musculoskeletal disorders part 2 bone infections
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MMusculoskeletal Disorders Part 2usculoskeletal Disorders Part 2Bone infectionsBone infections
Maria Carmela L. Domocmat, RN,MSN
Instructor
School of NursingNorthern Luzon Adventist College
Artacho, Sison, Pangasinan
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OverviewOverview Part 1: Degenerative & Metabolic bone
disorders: Part 2: Bone infections
Osteomyelitis
ep c ar r s Part 3: Muscular disorders
Part 4: Disorders of the hand
Part 5: Spinal column deformities Part 6 : Disorders of foot
Part 7: Sports Injuries
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BONE INFECTIONSBONE INFECTIONS
Osteomyelitis
Septic arthritis
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BONE INFECTIONS:BONE INFECTIONS:
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OsteomyelitisOsteomyelitis
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Osteomyelitis is infection in the bones. Often, the original site of
infection is elsewhere in the body, and spreads to the bone by the
blood. Bacteria or fungus may sometimes be responsible for
osteomyelitis.
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OsteomyelitisOsteomyelitis Infection of the bone, most often of the
cortex or medullary portion. Is commonly caused by bacteria, fungi,
arasites & viruses.
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OsteomyelitisOsteomyelitis Classified by mode of entry- Contiguous
or exogenous is caused by a pathogenfrom outside the body or the by the
s read of infection from adjacent soft
tissues. The organism is Staph aureus.
Example- pathogens from open fracture. The onset is insidious: initially cellulites
progressing to underlying bone.
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OsteomyelitisOsteomyelitis Hematogenous- caused by bloodborne
pathogens originating from infectious siteswithin the body.
Ex: sinus, ear, dental, respiratory & GUinfections.
The infection spreads from the bone tothe soft tissues & can eventually breakthrough the skin, becoming a draining
fistula. Again, Staph aureus is the most common
causative organism.
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S/sS/s Acute Osteomyelitis left untreated or
unresolved after 10 days is consideredchronic.
Necrotic bone is the distinguishing
eature o c ron c osteomye t s.
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SymptomsSymptoms Bone pain Fever General discomfort, uneasiness, or ill-feeling
(malaise) Other symptoms that may occur with this
disease: Chills Excessive sweating Low back pain Swelling of the ankles, feet, and legs
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PathophysiologyPathophysiology similar to that infectious processes in any
other body tissue.
Bone inflammation is marked by edema,increased vascularity & leukocyte activity.
ever, ma a se, anorex a, ea ac e. affected body may be erythematous, tender,
& edematous. There may be fistula draining
purulent material. Blood test- increase WBCs, ESR, & C-protein
levels.
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Causes, incidence, and riskCauses, incidence, and risk
factorsfactors Bone infection can be caused by bacteria
(more common) or fungi (less common). Infection may spread to a bone from
infected skin muscles or tendons next to
the bone, as in osteomyelitis that occursunder a chronic skin ulcer (sore).
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Causes, incidence, and riskCauses, incidence, and risk
factorsfactors The infection that causes osteomyelitis
can also start in another part of the bodyand spread to the bone through the
blood.
A current or past injury may have madethe affected bone more likely to develop
the infection.
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Causes, incidence, and riskCauses, incidence, and risk
factorsfactors A bone infection can also start after bone
surgery, especially if the surgery is doneafter an injury or if metal rods or plates
are laced in the bone.
children -- long bones usually affected.
Adults -- feet, vertebrae, and pelvis are
most commonly affected.
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Risk factorsRisk factors Diabetes
Hemodialysis Injected drug use
Recent trauma
People who have had their spleen
removed are also at higher risk forosteomyelitis
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OsteomyelitisOsteomyelitis Osteomyelitis of
diabetic foot
Osteomyelitis of T10
secondary tostreptococcal
disease.
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OsteomyelitisOsteomyelitis Osteomyelitis of the
great toe
Osteomyelitis of
index fingermetacarpal head
secondary to
c enc e st n ury
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OsteomyelitisOsteomyelitis Osteomyelitis of
index fingermetacarpal head
secondary to
Osteomyelitis of the
elbow.
c enc e st n ury.
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DxDx teststests A physical examination shows bone tenderness
and possibly swelling and redness.
