Project: Ghana Emergency Medicine Collaborative Document Title: Bone and Joint Infections Author(s): Keith Kocher (University of Michigan), MD, MPH 2012

Project: Ghana Emergency Medicine Collaborative

Document Title: Bone and Joint Infections

Author(s): Keith Kocher (University of Michigan), MD, MPH 2012

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Bone and Joint Bone and Joint InfectionsInfections

Keith Kocher, MD MPHKeith Kocher, MD MPH

University of MichiganUniversity of Michigan

Department of Emergency MedicineDepartment of Emergency Medicine

April 4April 4thth, 2012, 2012

3

Relationships with Relationships with IndustryIndustry

UMMS policy requires that faculty UMMS policy requires that faculty members disclose to students and trainees members disclose to students and trainees their industry relationships in order to their industry relationships in order to promote an ethical & transparent culture in promote an ethical & transparent culture in research, clinical care, and teaching.research, clinical care, and teaching.I occasionally am a consultant for Magellan I occasionally am a consultant for Magellan Health Services, Inc., a publicly traded health care Health Services, Inc., a publicly traded health care management company. I advise primarily on use management company. I advise primarily on use of imaging in the ED.of imaging in the ED.

Currently, I do not serve as the PI on any industry Currently, I do not serve as the PI on any industry supported research projects.supported research projects.

Disclosure required by the UMMS Policy on Faculty Disclosure of Industry Relationships to Students and Trainees. 4

ObjectivesObjectives Know when to suspect osteomyelitisKnow when to suspect osteomyelitis

Know how to evaluate someone with a Know how to evaluate someone with a monoarticular arthritismonoarticular arthritis

Know how to treat osteomyelitis and Know how to treat osteomyelitis and septic arthritisseptic arthritis

Know how to competently perform Know how to competently perform joint aspirationsjoint aspirations

5

OutlineOutline

BackgroundBackground

Small group discussionSmall group discussion

Evidence based lecture: bone then Evidence based lecture: bone then jointjoint

Final thoughts and Final thoughts and questions/commentsquestions/comments

6

Lecture/Topic Lecture/Topic BoundariesBoundaries

Lecture confined to evaluation and Lecture confined to evaluation and management of bone and joint management of bone and joint infections within the ED settinginfections within the ED setting

Generally discussing adultsGenerally discussing adults

Will touch on several neighboring Will touch on several neighboring disease processes as well, so not the disease processes as well, so not the definitive lecture on the entire range of definitive lecture on the entire range of arthritis, fracture management, etcarthritis, fracture management, etc

7


I want to specifically encourage I want to specifically encourage interruptions, questions, and discussion interruptions, questions, and discussion during my talk.during my talk.

The literature on osteomyelitis and The literature on osteomyelitis and septic arthritis has not particularly septic arthritis has not particularly advanced significantly in the last advanced significantly in the last decade. decade. Therefore much of the evidence comes from Therefore much of the evidence comes from

established practice, systematic reviews, established practice, systematic reviews, and textbook type sources.and textbook type sources.

8


However, we will touch on some more recent However, we will touch on some more recent evidence based help that can better guide evidence based help that can better guide the evaluation and work-up:the evaluation and work-up: Butalia S, et al. Does this patient with diabetes Butalia S, et al. Does this patient with diabetes

have osteomyelitis of the lower extremity? have osteomyelitis of the lower extremity? JAMAJAMA; ; 2008:299(7):806-813.2008:299(7):806-813.

Margaretten ME, et al. Does this adult patient Margaretten ME, et al. Does this adult patient have septic arthritis? have septic arthritis? JAMAJAMA; 2007:297(13):1478-; 2007:297(13):1478-1488.1488.

Janssens HJEM, et al. A diagnostic rule for acute Janssens HJEM, et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid gouty arthritis in primary care without joint fluid analysis? analysis? Archives of Internal MedicineArchives of Internal Medicine; ; 2010:170(13):1120-1126.2010:170(13):1120-1126.

