Orthopedics Inflammatory Process

1. Orthopedics Inflammatory Process Jan Bazner-Chandler RN, MSN, CNS, CPNP

2. Inflammatory Process • Osteomyelitis • Septic arthritis • Juvenile arthritis

3. Osteomyelitis Webmd.lycos.com

4. Osteomyelitis • Infection of bone and tissue around bone. • Requires immediate treatment • Can cause massive bone destruction and life-threatening sepsis

5. Pathogenesis of Acute Osteo In children 1 year to 15 years the infection is restricted to below the epiphysis. Under 1 year the epiphysis is nourished by arteries.

6. Clinical Manifestation • Localized pain • Decreased movement of area • With spread of infection • Redness • Swelling • Warm to touch

7. Diagnostic Tests: • X-ray • CBC • ESR / erythrocyte sedimentation rate • C-reactive protein • Bone scan – most definitive test for osteomyelitis

8. X-Ray 18-year-old boy with painful right arm

9. Osteomyelitis

10. Management • Culture of the blood • Aspiration at site of infection • Intravenous antibiotics x 4 weeks • PO antibiotics if ESR rate going down • Monitor ESR • Decrease in levels indicates improvement

11. Goals of Care • To maintain integrity of infected joint / joints

12. Septic Arthritis • Infection within a joint or synovial membrane • Infection transmitted by: • Bloodstream • Penetrating wound • Foreign body in joint

13. Septic Arthritis of Hip • Difficulty walking and fever • Diagnosis: x-ray, ESR, aspiration of fluid from joint

14. Septic Hip Flexed hip on affected side is common presentation.

15. Diagnostic Tests X-ray Needle aspiration under fluoroscopy

16. Erythrocyte Sedimentation Rate • ESR • Used as a gauge for determining the progress of an inflammatory disease. • Rises within 24 hours after onset of symptoms. • Men: 0 - 15 mm./hr • Women: 0 – 20 mm./hr • Children: 0 – 10 mm./hr

17. C-Reactive Protein • During the course of an inflammatory process an abnormal specific protein, CRP, appears in the blood. • The presence of the protein can be detected within 6 hours of triggering stimulus. • More sensitive than ESR / more expensive

18. Joint Space Fluid

19. Management • Administration of antibiotics for 4 to 6 weeks. • Oral antibiotics have been found to be effective if serum bactericidal levels are adequate. • Fever control • Ibuprofen for anti-inflammatory effect

20. Juvenile Rheumatoid Arthritis • Chronic inflammatory condition of the joints and surrounding tissues. • Often triggered by a viral illness • 1 in 1000 children will develop JRA • Higher incidence in girls

21. Clinical Manifestations • Swelling or effusion of one or more joints • Limited ROM • Warmth • Tenderness • Pain with movement

22. Diagnostic Evaluation • Elevated ESR / erythrocyte sedimentation rate • + genetic marker / HLA b27 • + RF 9 antinuclear antibodies • Bone scan • MRI • Arthroscopic exam

23. Goals of Therapy • To prevent deformities • To keep discomfort to a minimum • To preserve ability to do ADL

24. Management • First line drugs: • ASA • NSAIDs • Immunosuppressive drugs (oral): azulvadine or methotrexate • Disease modifying drugs • Enbrel - IM • Remicade - IV

25. ASA Therapy • Alert: The use of aspirin has been highly associated with the development of Reye’s syndrome in children who have had chickenpox or flu. Because aspirin may be an an ongoing p art of the regimen of the arthritic child, parents should be warned of the relationship between viral illnesses an aspirin, and be taught the symptoms of Reye’s syndrome.

26. Management • Physical therapy • Exercise program • Monitor ESR levels • Regular eye exams: Iriditis • Cardiac involvement: early studies show some correlation due to inflammatory process

27. Iriditis • Intraocular inflammation of iris and ciliary body • 2% to 21% in children with arthritis • Highest incidence in children with multi joint involvement disease.

28. Clinical Manifestations • Deep eye pain • Photophobia • Often report decrease in color perception • Redness no drainage • Treatment: prednisone eye drops or PO prednisone

29. Muscular Dystrophy • A group of more than 30 genetic diseases characterized by progressive weakness and degeneration of the skeletal muscles that control movement.

30. Duchenne • Most common form of MD and primarily affects boys. • Caused by absence of dystophin a protein needed to maintain integrity of muscle. • Onset between 3 and 5 years • Rapid progression: unable to walk by age 12.

31. Treatment • No cure • Physical therapy • Respiratory therapy • Speech therapy • Orthopedic appliances / corrective procedures • Meds: corticosteroids and immununosuppressants to slow progression of the disease.