JOINT

INFECTIONS
Mponda B.
OUTLINE
 Introduction
 Aetiology
 Risk Factors
 Epidemiology
 Pathophysiology
 Clinical Features
 Investigations
 Differentials
 Treatment
 Complications
INTRODUCTION

 Definition: Septic arthritis is inflammation

of a synovial membrane with purulent
effusion into the joint capsule, usually due
to bacterial infection.
CONT
• Classified as pyogenic (septic) or nonpyogenic.
gonococcal and nongonococcal
 Pyogenic septic arthritis is most frequently
caused by Staphylococcus aureus.

 Others including staphylococci, Strept pneu, group B stre,

Gonococcus species, E. coli, Haemophilus spp, Klebsiella spp,
Pseud spp, and Candida.
CONT.
 In infants hip is the commonest joint

 In older children the knee is the commonest joint

affected

 10% of patients have multiple joints involved

CONT
 Nonpyogenic infective arthritis tends to be
less aggressive and have a more chronic
course.
 Causative organisms include
Mycobacterium tuberculosis, fungi, and
spirochetes.
 Untreated, septic arthritis will lead to
destruction of the articular cartilage
 50% cases occur in children less than 3
years of age
CONT.
CONT.
Joint Adults % Children %

Knee 55 40
Hip 11 28
Ankle 8 14
Shoulder 8 4
Wrist 7 3
Elbow 6 11
Others 5 3
Multiple joints (12) (7)
PATHOPHYSIOLOGY
 ROUTES OF INFECTION

1.Hematogenous
2.Dissemination from osteomyelitis
3.Spread from adjacent soft tissue infection
4.Diagnostic or therapeutic measures
5.Penetrating damage by puncture or cutting
PATHO CONT
MECHANISM OF DESTRUCTION
 Release of proteolytic enzymes (matrix
metalloproteinases) from inflamation and
synovial cells,cartilage and bacterial which may
cause articular surface damage within 8hrs.
CLINICAL FEATURES
 Acute onset of pain in joint (80-90%
monoarticular) is classical presentation –
minimal movement induces pain;
 Local swelling and tenderness, erythema,
warmth and restricted ROM
 Most patients have fever.
 Bacterial infection normally only affects one
joint.
 Viral infection more commonly affects several
joints
CONT
 The presentation depends on the
 Age
 immune competency of the patient
 the joint involved and
 the type and virulence of the infective agent.
 In neonates and infants non-specific signs of
septicemia e.g. failure to thrive, irritability,
anemia
 These signs are usually present for a few days
before it is recognized that the child does not
move a joint or limb spontaneously and dislikes
passive movement.
CONT
 In children with septic arthritis the
symptoms and signs are usually very
acute and all movement of the joints are
extremely painful.
 In superficial joints, effusion and local
signs of infection are easily detectable.
 A single joint is usually infected except in
children under five years where more
joints can be affected simultaneously
LOCAL EXAMINATION
 Any attempt to move the joint for even a few
degrees, will be resisted by the patient due to the
fact of the joint being very painful.
 The joint is usually held in a slightly flexed
position and superficial warmth diffuse tenderness
and fluctuation is present.
 Infants may present with a so called
pseudoparesis or pseudoparalysis of the joint
whereby the child does not move the joint at all.
LOCAL EXAMINATION
 Every painful swollen joint is an infective
arthritis until proven otherwise.

 The
examining doctor should examine and
move all joints in patients with pyrexia of
unknown origin.

 Pain on movement and limitation of hip

joints movement are often overlooked
unless hip joint movement is tested
specifically.
CONT
 In septic arthritis, all movements of the involved
joint are usually painful.
 Joint effusions are easily detectable in superficial
joints but difficult or impossible to detect in other
joints e.g. hip and shoulder.
SEPTIC ARTHRITIS: KOCHER CRITERIA
4 Criteria
 Non-weight bearing on affected side
 ESR >40 mm/hr
 Fever
 WBC >12,000
 If 4/4 criteria met: 99% chance of septic
arthritis
 If ¾ criteria met: 93% chance of septic
arthritis
 If 2/4 criteria met: 40% chance of septic
arthritis
 If ¼ criteria met: 3% chance of septic
arthritis
INVESTIGATIONS

 CBC with differential –

 Often reveals leukocytosis

 Erythrocyte sedimentation rate

 C-reactive protein –
 Helpful in monitoring treatment course
CONT
 Synovial Fluid Analysis
 Blood cultures
 yield organisms 30-50% of cases

 Decreases with previous antibiotic therapy

 Gram stain, leukocyte cell count, PMNs

 Gram stain can give you a presumptive early
diagnosis. 1/3 are positive
 Cell counts 80,000 – 100,000/ml likely septic
arthritis. Other inflammatory processes can
give you >80,000/ml
CONT
 Synovial fluid culture results:

 positive in 85-95% of non-gonococcal arthritis

cases

 Approximately 25% in gonococcal arthritis

cases.
RADIOGRAPHY
-Soft tissue swelling around the joint
 widening of the joint space
 displacement of tissue planes.
 Bony erosions and narrowing of joint space in later
stages of progression.
 Ultrasonography
 Very sensitive in detecting joint effusions generated
by septic arthritis
CONT
 CT scans and MRIs are more sensitive for
distinguishing osteomyelitis, periarticular abscesses,
and joint effusions.

 MRI is preferred because of its greater

ability to image soft tissue.
DDX
 Osteomyelitis
 Osteonecrosis (Avascular necrosis)
Common in the femoral head. Consider in
sickle cell disease or other
hemoglobinopathies, steroid use and
elderly diabetics.
 Hemarthrosis: Common in patients with
bleeding diatheses (e.g. hemophilia) or on
anticoagulation.
 Systemic disease: e.g. RA, reactive
arthritis, endocarditis
TREATMENT

• Acute septic arthritis is a medical emergency!

 Medical therapy:

 IV antibiotics - appropriate dose, route and duration

 Drainage of the septic joint
 Surgical therapy:

 Adequate drainage of a septic joint is the

cornerstone of successful treatment
 Arthroscopic drainage and lavage
 Arthrotomy
 Copious irrigation is then instituted and the joint
is lavaged properly.
 Thereafter the wound is closed over a suction
drain system. A second look procedure may also
be done in a few days.
 Splinting of the joint is advocated, particularly in
the acute phase (first 48hrs after surgery)
APPROACHES FOR OPEN ARTHROTOMY
:
 Hip:
 anterior iliofemoral in children
 Adults posterorlateral approach better
drainage?
 Knee:

 Parapatellar approach
 Posteromedial approach for dependent
drainage
 Shoulder:

 Deltopectoral
CONT
 Wrist:
 Dorsal approach between 3rd and 4th compartments
 Elbow:
 Posterolateral

PAIN MANAGEMENT
 Pain management is of vital importance.
 It should not be neglected. Patient’s
cooperation can only be expected if
excellent pain management had been
given.
COMPLICATIONS
 Dislocation: a tense effusion may disrupt the joint
and cause a dislocation.
 Growth disturbance: epiphyseal or physeal damage
may result in shortening or deformity of the involved
leg.
 Ankylosis: if the articular cartilage is eroded and the
joint is kept still, ankylosis or even spontaneous fusion
of the joint may eventually ensue.
 Joint cartilage destruction: neglected, septic
arthritis may end up with destructed joint and
complete loss of articular cartilage.
 Osteomyelitis
 Death
 End