9

DefinitionsDefinitions OsteomyelitisOsteomyelitis

Inflammation in bone or bone marrow, Inflammation in bone or bone marrow, usually due to an infectionusually due to an infection

ArthritisArthritis Inflammation of a jointInflammation of a joint Monarticular vs. polyarticular vs. Monarticular vs. polyarticular vs.

periarticular arthritisperiarticular arthritis

Septic joint (septic arthritis, infectious Septic joint (septic arthritis, infectious arthritis)arthritis) Inflammation of a joint due to an infectionInflammation of a joint due to an infection

10

OutlineOutline



Evidence based lectureEvidence based lecture


11

RulesRules Groups of 4-5Groups of 4-5

Mix of experienceMix of experience Some junior level residents, Some junior level residents,

some senior level residents, some senior level residents, faculty spread aroundfaculty spread around

Elect a spokespersonElect a spokesperson Will report back to the groupWill report back to the group

12

RulesRules 2 Cases2 Cases

Specifically I want you to discuss:Specifically I want you to discuss: How evaluate (history, exam, labs, How evaluate (history, exam, labs,

imaging, other testing or imaging, other testing or procedures)procedures)

How manage (treatment options, How manage (treatment options, consultants)consultants)

How to disposition (admit, How to disposition (admit, discharge, outpatient treatment, discharge, outpatient treatment, follow up instructions)follow up instructions)

13

Case #1Case #1A 64 year old woman with a A 64 year old woman with a history of diabetes presents to history of diabetes presents to your ED with a non-healing your ED with a non-healing right foot ulcer. She has a right foot ulcer. She has a small wound over the 4small wound over the 4thth metatarsal head for last 3 metatarsal head for last 3 weeks. She was prescribed a weeks. She was prescribed a 10 day course of antibiotics by 10 day course of antibiotics by her PCP which she just her PCP which she just completed. She comes in to completed. She comes in to the ED because it has not the ED because it has not healed, ithealed, it’’s the weekend, and s the weekend, and sheshe’’s concerned. On exam the s concerned. On exam the wound is round, 3 cm in wound is round, 3 cm in diameter, with redness and diameter, with redness and swelling. Vital signs are: bp swelling. Vital signs are: bp 155/85, pulse 85, temp 37.5, 155/85, pulse 85, temp 37.5, pulse ox 99% on RA.pulse ox 99% on RA.

Case #2Case #2

Questions:Questions:

1.1. What do you want to do What do you want to do diagnostically?, diagnostically?, therapeutically?therapeutically?

2.2. What is your disposition What is your disposition plan?plan?

A 57 year old man with a A 57 year old man with a history of hypertension and history of hypertension and alcoholism presents with a alcoholism presents with a swollen knee. He noticed swollen knee. He noticed development of this over the development of this over the last 24 hours. No other last 24 hours. No other joints hurt. He denies fever joints hurt. He denies fever or rashes. He recalls no or rashes. He recalls no recent trauma. He has no recent trauma. He has no history of arthritis. He history of arthritis. He denies any history of similar denies any history of similar episodes of painful joints. episodes of painful joints. Exam shows a swollen, red, Exam shows a swollen, red, and warm right knee joint. and warm right knee joint. He is neurovascularly intact He is neurovascularly intact and without associated rash. and without associated rash. Vital signs are: bp 155/85, Vital signs are: bp 155/85, pulse 85, temp 37.5, pulse ox pulse 85, temp 37.5, pulse ox 99% on RA. 99% on RA.



