Orthopedics Inflammatory Process

Jan Bazner-Chandler RN, MSN, CNS, CPNP

Inflammatory Process Osteomyelitis

Septic arthritis

Juvenile arthritis

Osteomyelitis

Webmd.lycos.com

Osteomyelitis Infection of bone and tissue around bone.

Requires immediate treatment

Can cause massive bone destruction and life-threatening sepsis

Pathogenesis of Acute Osteo

Under 1 yearthe epiphysis is nourished byarteries.

In children 1 yearto 15 years theinfection is restrictedto below the epiphysis.

Clinical Manifestation Localized pain Decreased movement of area With spread of infection

Redness Swelling Warm to touch

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

osteomyelitis

X-Ray

18-year-old boy with painful right arm

Osteomyelitis

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

Goals of Care To maintain integrity of infected joint / joints

Septic Arthritis Infection within a joint or synovial membrane Infection transmitted by:

Bloodstream Penetrating wound Foreign body in joint

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

joint

Septic Hip

Flexed hip on affectedside is common presentation.

Diagnostic Tests

X-ray

Needle aspirationunder fluoroscopy

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

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

Joint Space Fluid

WBC 80,000

Segs 88%

Monos 1%

Lymphs 11%

RBC 16,000

Gram Stain Gram-positive cocci in chains

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

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

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

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

Goals of Therapy To prevent deformities

To keep discomfort to a minimum

To preserve ability to do ADL

Management First line drugs:

ASA NSAIDs

Immunosuppressive drugs (oral): azulvadine or methotrexate

Disease modifying drugs Enbrel - IM Remicade - IV

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.

Management Physical therapy Exercise program Monitor ESR levels Regular eye exams: Iriditis Cardiac involvement: early studies show some

correlation due to inflammatory process

Iriditis Intraocular inflammation of iris and ciliary

body

2% to 21% in children with arthritis

Highest incidence in children with multi joint involvement disease.

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

prednisone

Muscular Dystrophy A group of more than 30 genetic diseases

characterized by progressive weakness and degeneration of the skeletal muscles that control movement.

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.

Treatment No cure Physical therapy Respiratory therapy Speech therapy Orthopedic appliances / corrective

procedures Meds: corticosteroids and

immununosuppressants to slow progression of the disease.