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 year the epiphysis is nourished by arteries. In children 1 year to 15 years the infection is restricted to 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 affected side is common presentation.

Diagnostic Tests X-ray Needle aspiration under 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: 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 WBC80,000 Segs88% Monos1% Lymphs11% RBC16,000 Gram StainGram-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.