Soft Tissue &

Musculoskeletal
Infections
in the Primary Care Setting

Patty W. Wright, MD
March 2011
Objectives
 To familiarize participants with some of the most
common soft tissue and musculoskeletal
infections in the primary care setting, including
their diagnosis and treatment.
Case 1
 A 42 yo female who
works as a housekeeper
presents with a one year
history of swelling and
redness along the
borders of her nails
bilaterally.
 What is the diagnosis?
 How would you treat
her?

http://missinglink.ucsf.edu/lm/DermatologyGlossary/paronychia.html
 Paronychia
 Infection of the skin
(epidermis) bordering
the nail
 Typically associated
with trauma:
 Manicures
 Ingrown nails
 Dishwashing
 Thumb sucking

http://en.wikipedia.org/wiki/File:Paronychia_argentea_(286232698).jpg
Chronic Paronychia
 Chronic paronychia typically due to eczema
 Often have superinfection with yeast
(Candida)
 Rx with steroid and antifungal creams
 If no response, trial of oral antifungals with
topical steroids
 Patient should avoid prolonged water
exposure to the hands
 Consider alternative diagnoses such as
psoriasis
Acute Paronychia

 Commonly due
bacteria such to
Staph aureus or
Group A Strep
 Soaks and surgical
drainage usually
enough
 If severe, treat with
oral antibiotics
http://en.wikipedia.org/wiki/File:Paronychia.jpg
 Case 2
 A 26 yo female hair
dresser develops
throbbing pain, swelling,
redness, & warmth in the
distal portion of her index
finger. She recalls that she
accidentally stuck herself
in the finger with her
scissors the day before.
http://drhem.com/2009/08/16/hand-case-3-1/
 What is the diagnosis?
 How would you treat her?
Felon
 Abscess of the pad (or pulp) of the tip of the finger
or toe
 Significant pain, redness, and swelling in finger tip
 Most commonly due to S. aureus
 May spread to bone with resulting infection
(osteomyelitis)
 Most commonly in thumb and index finger
 Typically related to trauma: splinters, puncture
wounds, scraps or abrasions
Felon
 If early: elevation, soaks, and oral antibiotics
 If late: rx as above plus surgical drainage
 Culture the fluid to direct antibiotic therapy
 Consider x-ray to rule out foreign body or
bone infection
 Rx for 5-14 days depending on severity
Case 3
 A 33 year old female
presents with a red
pustular lesion on her
left 5th finger. The lesion
is tender and has been
present for almost a
week.
 What additional
questions would you
like to ask this patient?
 What pathogens are on
your differential
diagnosis?
Herpetic Whitlow
 Autoinoculation of HSV 1 or 2 into non-intact
skin
 Health care workers at risk if not using
universal precautions
 Abrupt onset of edema, erythema and
tenderness
 Clear vessicles may coalesce become cloudy
 Confirm with Tzanck test, viral culture, DFA,
or HSV PCR
Herpetic Whitlow
 Typically resolves in 2-3 weeks without rx
 Treatment with antivirals (acyclovir,
famciclovir, valacyclovir) within 48hrs of onset
may lessen severity
 Cover with dry dressing to avoid spread to
other areas
 Recurs in up to 50% of patients, though
primary outbreak most severe
Case 4
 A 47 yo male construction
worker with a history of
“athletes' foot” presents to
the ED with redness, pain,
and swelling over his
ankle and lower leg.
 What is the diagnosis?
 How would you treat him?

http://battlegames.wordpress.com/2008/12/
Cellulitis
 Infection of the skin (dermis and hypodermis)
with some extension into the fatty,
subcutaneous tissues
 Local signs: redness, swelling, warmth, and
tenderness +/- enlarged lymph nodes
 Systemic signs may include low grade fevers,
chills, and body aches
 Blood cultures rarely positive (2%)
Cellulitis
 Most common causes are Group A Strep and
S. aureus
 Rx with iv antibiotics (vancomycin) for
inpatients
 Rx with oral antibiotics for outpatient therapy
 If pt not systemically ill, has a normal immune
system, and has reliable follow up and access to
antibiotics
 Remember that trim-sulfa may not be the best
coverage for Strep
Case 5