Tests may include: Blood cultures
Bone biopsy (which is then cultured)
one scan
Bone x-ray
Complete blood count (CBC)
C-reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
MRI of the bone
Needle aspiration of the area around affected bones
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DxDx teststests Diagnosis requires 2 of the 4 following
criteria: Purulent material on aspiration of affected
bone
Positive findings of bone tissue or bloodculture
Localized classic physical findings of bony
tenderness, with overlying soft-tissueerythema or edema
Positive radiological imaging study
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http://emedicine.medscape.com/article/785020-treatment
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Emergency Department CareEmergency Department Care Select the appropriate antibiotics using direct
culture results in samples from the infected site,
whenever possible.
Further surgical management may involve
remova o t e n us o n ect on, mp antat onof antibiotic beads or pumps, hyperbaric oxygen
therapy,or other modalities.
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http://emedicine.medscape.com/article/785020-treatment
Nidus: a nest; A central point or focus of bacterial growth in a living organism.
the point of origin or focus of a disease process.
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TreatmentTreatment Treatment is difficult & costly.
Goal of treatment complete removal of necrotic bone & affected
soft tissue
control of infection & elimination of deadspace (after removal of necrotic bone).
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TreatmentTreatment The primary treatment for osteomyelitis
parenteral (IV) antibiotics that penetratebone and joint cavities for at least 4-6 weeks.
After intravenous antibiotics are initiated on
an inpatient basis, therapy may be continuedwith intravenous or oral antibiotics, depending
on the type and location of the infection, on
an outpatient basis.
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AntibioticsAntibiotics Nafcillin (Nafcil, Unipen)
Ceftriaxone (Rocephin) Cefazolin (Ancef)
Ceftazidime (Fortaz, Ceptaz)
Clindamycin (Cleocin)
Vancomycin (Vancocin)
Linezolid (Zyvox)
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TreatmentTreatment Surgery
to remove dead bone tissue if have aninfection that does not go away.
If there are metal plates near the infection,
they may need to be removed. The open space left by the removed bone
tissue may be filled with bone graft or packing
material that promotes the growth of newbone tissue.
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TreatmentTreatment Infection of an orthopedic prosthesis,
such as an artificial joint, may needsurgery to remove the prosthesis and
infected tissue around the area.
If have diabetes- need to be wellcontrolled.
If problems with blood supply to theinfected area, such as the foot, surgery to
improve blood flow may be needed.
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Nursing managementNursing management use of aseptic technique during dressing
changes. Observed for S/S of systemic infection, &
.
ROM exercises are encouraged to
prevent contractures & flexion
deformities & participation in ADL to thefullest extent is encouraged.
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Expectations (prognosis)Expectations (prognosis) markedly improved with timely diagnosis
and aggressive therapeutic intervention. The outlook is worse for those with long-
term chronic osteom elitis even with
surgery. Amputation may be needed, especially in
those with diabetes or poor blood circulation.
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Expectations (prognosis)Expectations (prognosis) The outlook for those with an infection
of an orthopedic prosthesis depends, inpart, on:
The atient's health
The type of infection Whether the infected prosthesis can be safely
removed
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ComplicationsComplications Bone abscess
Paravertebral/epidural abscess Bacteremia
Loosening of the prosthetic implant
Overlying soft-tissue cellulitis
Draining soft-tissue sinus tracts
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ComplicationsComplications When the bone is infected, pus is produced
in the bone, which may result in an abscess. The abscess steals the bone's blood supply.
The lost blood supply can result in a
complication called chronic osteomyelitis. Other complications include:
Need for amputation
Reduced limb or joint function
Spread of infection to surrounding tissues or the
bloodstream
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PreventionPrevention Prompt and complete treatment of
infections is helpful. People who are athigh risk or who have a compromised
immune s stem should see a health care
provider promptly if they have signs of aninfection anywhere in the body.
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Deterrence/PreventionDeterrence/Prevention Acute hematogenous osteomyelitis
can potentially be avoided by preventingbacterial seeding of bone from a remote site.
This involves the appropriate diagnosis and
treatment of primary bacterial infections.
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Deterrence/PreventionDeterrence/Prevention Direct inoculation osteomyelitis
can best be prevented with appropriatewound management and consideration of
prophylactic antibiotic use at the time of
injury.
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SEPTIC ARTHRITISSEPTIC ARTHRITIS
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Septic arthritisSeptic arthritis Septic arthritis is inflammation of a
joint due to a bacterial or fungal infection. AKA:
Bacterial arthritis
Non-gonococcal bacterial arthritis
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CausesCauses Septic arthritis develops when bacteria or
other tiny disease-causing organisms(microorganisms) spread through the
bloodstream to a joint. It ma also occur
when the joint is directly infected with amicroorganism from an injury or during
surgery.