2.2. What is your disposition?What is your disposition?14

OutlineOutline





15

OsteomyelitisOsteomyelitis How do you get osteomyelitis?:How do you get osteomyelitis?:

(1) (1) Contiguous Contiguous focusfocus

Most commonMost common

After trauma, After trauma, surgery, surgery, insertion of insertion of hardwarehardware

Can occur at Can occur at any age and any age and with any bonewith any bone

(2) Vascular (2) Vascular insufficiencyinsufficiency

Second commonSecond common

Related to Related to diseases such as diseases such as diabetes diabetes (predominantly) (predominantly) , peripheral , peripheral vascular diseasevascular disease

Almost always Almost always begins with a begins with a soft tissues soft tissues infection that infection that spreads to bonespreads to bone

(3) (3) Hematologic Hematologic spreadspread

Least commonLeast common

Seeded from Seeded from another sourceanother source

Examples: IV Examples: IV drug use, sickle drug use, sickle cell diseasecell disease

Seen mostly in Seen mostly in pre-adolescent pre-adolescent children and children and elderlyelderly

16

TypesTypes Differences between acute and chronic Differences between acute and chronic

osteomyelitisosteomyelitis Acute = develops over days to weeksAcute = develops over days to weeks Chronic = develops over months to years, Chronic = develops over months to years,

involves relapsesinvolves relapses

Probably not an important distinction in Probably not an important distinction in the ED, except to know that a chronic the ED, except to know that a chronic infection that appears infection that appears ““healedhealed”” can can relapserelapse

17

EvaluationEvaluation First step in evaluation is always to be First step in evaluation is always to be

able to generate the differentialable to generate the differential

Presentation – variety of symptoms:Presentation – variety of symptoms:

open wound with exposed bone → draining open wound with exposed bone → draining sinussinus

tract→ local swelling with bone pain tract→ local swelling with bone pain tendernesstenderness

18

EvaluationEvaluation Specific clinical scenarios to consider:Specific clinical scenarios to consider:

Vertebral osteomyelitis (discitis)Vertebral osteomyelitis (discitis): IV drug user : IV drug user (or those with indwelling vascular catheters) with (or those with indwelling vascular catheters) with sub-acute back painsub-acute back pain

SalmonellaSalmonella related osteomyelitis related osteomyelitis: sickle cell : sickle cell patient with hip painpatient with hip pain

Prosthetic joint related osteomyelitisProsthetic joint related osteomyelitis: risk of : risk of infection remains highest for first 2 years, but infection remains highest for first 2 years, but still persistent at lower levels for life of prosthesisstill persistent at lower levels for life of prosthesis

Pseudomonas Pseudomonas related osteomyelitisrelated osteomyelitis: puncture : puncture wound to heel (osteomyelitis of the calcaneus)wound to heel (osteomyelitis of the calcaneus)

Sternal osteomyelitisSternal osteomyelitis: after cardiac surgery: after cardiac surgery Diabetic foot ulcer relatedDiabetic foot ulcer related

19

MicroorganismsMicroorganisms

Lewis DP and Waldvogel FA. Osteomyelitis. Lewis DP and Waldvogel FA. Osteomyelitis. The LancetThe Lancet, 2004;364:369-, 2004;364:369-379.379.

Note: source of infection generally determines organismNote: source of infection generally determines organism20

EvaluationEvaluation Testing optionsTesting options

Blood tests:Blood tests: CBC (the ubiquitous, over-played, and over-relied-upon CBC (the ubiquitous, over-played, and over-relied-upon

WBC)WBC) Inflammatory markers Inflammatory markers

ESR – traditional markerESR – traditional marker CRP – tends to rise earlier in illness, probably more reliable in CRP – tends to rise earlier in illness, probably more reliable in

following response to treatmentfollowing response to treatment Blood cultures – attempt to isolate the organism (although Blood cultures – attempt to isolate the organism (although

bone biopsy with culture is gold standard)bone biopsy with culture is gold standard) Imaging:Imaging:

Plain filmsPlain films USUS CTCT MRIMRI Bone scanBone scan

21

EvaluationEvaluation Plain films:Plain films:

cortical erosionscortical erosions bony bony

radiolucencies/destructionradiolucencies/destruction periosteal reactionperiosteal reaction soft tissue gas or swellingsoft tissue gas or swelling narrowing/widening joint narrowing/widening joint

spacesspaces

May not see changes until May not see changes until 1-2 weeks into an episode 1-2 weeks into an episode of acute osteomyelitisof acute osteomyelitis

Learch TJ and Gentili A. Advanced Imaging of the Learch TJ and Gentili A. Advanced Imaging of the Diabetic Foot and Its Complications. Diabetic Foot and Its Complications. American Journal American Journal of Roentgenologyof Roentgenology; 2000:175(5):1328.; 2000:175(5):1328.

