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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