Bursitis and Septic Arthritis Thomas Diffley This
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slide1. Bursitis and Septic Arthritis Thomas Diffley<br>
slide2. This will work best by going into full screen mode then checking your answers with the notes afterwards<br>
slide3. Learning Objectives Understand the Anatomy and Epidemiology of Bursitis
Understand the Anatomy and Epidemiology of Septic Arthritis
Understand the Bacteriological and pathological basis of septic arthritis
Describe the clinical features of septic arthritis
Be able to produce a differential diagnosis of ‘the patient with a hot knee’
Understand the principles of management of septic arthritis<br>
slide4. Bursitis The Acute or Chronic Inflammation of a Bursa<br>
slide5. Aetiology Acute Infection
Direct Trauma Chronic Lupus
Rheumatoid Arthritis
Repeated Microtrauma
Scleroderma
Crystallopathies – Gout, pseudogout etc.<br>
slide6. Epidemiology M:F = 1:1*
More common in the Obese
Evenly distributed amongst age groups, however some specific forms may favour certain age groups
Septic Bursitis is more common in immunocompromised patients (T2DM, HIV+ve, Chemotherapy) *Pes Anserine and Trochanteric Bursitis are more common in Females. Olecranon Bursitis is more common in males<br>
slide7. Anatomy Where are Bursa? Everywhere!<br>
slide8. Anatomy They are Synovial lined fluid filled sacs
They exist between bones, ligaments, tendons and muscles
They reduce the friction when moving<br>
slide9. Knee Bursa 14 bursa exist in total
Some communicate with the joint space
4 that we will focus on that do not are the SUPRAPATELLAR, PREPATELLAR, INFRAPATELLAR and PES ANSERINE Bursae<br>
slide10. Olecranon Bursitis ‘Students Elbow’
Very common in those with a lot of repeated irritation to the elbow (Good students) or with repeated strains (Manual Labourers)
Pretty Obvious: Swelling, localised pain and reduced movement<br>
slide11. Honourable Mentions: Trochanteric Bursitis Fairly Common
Pain at the Trochanters of the hip, spreading laterally
More common in Women than Men
Gradual Onset, Typically Chronic Bursitis rather than acute Shoulder Bursitis Rarer, tend to actually be tendinopathies
Again, more chronic than acute
Detailed history and examination needed
Don’t confuse with frozen shoulder or rotator cuff injuries<br>
slide12. Investigations CRP
FBC
ESR
Consider Aspiration with specialist input<br>
slide13. Management: Acute ACE-A
Assessment – is the patient unwell?
Cause?
Exacerbating Factors?
Antibiotics? - Antimicrobial guidance (nhsgrampian.org)<br>
slide14. Management Chronic ACE-C
Assessment
Cause
Exacerbating Factors
Control<br>
slide15. Septic Arthritis<br>
slide16. Epidemiology<br>
slide17. Anatomy Septic Arthritis is Infection within the joint space (as opposed to some bursa)
The acidic environment provided by the bacteria eats away at the hyaline cartilage
Can be spread via direct inoculation or via haematogenous spread from other soft tissue infection<br>
slide18. Aetiology Staphylococcus Aureus Streptococcus Pneumoniae Neisseria Gonorrhea Mycobacterium Tuberculosis MRSA<br>
slide19. Clinical Findings Hot
Swollen
Painful
Reduced Movement<br>
slide20. Diagnosis Arthrocentesis
Swabs
CRP
FBC / U+E
Imaging
Blood Culture All
Septic
Cartilage
Feels
Incredibly
Bad<br>
slide21. Management Just start Abx… NO!<br>
slide22. Management NEVER LET THE SUN SET AND RISE ON PUS Urgent Washout is needed in order to remove infected material and pus from the joint space
The more aggressive the washout the better
Follow up treatment for antibiotics should be par for the course
Watch out for Sepsis post operatively
If there is metalwork – DO NOT ASPIRATE – Needs a different pathway of decision making out with this teaching exercise.<br>
slide23. Cases<br>
slide24. Case 1<br>
slide25. Case 1<br>
slide26. Case 1 - Examination Where do you want to examine?
What might be your findings?
Look, Feel, Move<br>
slide27. Case 1 - Investigations<br>
slide28. Case 1 - Management Open Washout and post operative Antibiotics
Pain relief<br>
slide29. Case 2<br>
slide30. Case 2 - Details 84 Yo female on ward 102, referred to the ortho reg over having a ‘hot and swollen hip’
PMH – T2DM, UTI in 2022, Parkinsonism 2021
In hospital currently for a Community Acquired chest infection
Sore and mildly unwell<br>
slide31. Case 2 - Examination On examination you find the following localised around her hip and buttocks
It is hot and very tender to touch<br>
slide32. Case 2 - Investigations ESR, FBC, U+E
Blood Cultures
CRP
Do you aspirate?<br>
slide33. No! This patient has cellulitis, if you aspirate into the hip through the cellulitis tissue you will introduce infective material into the joint and cause a septic arthritis!