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Source undetermined

EvaluationEvaluation Plain films:Plain films:

Sensitivity: 28% - 93%Sensitivity: 28% - 93% Specificity: 33% - 92%Specificity: 33% - 92%

+LR: ~2.2+LR: ~2.2 -LR: ~0.5-LR: ~0.5

Learch TJ and Gentili A. Advanced Imaging of the Learch TJ and Gentili A. Advanced Imaging of the Diabetic Foot and Its Complications. Diabetic Foot and Its Complications. American Journal American Journal of Roentgenologyof Roentgenology; 2000:175(5):1328.; 2000:175(5):1328.

23Source undetermined

LearningRadiology.com

EvaluationEvaluation *MRI:*MRI:

Superior studySuperior study Sensitivity: 29% - 100%Sensitivity: 29% - 100% Specificity: 67% - 95%Specificity: 67% - 95%

+LR: ~7.2+LR: ~7.2 -LR: ~0.04-LR: ~0.04

CTCT Not as good as MRI which can detect Not as good as MRI which can detect

osteomyelitis earlierosteomyelitis earlier However, can be used to evaluated extent of However, can be used to evaluated extent of

bony involvement and can be used to follow bony involvement and can be used to follow response to therapyresponse to therapy

Learch TJ and Gentili A. Advanced Imaging of the Diabetic Foot and Its Learch TJ and Gentili A. Advanced Imaging of the Diabetic Foot and Its Complications. Complications. American Journal of RoentgenologyAmerican Journal of Roentgenology; 2000:175(5):1328.; 2000:175(5):1328.

Bone scan:Bone scan: Uses a radiotracerUses a radiotracer Takes time to perform Takes time to perform

(?6 hours) = not an (?6 hours) = not an ED testED test

US:US: Useful to look for Useful to look for

joint effusion for joint effusion for aspirationaspiration

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Diabetic Foot – Diabetic Foot – OsteomyelitisOsteomyelitis

No studies addressed aspects of history that No studies addressed aspects of history that are helpfulare helpful

Physical exam features:Physical exam features: *Ulcer area larger than 2 cm*Ulcer area larger than 2 cm22: +LR 7.2, -LR 0.5: +LR 7.2, -LR 0.5

Presence/absence of erythema, swelling, purulence Presence/absence of erythema, swelling, purulence doesndoesn’’t make a differencet make a difference

*Probe-to-bone test: +LR 6.4, *Probe-to-bone test: +LR 6.4,

-LR 0.4-LR 0.4 Clinical gestalt: +LR 5.5, -LR 0.5Clinical gestalt: +LR 5.5, -LR 0.5 Temperature uselessTemperature useless

Butalia S, et al. Does this patient with diabetes have osteomyelitis of the Butalia S, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? lower extremity? JAMAJAMA; 2008:299(7):806-813.; 2008:299(7):806-813. 25

Diabetic Foot – Diabetic Foot – OsteomyelitisOsteomyelitis

Laboratory tests:Laboratory tests: ESR >70: +LR 11, -LR 0.35ESR >70: +LR 11, -LR 0.35 WBC uselessWBC useless Swab culture useless, doesnSwab culture useless, doesn’’t reliably detect t reliably detect

bone organismbone organism ?CRP?CRP

Imaging tests:Imaging tests: Plain films: +LR 2.3, -LR 0.6Plain films: +LR 2.3, -LR 0.6 MRI (foot/ankle): +LR 5.1, -LR 0.12MRI (foot/ankle): +LR 5.1, -LR 0.12

Butalia S, et al. Does this patient with diabetes have osteomyelitis of the Butalia S, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? lower extremity? JAMAJAMA; 2008:299(7):806-813, and Kapoor A, et al. MRI for ; 2008:299(7):806-813, and Kapoor A, et al. MRI for diagnosing foot osteomyelitis. diagnosing foot osteomyelitis. Archives of Internal MedicineArchives of Internal Medicine; 2007:167:125-; 2007:167:125-132.132.