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CausesCauses most common sites - knee and hip.
acute septic arthritis bacteria such as staphylococcus or
stre tococcus.
chronic septic arthritis less common
caused by organisms such asMycobacterium
tuberculosisand Candida albicans.
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Risk factorsRisk factors Artificial joint implants Bacterial infection somewhere else in your
body Chronic illness or disease (such as
diabetes, rheumatoid arthritis, and sickle cell
disease) Intravenous (IV) or injection drug use Medications that suppress your immune
system Recent joint injury Recent joint arthroscopy or other surgery
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Risk factorsRisk factors seen at any age.
Children occurs most often in those younger than 3
years.
The hip is often the site of infection in infants.
uncommon from age 3 to adolescence.
Children - more likely than adults infected
with Group Bstreptococcus or Haemophilus influenza, ifthey have not been vaccinated.
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SymptomsSymptoms Symptoms usually come on quickly.
Feverjoint swelling - usually just one joint.
-
movement.
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Symptoms in newborns or infants:Symptoms in newborns or infants: Cries when infected joint is moved
(example: diaper change causes crying ifhip joint is infected)
Fever
Inability to move the limb with theinfected joint (pseudoparalysis)
Irritability
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Symptoms in children and adults:Symptoms in children and adults: Inability to move the limb with the
infected joint (pseudoparalysis) Intense joint pain
Joint redness
Low fever
Chills may occur, but are uncommon
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Exams and TestsExams and Tests Aspiration of joint fluid for cell count,
examination of crystals under themicroscope, gram stain, and culture
Blood culture
X-ray of affected joint
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TreatmentTreatment Antibiotics are used to treat the infection.
Joint Immobilization and Physical Therapy Resting, keeping the joint still, raising the joint,
and usin cool com resses ma hel relieve
pain. Exercising the affected joint helps the
recovery process.
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TreatmentTreatment Arthrocentesis
If synovial fluid builds up quickly due to theinfection, a needle may be inserted into the
joint often to aspirate the fluid.
Severe cases may need surgery to drainthe infected joint fluid.
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TreatmentTreatment Medical management of infective arthritis
focuses adequate and timely drainage of the infected
synovial fluid,
administration of appropriate antimicrobialtherapy
immobilization of the joint to control pain.
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Antibiotic TherapyAntibiotic Therapy In native joint infections, parenteral antibiotics - at least 2
weeks.
Infection with either methicillin-resistant S aureus (MRSA) or
methicillin-susceptible S aureus (MSSA) - at least 4 full weeksIV antibiotic therapy.
Orally administered antimicrobial agents are almost never.
Gram-negative native joint infections with a pathogen that issensitive to quinolones can be treated with oral ciprofloxacinfor the final 1-2 weeks of treatment.
As a rule, a 2-week course of intravenous antibiotics issufficient to treat gonococcal arthritis.
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AntibioticsAntibiotics linezolid with or without rifampin - for
staphylococcal prosthetic joint infection (PJI).
Ceftriaxone (Rocephin)
drug of choice (DOC) against N gonorrhoeae.
This agent is effective against gram-negativeenteric rods.
Monitor sensitivity data.
Ciprofloxacin (Cipro) alternative antibiotic to ceftriaxone to treat N
gonorrhoeae and gram-negative enteric rods.
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AntibioticsAntibiotics Cefixime (Suprax)
a third-generation oral cephalosporin withbroad activity against gram-negative bacteria.
Oral cefixime is used as a follow-up to
intravenous (IV) ceftriaxone to treat Ngonorrhoeae.
Oxacillin
useful against methicillin-sensitive S aureus(MSSA).
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AntibioticsAntibiotics Vancomycin (Vancocin)
anti-infective agent used against methicillin-
sensitive S aureus (MSSA), methicillin-resistantcoagulase-negative S aureus (CONS), and
-
allergic to penicillin. Linezolid (Zyvox)
an alternative antibiotic that is used in
patients allergic to vancomycin and for thetreatment of vancomycin-resistantenterococci.
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http://emedicine.medscape.com/article/236299-
medication#showall
Joint Immobilization andJoint Immobilization and
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Joint Immobilization andJoint Immobilization and
Physical TherapyPhysical Therapy Usually, immobilization of the infectedjoint to control pain is not necessary after
the first few days. If the patient's condition responds
a equate y a ter ays o treatment,begin gentle mobilization of the infected
joint.
Most patients require aggressive physicaltherapy to allow maximum postinfectionfunctioning of the joint.
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Joint Immobilization andJoint Immobilization and
Physical TherapyPhysical Therapy Initial physical therapy consists of
maintaining the joint in its functional
position and providing passive ROMexercises.
e o nt s ou ear no we g t unt t eclinical signs and symptoms of synovitishave resolved.