Aspiration always requires senior input and should never be attempted blind – Requires X-ray screening GMC<br>
slide34. Management<br>
slide35. Case 2 - Complications<br>
slide36. Case 3<br>
slide37. Case 3 - Presentation<br>
slide38. Case 3 - History<br>
slide39. Case 3 - Examination<br>
slide40. Case 3 - Investigations<br>
slide41. Case 3 - Management<br>
slide42. Thankyou for watching! Questions – Email: tom.diffley@nhs.scot<br>
slide43. Notes<br>
slide2. This will work best by going into full screen mode then checking your answers with the notes afterwards<br>
slide3. Learning Objectives Understand the Anatomy and Epidemiology of Bursitis
Understand the Anatomy and Epidemiology of Septic Arthritis
Understand the Bacteriological and pathological basis of septic arthritis
Describe the clinical features of septic arthritis
Be able to produce a differential diagnosis of ‘the patient with a hot knee’
Understand the principles of management of septic arthritis<br>
slide4. Bursitis The Acute or Chronic Inflammation of a Bursa<br>
slide5. Aetiology Acute Infection
Direct Trauma Chronic Lupus
Rheumatoid Arthritis
Repeated Microtrauma
Scleroderma
Crystallopathies – Gout, pseudogout etc.<br>
slide6. Epidemiology M:F = 1:1*
More common in the Obese
Evenly distributed amongst age groups, however some specific forms may favour certain age groups
Septic Bursitis is more common in immunocompromised patients (T2DM, HIV+ve, Chemotherapy) *Pes Anserine and Trochanteric Bursitis are more common in Females. Olecranon Bursitis is more common in males<br>
slide7. Anatomy Where are Bursa? Everywhere!<br>
slide8. Anatomy They are Synovial lined fluid filled sacs
They exist between bones, ligaments, tendons and muscles
They reduce the friction when moving<br>
slide9. Knee Bursa 14 bursa exist in total
Some communicate with the joint space
4 that we will focus on that do not are the SUPRAPATELLAR, PREPATELLAR, INFRAPATELLAR and PES ANSERINE Bursae<br>
slide10. Olecranon Bursitis ‘Students Elbow’
Very common in those with a lot of repeated irritation to the elbow (Good students) or with repeated strains (Manual Labourers)
Pretty Obvious: Swelling, localised pain and reduced movement<br>
slide11. Honourable Mentions: Trochanteric Bursitis Fairly Common
Pain at the Trochanters of the hip, spreading laterally
More common in Women than Men
Gradual Onset, Typically Chronic Bursitis rather than acute Shoulder Bursitis Rarer, tend to actually be tendinopathies
Again, more chronic than acute
Detailed history and examination needed
Don’t confuse with frozen shoulder or rotator cuff injuries<br>
slide12. Investigations CRP
FBC
ESR
Consider Aspiration with specialist input<br>
slide13. Management: Acute ACE-A
Assessment – is the patient unwell?
Cause?
Exacerbating Factors?
Antibiotics? - Antimicrobial guidance (nhsgrampian.org)<br>
slide14. Management Chronic ACE-C
Assessment
Cause
Exacerbating Factors
Control<br>
slide15. Septic Arthritis<br>
slide16. Epidemiology<br>
slide17. Anatomy Septic Arthritis is Infection within the joint space (as opposed to some bursa)
The acidic environment provided by the bacteria eats away at the hyaline cartilage
Can be spread via direct inoculation or via haematogenous spread from other soft tissue infection<br>
slide18. Aetiology Staphylococcus Aureus Streptococcus Pneumoniae Neisseria Gonorrhea Mycobacterium Tuberculosis MRSA<br>
slide19. Clinical Findings Hot
Swollen
Painful
Reduced Movement<br>
slide20. Diagnosis Arthrocentesis
Swabs
CRP
FBC / U+E
Imaging
Blood Culture All
Septic
Cartilage
Feels
Incredibly
Bad<br>
slide21. Management Just start Abx… NO!<br>
slide22. Management NEVER LET THE SUN SET AND RISE ON PUS Urgent Washout is needed in order to remove infected material and pus from the joint space
The more aggressive the washout the better
Follow up treatment for antibiotics should be par for the course
Watch out for Sepsis post operatively
If there is metalwork – DO NOT ASPIRATE – Needs a different pathway of decision making out with this teaching exercise.<br>
slide23. Cases<br>
slide24. Case 1<br>
slide25. Case 1<br>
slide26. Case 1 - Examination Where do you want to examine?
What might be your findings?
Look, Feel, Move<br>
slide27. Case 1 - Investigations<br>
slide28. Case 1 - Management Open Washout and post operative Antibiotics
Pain relief<br>
slide29. Case 2<br>
slide30. Case 2 - Details 84 Yo female on ward 102, referred to the ortho reg over having a ‘hot and swollen hip’
PMH – T2DM, UTI in 2022, Parkinsonism 2021
In hospital currently for a Community Acquired chest infection
Sore and mildly unwell<br>
slide31. Case 2 - Examination On examination you find the following localised around her hip and buttocks
It is hot and very tender to touch<br>
slide32. Case 2 - Investigations ESR, FBC, U+E
Blood Cultures
CRP
Do you aspirate?<br>
slide33. No! This patient has cellulitis, if you aspirate into the hip through the cellulitis tissue you will introduce infective material into the joint and cause a septic arthritis!
Aspiration always requires senior input and should never be attempted blind – Requires X-ray screening GMC<br>
slide34. Management<br>
slide35. Case 2 - Complications<br>
slide36. Case 3<br>
slide37. Case 3 - Presentation<br>
slide38. Case 3 - History<br>
slide39. Case 3 - Examination<br>
slide40. Case 3 - Investigations<br>
slide41. Case 3 - Management<br>
slide42. Thankyou for watching! Questions – Email: tom.diffley@nhs.scot<br>
slide43. Notes<br>