26

TreatmentTreatment Antibiotics (in the ED)Antibiotics (in the ED)

But often times paired with eventual surgical But often times paired with eventual surgical source controlsource control

No clear guidelines because no clear evidenceNo clear guidelines because no clear evidence

Open fracture prophylaxisOpen fracture prophylaxis

Clinical bottom line: choice of initial Clinical bottom line: choice of initial antibiotics depends on likely pathogen (like antibiotics depends on likely pathogen (like all of our clinical scenarios) all of our clinical scenarios)

Lazzarini L, et al. Antibiotic treatment of osteomyelitis: what have we learned Lazzarini L, et al. Antibiotic treatment of osteomyelitis: what have we learned from 30 years of clinical trials? from 30 years of clinical trials? International Journal of Infectious DiseasesInternational Journal of Infectious Diseases; ; 2005:9:127-138.2005:9:127-138.

27

TreatmentTreatment

Levine BJ, ed. Levine BJ, ed. 2011 EMRA Antibiotic Guide2011 EMRA Antibiotic Guide; Irving, ; Irving, TX:2010.TX:2010.

2011 EMRA Antibiotic Guide2011 EMRA Antibiotic Guide

28

TreatmentTreatment

Levine BJ, ed. Levine BJ, ed. 2011 EMRA Antibiotic Guide2011 EMRA Antibiotic Guide; Irving, TX:2010.; Irving, TX:2010.

2011 EMRA Antibiotic Guide2011 EMRA Antibiotic Guide

29

Joint InfectionsJoint Infections Trauma in the most likely Trauma in the most likely

cause of an acute cause of an acute monoarticular arthritis in monoarticular arthritis in the ED settingthe ED setting

Clinical bottom line:Clinical bottom line: Distinguish between septic Distinguish between septic

arthritis and other acute arthritis and other acute arthritisarthritis

Important because the Important because the infection can destroy the infection can destroy the joint within a matter of joint within a matter of daysdays

Rudor S and Lewiss RE. Arthritis in the ED: detecting high-risk etiologies and Rudor S and Lewiss RE. Arthritis in the ED: detecting high-risk etiologies and providing effective pain management. providing effective pain management. Emergency Medicine PracticeEmergency Medicine Practice; ; 2004:6(10).2004:6(10).

30

Joint InfectionsJoint Infections Polyarticular infectious arthritis:Polyarticular infectious arthritis: Lyme disease Lyme disease ((Borrelia burgdorferi)Borrelia burgdorferi)

Transmitted by tick biteTransmitted by tick bite Pathognomonic rash: erythema chronicm Pathognomonic rash: erythema chronicm

migransmigrans Can develop arthritis in ~50% of patientsCan develop arthritis in ~50% of patients Occurs late in illness (weeks to years)Occurs late in illness (weeks to years) Usually afebrile with asymmetric arthritis, primarily Usually afebrile with asymmetric arthritis, primarily

affecting large jointsaffecting large joints Treat with extended course of oral antibiotics Treat with extended course of oral antibiotics

(doxycycline or amoxicillin)(doxycycline or amoxicillin) Admit if patient has additional neurologic or cardiac Admit if patient has additional neurologic or cardiac

manifestations for treatment with IV antibioticsmanifestations for treatment with IV antibiotics

Rudor S and Lewiss RE. Arthritis in the ED: detecting high-risk etiologies and Rudor S and Lewiss RE. Arthritis in the ED: detecting high-risk etiologies and providing effective pain management. providing effective pain management. Emergency Medicine PracticeEmergency Medicine Practice; 2004:6(10).; 2004:6(10).