 A 50 yo male carpenter presents to the ER c/o pain

in his hand. He reports that a board fell on his hand
yesterday with some mild bruising. He awoke today
with pain so severe that he was unable to drive
himself to the ED.
 What is the diagnosis?
 How would you treat him?
Fasciitis / Myositis
 Fasciitis
 Infection of the fascia (thick layer of connective
tissue that surrounds the muscles, bones, nerves
and blood vessels)
 Myositis
 Infection of the muscles
 Rare: 500-1500 cases/year in the US
 Clinical Presentation
 Fever, elevated heart rate, & low blood pressure
 Local signs and symptoms such as swelling, large
blisters, crepitus, and pain out of proportion to the
exam
Fasciitis
 Imaging studies
such as CT or MRI
scans helpful if gas
present in the soft
tissues
 Negative imaging
does not rule out
fasciitis
Fasciitis
 Type 1
 Mixed infection of aerobic and anaerobic bacteria
 Seen in post surgical patients, diabetics and
patients with PVD
 Type 2
 Monomicrobial infection caused by GAS or MRSA
in previously healthy patients
Fasciitis
 Surgery, Surgery, Surgery
 Re-exploration after 24 hours with repeat
debridement, if necessary
 Blood pressure support and ICU care, if
indicated
 Antibiotic therapy
Fasciitis
 Empiric Antibiotics  Target
1. Core antibiotic: 1. Sensitive Gram
Imipenem, positives, Gram
Meropenem, Pip-tazo negatives & anerobes

2. Secondary antibiotic: 2. MRSA

Vancomycin, Linezolid,
Daptomycin

3. Clindamycin and IVIG

3. Group A Streptococcus
toxin
Case 6
 An 28 yo male
landscaper presents with
pain and swelling along
the length of his middle
finger. He reports that
his pain is most severe
when he tries to move
the finger.
 What is the diagnosis?
 How would you treat
him?
Infectious
Tenosynovitis
 Infection of the fluid-
filled sheath that
surrounds the tendon
 Leads to swelling and
pain of the finger (or
toe) especially with
movement

http://www.sportnetdoc.com/injury/07-06.htm
Acute Infectious
Tenosynovitis
 Kanavel signs for pyogenic flexor
tenosynovitis:
 Uniform symmetric swelling of the digit
 Digit held in partial flexion at rest
 Excessive tenderness along the entire
tendon sheath
 Pain along the sheath with passive digit
extension
 Most clinically reproducible sign
Acute Infectious
Flexor Tenosynovitis
 Most commonly related to trauma, particularly
at the flexor crease
 Most common pathogens are Staph and
Strep
 Polymicrobial infections possible in DM or
immunocompromised
 May occur following hematogenous spread,
particularly with N. gonorrhoeae
 Early stage may respond to elevation,
splinting, and iv abx
Acute Infectious
Tenosynovitis
 I&D if…
 DM

 Immunocompromised

 No improvement within 12-24 hrs of abx

therapy
 Gram stain and culture to direct abx therapy
 Rx empirically with vancomycin and
quinolone (ciprofloxacin, levofloxacin) then
tailor regimen to cx results
Chronic Infectious
Tenosynovitis
 Often due to atypical mycobacterial or fungal
infections
 Empiric therapy is difficult given wide
spectrum of etiologies
 Cultures for AFB and fungi essential to
diagnosis and treatment
 Pathology with special stains may be helpful,
but cultures best
Case 7
 A 44 yo former roofer is
paralyzed following a fall with
spinal cord injury 5 years ago.
Recently he developed a small
ulceration on his lower back
which has progressed despite
local care. On exam, the
wound probes to the bone.
 What is the diagnosis?
 How would you treat him?

http://boneandspine.com/orthopaedic-images/clinical-photograph-of-stage-iv-sacral-bed-sore-in-a-patient-of-cervical-spine-injury/
Osteomyelitis

