARTHRITIS

• Soft tissue infection• Crystal-induced arthritis• Traumatic

arthritis/hemarthrosis• Reactive arthritis

NEWMAN’S CRITERIA FOR DIAGNOSIS OF SEPTIC ARTHRITIS

A. Organism isolated from jointB. Organism isolated from elsewhereC. No organism isolated but

(i) histological or radiological evidence of infection(ii) turbid fluid aspirated from joint

Normalsynovial fluid

Septic (Type 3)

Transparent, colorless or pale straw-colored

Purulent or opaque

WBC < 200 WBC > 60,000PMN < 25% PMN > 80%

Sugar = Blood Sugar <50% blood

Gram stain: (-) May be (+) in septic arthritis

Culture: (-) (+) in septic arthritis

Wet prep : (-) Crystals

Normal synovialfluid

Crystal – induced arthritis, Bacterial arthritis

SYNOVIAL FLUID ANALYSIS• Macroscopic finding

• Turbid, decreased viscosity• WBC count

• > 60,000 mm3, PMN > 80%• Glucose < 50-75% of serum value

• Blood

-CBC-ESR,CRP-Hemoculture

• Imaging

-plain film-ultrasound-CT-MRI

• Synovial fluid analysis

-color, transparency-G/S, C/S-Cell diff/cell count-crystal-glucose

RADIOLOGICAL INVESTIGATIONS

TREATMENT

Antibiotics

Aspiration

Rehabilitation

ANTIBIOTICS • Start as soon as all specimens are obtained for C/S

• Intravenous antibiotic at least 2 weeksS. Aureus : cloxacillin,1st 2nd gen cephalosporin

MRSA : vancomycin

Strep gr.A , H. influenza : cefuroxime

Pseudomonas aeruginosa : ceftazidime + gentamycin

• Oral antibiotic for the following 2 – 6 weeks

• Surgical debridementserial joint aspiration in 24-36 Hr.arthrotomy, arthroscopic technique

JOINT ASPIRATION

REHABILITATION • Rest in optimal joint position

• Continuous passive motion device

• Muscle strengthening exercise

• Active ROM and weight-bearing as pain resolves

• Difficult to drain or to assess the adequacy of drainage

• Inability to adequate drainage by needle aspiration• Unresponsive to medical treatment• Vertebral osteomyelitis with spinal cord compression• Coexistent osteomyelitis• Prosthesis septic joint• Foreign body in joint

INDICATION FOR ORTHOPEDIC CONSULTATION

OUTCOME• Complete resolution• Partial loss articular cartilage and fibrosis of joint• Loss of articular cartilage and bony ankylosis• Bone destruction and permanent deformity of

the joint

THANK YOU