Hannah Garrison, Wikimedia Commons

31

Joint InfectionsJoint Infections Septic arthritis occurs primarily in large Septic arthritis occurs primarily in large

peripheral jointsperipheral joints 50% of the time in the knee, can also be wrist, 50% of the time in the knee, can also be wrist,

ankles, hipsankles, hips IV drug users seem to have predilection for axial IV drug users seem to have predilection for axial

joints as well (sternoclavicular, sternomanubrial)joints as well (sternoclavicular, sternomanubrial)

2 different kinds of septic arthritis:2 different kinds of septic arthritis: NongonococcalNongonococcal Gonococcal – from bacteremic spread of sexually Gonococcal – from bacteremic spread of sexually

transmitted infection (disseminated gonococcal transmitted infection (disseminated gonococcal infection), often associated with a infection), often associated with a polyarthritis/tenosynovitis, skin lesions, age <40, polyarthritis/tenosynovitis, skin lesions, age <40, often synovial fluid culture negativeoften synovial fluid culture negative

Margaretten ME, et al. Does this adult patient have septic arthritis? Margaretten ME, et al. Does this adult patient have septic arthritis? JAMAJAMA; ; 2007:297(13):1478-1488.2007:297(13):1478-1488.

32

Joint InfectionsJoint Infections How do you get septic arthritis?:How do you get septic arthritis?:

(1) Hematologic (1) Hematologic spreadspread

Most commonMost common

Related to bacteremia Related to bacteremia of any causeof any cause More likely to occur More likely to occur

with underlying joint with underlying joint disease (rheumatoid disease (rheumatoid arthritis, osteoarthritis, arthritis, osteoarthritis, etc)etc)

(2) Direct (2) Direct innoculationinnoculation

Less commonLess common

ExamplesExamples Trauma or biteTrauma or bite SurgerySurgery Pre-existing Pre-existing

osteomyelitisosteomyelitis Overlying skin Overlying skin

infectionsinfections

33

EvaluationEvaluation

HistoryHistory No studies specifically addressed both No studies specifically addressed both

sensitivity and specificitysensitivity and specificity Joint pain and swelling is suggestive of septic Joint pain and swelling is suggestive of septic

arthritisarthritis

Physical examPhysical exam Fever fairly uselessFever fairly useless No findings or maneuvers that have been No findings or maneuvers that have been

studied that help (e.g., range of motion, studied that help (e.g., range of motion, degrees of swelling, etc)degrees of swelling, etc)


JAMAThe Journal of the American Medical

Association

34

EvaluationEvaluation TestsTests Serum studiesSerum studies

CBCCBC Blood culturesBlood cultures Inflammatory markers (CRP, ESR)Inflammatory markers (CRP, ESR) Uric acid level?Uric acid level?

ImagingImaging Plain filmsPlain films

Joint fluid analysisJoint fluid analysis


35



Serum laboratory testing of Serum laboratory testing of limited valuelimited value

36


37



38

Clinical bottom line: history and Clinical bottom line: history and physical exam are not able to physical exam are not able to substantially change the pretest substantially change the pretest probability of disease with an acutely probability of disease with an acutely painful and swollen jointpainful and swollen joint

Requires arthrocentesis with joint fluid Requires arthrocentesis with joint fluid analysisanalysis WBC count and %PMNWBC count and %PMN Synovial fluid protein, glucose, LDH not Synovial fluid protein, glucose, LDH not

informativeinformative Caution: a low synovial WBC count cannot Caution: a low synovial WBC count cannot

completely rule out the possibility of septic completely rule out the possibility of septic arthritisarthritis



39

Synovial fluid should be sent for:Synovial fluid should be sent for: *Cell count and differential*Cell count and differential *Crystals*Crystals

Joint InfectionsJoint Infections

Sholter DE and Russell AS. Synovial fluid analysis and the diagnosis of septic Sholter DE and Russell AS. Synovial fluid analysis and the diagnosis of septic arthritis. arthritis. UpToDateUpToDate, 2012., 2012.

*Gram stain and *Gram stain and cultureculture

Protein, glucoseProtein, glucose 40

Is there a way to determine if a patient Is there a way to determine if a patient has gout as a cause of their acute has gout as a cause of their acute monoarticular arthritis?monoarticular arthritis?