 May be acute (progressing over days) or chronic

(progressing over weeks to months)
 May occur from direct spread of infection or
spread of infection through the blood stream
 Hematogenous (20%)
 Children
 Contiguous with vascular insufficiency (30%)
 Diabetic neuropathy
 Contiguous without vascular insufficiency (50%)
 Trauma (natural or iatrogenic)
Haematogenous Osteomyelitis
 PAIN is primary symptom
 Frequently progressive over several months
 Constitutional symptoms or local edema/erythema
less common
 Long bones most common site in children
 Vertebrae most common site in adults
 Single pathogen most likely
 S. aureus most common
 P. aeruginosa with injection drug use
Osteomyelitis
 Definitive diagnosis
requires bone biopsy
 Often diagnosed clinically
based on exam, labs, and
imaging
 WBC count rarely elevated
 Sedimentation rate (ESR)
and C-reactive protein
www4.path.utah.edu
(CRP) measures of
inflammation are useful for
serial monitoring
“Probe Test” of Osteomyelitis

 Obtain sterile probe

 Gently insert into
deepest portion of ulcer
 Sens = 66%
 Spec = 85%
 PPV = 89%
 NPV = 56%

 Exposed bone is
infected bone
Osteomyelitis Imaging – Xrays

 Cheap and easy

 Able to evaluate for
foreign body
 Not useful for acute
osteomyelitis
 Radiolucent areas do not
appear until 50-75%
bone loss
Osteomyelitis Imaging –
Technetium Bone Scan
 More sensitive than plain radiography
 Taken up in areas with
 Increased blood flow

 New bone formation

 May be positive as early as 48 hours

after infection
 Gallium and indium scans less sensitive
Osteomyelitis Imaging –
CT and MRI scans
 Excellent bone
resolution
 Hindered by presence
of prosthetic material
 MRI preferred for
small bones of
hands/feet

flickr.com/photos/69918874@N00/2208251162/
Osteomyelitis
 Treatment typically involves…
 Surgical debridement followed by aggressive
wound care
 Prolonged antibiotic therapy
 6 weeks minimum, may extend for months
depending on clinical course
 IV antibiotics needed for acute osteomyelitis
 Oral antibiotics alone may be indicated for
some chronic osteomyelitis
 Unless definitive pathogen identified by bone
biopsy, broad spectrum coverage indicated
Case 8
 An 82 year old woman
presents with swelling and
pain in her left knee. She
underwent a total knee
arthroplasty 10 years ago for
OA with a revision 3 years
ago for loosening of the
hardware.
 What is the diagnosis?
 How would you treat her?
Epidemiology of
Prosthetic Joint Infections
 1-3% of primary joint replacements
 Knee = 1-2%
 Hip = 0.3 – 1.3%
 Shoulder - <1%
 3-6% of revision procedures
 Knee = 6%
 Hip = 3%
Prosthetic Joint Infections-
Timing of Infection
Classification Characteristic
Early (<3 months) Typically acquired at surgery and associated
more virulent organisms
e.g. Staphylococcus aureus, Gram-negative
bacilli
Delayed (3 – 24 months) Typically acquired at surgery and associated
with less virulent organisms
e.g. coagulase-negative Staphylococci,
Proprionibacterium acnes
Late (>24 months) Usually associated with haematogenous
spread from distant infection
Prosthetic Joint Infections-
Clinical Presentation
PAIN
 Present in >90% cases
 Night pain more concerning for
infection
 Start-up pain appears more
consistent with aseptic loosening
Prosthetic Joint Infections-
Diagnosis
 Primary differentiation is between infection
and aseptic loosening
 Rely on “totality of circumstances”
 Clinical exam

 Laboratory data
 ESR/CRP
 Culture of joint fluid
 Imaging
 Prosthetic Joint Infections-
Treatment Approach
 Acute infection (<4 wks)
 AND stable implant
 AND no sinus tract…
 Consider debridement
with retention followed
by IV antibiotics +/-
additional PO antibiotics
 Chronic PJI…
 Joint removal is
necessary for cure
 Debridement with
retention followed by
IV antibiotics then
suppressive PO
antibiotics may be
considered in
debilitated patients who
cannot tolerate joint
removal
Summary
 Paronychia & felons are infections of the
fingers/toes which often improve with simple I&D
and/or po abx
 Treatment for cellulitis should include coverage of
Staph and Strep
 Fasciitis is a surgical emergency & should be
treated with very broad-spectrum antibiotics
 Acute infectious tenosynovitis is typically due to
bacteria; chronic is often due to mycobacteria or
fungi
 Exposed bone is infected bone
 Osteomyelitis and PJI’s typically require surgery
and long-term abx therapy