Thomas Diffley This will work best by going into full screen mode then checking your answers with the notes afterwards Learning Objectives Understand the Anatomy and Epidemiology of Bursitis ID: 1037746
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1. Bursitis and Septic ArthritisThomas Diffley
2. This will work best by going into full screen mode then checking your answers with the notes afterwards
3. Learning ObjectivesUnderstand the Anatomy and Epidemiology of BursitisUnderstand the Anatomy and Epidemiology of Septic ArthritisUnderstand the Bacteriological and pathological basis of septic arthritisDescribe the clinical features of septic arthritisBe able to produce a differential diagnosis of ‘the patient with a hot knee’Understand the principles of management of septic arthritis
4. BursitisThe Acute or Chronic Inflammation of a Bursa
5. AetiologyAcuteInfectionDirect TraumaChronicLupusRheumatoid ArthritisRepeated MicrotraumaSclerodermaCrystallopathies – Gout, pseudogout etc.
6. EpidemiologyM:F = 1:1*More common in the ObeseEvenly distributed amongst age groups, however some specific forms may favour certain age groupsSeptic 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
7. AnatomyWhere are Bursa?Everywhere!
8. AnatomyThey are Synovial lined fluid filled sacsThey exist between bones, ligaments, tendons and musclesThey reduce the friction when moving
9. Knee Bursa14 bursa exist in totalSome communicate with the joint space4 that we will focus on that do not are the SUPRAPATELLAR, PREPATELLAR, INFRAPATELLAR and PES ANSERINE Bursae
10. 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
11. Honourable Mentions:Trochanteric BursitisFairly CommonPain at the Trochanters of the hip, spreading laterallyMore common in Women than MenGradual Onset, Typically Chronic Bursitis rather than acuteShoulder BursitisRarer, tend to actually be tendinopathiesAgain, more chronic than acuteDetailed history and examination neededDon’t confuse with frozen shoulder or rotator cuff injuries
12. InvestigationsCRPFBCESRConsider Aspiration with specialist input
13. Management: AcuteACE-AAssessment – is the patient unwell?Cause?Exacerbating Factors?Antibiotics? - Antimicrobial guidance (nhsgrampian.org)
14. Management ChronicACE-CAssessmentCauseExacerbating FactorsControl
15. Septic Arthritis
16. Epidemiology
17. AnatomySeptic Arthritis is Infection within the joint space (as opposed to some bursa)The acidic environment provided by the bacteria eats away at the hyaline cartilageCan be spread via direct inoculation or via haematogenous spread from other soft tissue infection
18. AetiologyStaphylococcus AureusStreptococcus PneumoniaeNeisseria GonorrheaMycobacterium TuberculosisMRSA
19. Clinical FindingsHotSwollenPainfulReduced Movement
20. DiagnosisArthrocentesisSwabsCRPFBC / U+EImagingBlood CultureAllSepticCartilageFeelsIncrediblyBad
21. ManagementJust start Abx…NO!
22. ManagementNEVER LET THE SUN SET AND RISE ON PUSUrgent Washout is needed in order to remove infected material and pus from the joint spaceThe more aggressive the washout the betterFollow up treatment for antibiotics should be par for the courseWatch out for Sepsis post operativelyIf there is metalwork – DO NOT ASPIRATE – Needs a different pathway of decision making out with this teaching exercise.
23. Cases
24. Case 1
25. Case 1
26. Case 1 - ExaminationWhere do you want to examine?What might be your findings?Look, Feel, Move
27. Case 1 - Investigations
28. Case 1 - ManagementOpen Washout and post operative AntibioticsPain relief
29. Case 2
30. Case 2 - Details84 Yo female on ward 102, referred to the ortho reg over having a ‘hot and swollen hip’PMH – T2DM, UTI in 2022, Parkinsonism 2021In hospital currently for a Community Acquired chest infectionSore and mildly unwell
31. Case 2 - ExaminationOn examination you find the following localised around her hip and buttocksIt is hot and very tender to touch
32. Case 2 - InvestigationsESR, FBC, U+EBlood CulturesCRPDo you aspirate?
33. 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
34. Management
35. Case 2 - Complications
36. Case 3
37. Case 3 - Presentation
38. Case 3 - History
39. Case 3 - Examination
40. Case 3 - Investigations
41. Case 3 - Management
42. Thankyou for watching!Questions – Email: tom.diffley@nhs.scot
43. Notes