Prospective study of patients in Dutch Prospective study of patients in Dutch family practice office settingfamily practice office setting Signs/symptoms of acute monoarticular Signs/symptoms of acute monoarticular

arthritis, irrespective of previous similar arthritis, irrespective of previous similar episodesepisodes

Collected detailed information on history, PE, Collected detailed information on history, PE, meds, etcmeds, etc

Underwent joint aspiration within 24 hoursUnderwent joint aspiration within 24 hours Created scoring system to predict possibility Created scoring system to predict possibility

of goutof gout


Janssens HJEM, et al. A diagnostic rule for acute gouty arthritis in primary Janssens HJEM, et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis? care without joint fluid analysis? Archives of Internal MedicineArchives of Internal Medicine; ; 2010:170(13):1120-1126.2010:170(13):1120-1126.

41

7 variables to 7 variables to score, 13 total score, 13 total pointspoints

Authors suggest:Authors suggest: ≤≤4 or less rules out 4 or less rules out

goutgout ≥≥8 or more rules in 8 or more rules in

goutgout

In the ED:In the ED: High score (≥ 8) High score (≥ 8)

probably rules in probably rules in gout and can treat gout and can treat empirically without empirically without arthrocentesisarthrocentesis


Janssens HJEM, et al. A diagnostic rule for acute gouty arthritis in primary care Janssens HJEM, et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis? without joint fluid analysis? Archives of Internal MedicineArchives of Internal Medicine; 2010:170(13):1120-1126.; 2010:170(13):1120-1126.

http://www.umcn.nl/goutcalchttp://www.umcn.nl/goutcalc

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TreatmentTreatment Irrigation in the ORIrrigation in the OR

AntibioticsAntibiotics

Levine BJ, ed. Levine BJ, ed. 2011 EMRA Antibiotic Guide2011 EMRA Antibiotic Guide; ; Irving, TX:2010.Irving, TX:2010.

43

What joints do we do in the ED?What joints do we do in the ED? Needle size?Needle size? Do you go through an area of cellulitis Do you go through an area of cellulitis

(redness) or not?(redness) or not? Do you inject (steroids) or only aspirate?Do you inject (steroids) or only aspirate? Risks?Risks?

Iatrogenic septic arthritis: 1 in 2,000 to 1 in Iatrogenic septic arthritis: 1 in 2,000 to 1 in 15,000 (UpToDate)15,000 (UpToDate)

How much fluid to you take off?How much fluid to you take off? What do you do if you get a What do you do if you get a ““drydry”” tap? tap?

Use US guidance?Use US guidance? Try a different approachTry a different approach

ArthrocentesisArthrocentesis

44

Sterile procedureSterile procedure


Burton, JH. Burton, JH. ““Acute disorders of the joints and bursae,Acute disorders of the joints and bursae,”” in Tintinalli in Tintinalli’’s s Emergency Medicine: A Comprehensive Study Guide, ed. 7. 2011.Emergency Medicine: A Comprehensive Study Guide, ed. 7. 2011.

Lateral approachLateral approachMedial approachMedial approach

45


Burton, JH. Burton, JH. ““Acute disorders of the joints and bursae,Acute disorders of the joints and bursae,”” in Tintinalli in Tintinalli’’s Emergency s Emergency Medicine: A Comprehensive Study Guide, ed. 7. 2011; and, Roberts WN, Jr. Joint Medicine: A Comprehensive Study Guide, ed. 7. 2011; and, Roberts WN, Jr. Joint

aspiration of injection in adults: techniques and indications. aspiration of injection in adults: techniques and indications. UpToDateUpToDate, 2012., 2012.46

Is it safe to do on someone taking Is it safe to do on someone taking warfarin?warfarin?