Aggressive physical therapy is oftenrequired to achieve maximum therapybenefit.
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Synovial Fluid DrainageSynovial Fluid Drainage The choice of the type of drainage, whether
percutaneous or surgical, has not been
resolved completely. In general, use a needle aspirate initially,
repeating joint taps frequently enough toprevent signi icant reaccumu ation o ui .
Aspirating the joint 2-3 times a day may benecessary during the first few days.
If frequent drainage is necessary, surgical
drainage becomes more attractive. Gonococcal-infected joints rarely require
surgical drainage.
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Synovial Fluid DrainageSynovial Fluid Drainage Surgical drainage is indicated when one or more
of the following occur:
The appropriate choice of antibiotic and vigorouspercutaneous drainage fails to clear the infection after5-7 days
e in ecte joints are i icu t to aspirate eg, ip
Adjacent soft tissue is infected
Routine arthroscopic lavage is rarely indicated.However, drainage through the arthroscope is
replacing open surgical drainage. With arthroscopicdrainage, the operator can visualize the interior of thejoint and can drain pus, debride, and lyse adhesions.
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Surgical Intervention inSurgical Intervention in
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gg
Prosthetic Joint InfectionProsthetic Joint Infection In cases of prosthetic joint infection (PJI) that require
surgery for cure, successful treatment requiresappropriate antibiotic therapy combined with removal
of the hardware. Despite appropriate antibiotic use, the success rate
has been only about 20% if the prosthesis is left inp ace.
In recent years, evidence has shown that debridementalone could yield a cure rate of 74.5% of patients witha prosthetic joint infection and a C-reactive protein(CRP) level of 15 mg/dL or less who are treated with
a fluoroquinolone. For the time being, a 2-stage approach should be
regarded as the most effective technique.
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Surgical Intervention inSurgical Intervention in
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gg
Prosthetic Joint InfectionProsthetic Joint Infection First, remove the prosthesis and follow with
6 weeks of antibiotic therapy.
Then, place the new joint, impregnating themethylmethacrylate cement with an anti-
, , .
Antibiotic diffusion into the surroundingtissues is the goal.
The success rate for this approach is
approximately 95% for both hip and kneejoints.
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Surgical Intervention inSurgical Intervention in
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gg
Prosthetic Joint InfectionProsthetic Joint Infection An intermediate method is to exchange
the new joint for the infected joint in a 1-
stage surgical procedure with
concomitant antibiotic thera .
This method, with concurrent use ofantibiotic cement, succeeds in 70-90% of
cases.
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Outlook (Prognosis)Outlook (Prognosis)
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Outlook (Prognosis)Outlook (Prognosis)
Recovery is good with prompt antibiotic
treatment. If treatment is delayed,
permanent joint damage may result.
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Possible ComplicationsPossible Complications
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Possible ComplicationsPossible Complications
Joint degeneration (arthritis)
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PreventionPrevention
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PreventionPrevention
Strictly adhere to sterile procedureswhenever the joint space is invaded (eg, in
aspiration or arthroscopic procedures). Antibiotic prophylaxis
with an antistaphylococcal antibiotic has beendemonstrated to reduce wound infections injoint replacement surgery.
Polymethylmethacrylate cement impregnated
with antibiotics may decrease perioperativeinfections.
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PreventionPrevention
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PreventionPrevention
Treat any infection promptly to lessen the
chance of bloodstream invasion.
decreasing the incidence of underlying
infections best revents reactive arthritis
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ReferencesReferences
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ReferencesReferences
Espinoza LR. Infections of bursae, joints, andbones. In: Goldman L, Ausiello D, eds. CecilMedicine. 23rd ed. Philadelphia, Pa: SaundersElsevier; 2007:chap 290.
Ohl CA. Infectious arthritis of native joints. In:,
Douglas, and Bennett's Principles and Practice ofInfectious Disease. 7th ed. Philadelphia, Pa: SaundersElsevier; 2009:chap 102.
http://www.nlm.nih.gov/medlineplus/ency/article/0
00430.htm http://emedicine.medscape.com/article/236299-
medication#showall
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REACTIVE ARTHRITISREACTIVE ARTHRITIS
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Reactive arthritisReactive arthritis
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Reactive arthritisReactive arthritis
AKA: Reiter syndrome; Post-infectious
arthritis
a sterile inflammatory process that usually
results from an extra-articular infectious
process. Bacteria are the most significant
pathogens because of their rapidly
destructive nature.
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