Prospective study of patients in Prospective study of patients in rheumatology office setting with most rheumatology office setting with most recent INR < 4.5recent INR < 4.5 Typical needle sizes (18 gauge for knee, 20 Typical needle sizes (18 gauge for knee, 20

for other procedures, 25 for the MTP joint)for other procedures, 25 for the MTP joint) Telephone follow up at 4 weeksTelephone follow up at 4 weeks No patients experienced self-reported joint No patients experienced self-reported joint

or soft tissue hemorrhageor soft tissue hemorrhage


Thumboo J and OThumboo J and O’’Duffy JD. A prospective study of the safety of joint and soft Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium? tissue aspirations and injections in patients taking warfarin sodium? Arthritis Arthritis and Rheumatismand Rheumatism; 1998:41(4):736-739.; 1998:41(4):736-739.

47

OutlineOutline





48

ObjectivesObjectives Know when to suspect osteomyelitisKnow when to suspect osteomyelitis

Know how to evaluate someone with a Know how to evaluate someone with a monoarticular arthritismonoarticular arthritis

Know how to treat osteomyelitis and Know how to treat osteomyelitis and septic arthritisseptic arthritis

Know how to competently perform Know how to competently perform joint aspirationsjoint aspirations

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Case #1Case #1A 64 year old woman with a A 64 year old woman with a history of diabetes presents to history of diabetes presents to your ED with a non-healing your ED with a non-healing right foot ulcer. She has a right foot ulcer. She has a small wound over the 4small wound over the 4thth metatarsal head for last 3 metatarsal head for last 3 weeks. She was prescribed a weeks. She was prescribed a 10 day course of antibiotics by 10 day course of antibiotics by her PCP which she just her PCP which she just completed. She comes in to completed. She comes in to the ED because it has not the ED because it has not healed, ithealed, it’’s the weekend, and s the weekend, and sheshe’’s concerned. On exam the s concerned. On exam the wound is round, 3 cm in wound is round, 3 cm in diameter, with redness and diameter, with redness and swelling. Vital signs are: bp swelling. Vital signs are: bp 155/85, pulse 85, temp 37.5, 155/85, pulse 85, temp 37.5, pulse ox 99% on RA.pulse ox 99% on RA.

Case #2Case #2



2.2. Would you do anything Would you do anything differently now?differently now?

A 57 year old man with a A 57 year old man with a history of hypertension and history of hypertension and alcoholism presents with a alcoholism presents with a swollen knee. He noticed swollen knee. He noticed development of this over the development of this over the last 24 hours. No other last 24 hours. No other joints hurt. He denies fever joints hurt. He denies fever or rashes. He recalls no or rashes. He recalls no recent trauma. He has no recent trauma. He has no history of arthritis. He history of arthritis. He denies any history of similar denies any history of similar episodes of painful joints. episodes of painful joints. Exam shows a swollen, red, Exam shows a swollen, red, and warm right knee joint. and warm right knee joint. He is neurovascularly intact He is neurovascularly intact and without associated rash. and without associated rash. Vital signs are: bp 155/85, Vital signs are: bp 155/85, pulse 85, temp 37.5, pulse ox pulse 85, temp 37.5, pulse ox 99% on RA. 99% on RA.



2.2. Would you do anything Would you do anything differently now?differently now?

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Osteomyelitis: goals in evaluationOsteomyelitis: goals in evaluation Decide if someone has clinical concern for Decide if someone has clinical concern for

osteomyelitis, think about specific high risk osteomyelitis, think about specific high risk clinical scenariosclinical scenarios

Understand (limitations) testing optionsUnderstand (limitations) testing options Treat based on likely pathogensTreat based on likely pathogens Disposition without definitive diagnosisDisposition without definitive diagnosis

Septic arthritis: goals in evaluationSeptic arthritis: goals in evaluation Decide if someone has clinical concern for Decide if someone has clinical concern for

septic arthritisseptic arthritis Understand testing options: arthrocentesis Understand testing options: arthrocentesis

or not?or not? Know how to competently perform an Know how to competently perform an

arthrocentesisarthrocentesis

Questions/comments?Questions/comments?

Final ThoughtsFinal Thoughts

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Documents

Project: Ghana Emergency Medicine Collaborative Document Title: Bone and Joint Infections Author(s): Keith Kocher (University of Michigan), MD, MPH 2012