Topic confernce

INT NONTAPAT PAESAROCH

 Septic arthritis

• Septic arthritis is inflammation of a synovial membrane with purulent

effusion into the joint capsule, due to infection.
 Predisposing Factor :

- Rheumatoid arthritis
- Immunosuppressive drug therapy
- Chronic disorder
- AIDS
- Intravenous drug abuse
- Alcoholism
 Pathogenesis
ㆍ Bacteria can gain entrance to a joint via 3
routes:

Direct Direct spread

Hematoge
inoculation from adjacent
nous
focal infection
Hematogenous Spread
Most common form of spread
Usually affect people with underlying medical problem

Direct Inoculation
May result from penetrating trauma
Introduction of organisms during diagnostic and surgical procedures. For eg arthroscopy and intra-articular
injection

Direct spread from adjacentfocal of infection

More common in children.
Osteomyelitis usually begin in the metaphyseal region,
from which it breaks through the periosteum into the joint.
a) In the early stage, there is an acute synovitis with a purulent
joint effusion
b) Soon the articular cartilage is attacked by bacterial and
cellular enzyme.
c) If infection is not arrested, the cartilage may be completely
destroyed
d) Healing then leads to ankylosis
 If left untreated, it will spread to the underlying bone
and out of joint to form abscess and sinus.

Healing with:
1.Complete resolution
2.Partial loss of articular cartilage and fibrosis of joint
3.Loss of articular cartilage and bony ankylosis
4.Bony destruction and permanent deformity
 Clinical Features
Differ according to age
In new born infants In children In adults

- More on septicaemia
Rather than joint pain
- Baby is irritable & refuse
to feed
- Tachycardia with fever
- Joints are warmth,
tenderness, resistance to
movement
- Umbilical cord and
inflamed IV site should be
suspicious of source of
Infection
- acute pain in single large joint
(esp hip)
-Pseudoparesis
- Child is ill, rapid pulse
and swingingfever
- Overlying skin looks red
& superficial joint swelling
may be obvious
- Local warmth and
marked tenderness
- All movements are restricted by
pain or spasm.
- Look for source of infection
from septic toe or discharge ear
- Often in the superficial joint
(knee, wrist or ankle )
- Joints painful, swollen &
inflamed.
- Warmth and marked local
tenderness & movement
restricted.
- look for gonococcal infection
or drug abuse.
- Patient with rheumatoid
arthritis and especially those
on corticosteroid may develop
Physical examination:
- Lower limb → antalgic limp / cannot walk
- Upper limb → affected part is closedly guarded
- Marked tenderness, active and passive range of motion are limited
- Examine for synovial effusion, erythema, heat and tenderness.
- Spasm of muscles around the joint may be marked.
- Patient may hold the joint in a position to reduce the intra-articular pressure to minimize
pain.
 Investigations

Blood Imaging Synovial fluid

investigations analysis

Investigations Explaination

Full blood count Elevated white blood cell count

ESR > 40 mm/hr

CRP > 20 mg/dL

Blood culture May be positive

 Imaging

X ray
o Early Stage – Normal
o Look for soft tissue swelling, loss of tissue planes, widening of joint
space and slight subluxation due to fluid in joint. Gas may be seen with
E. coli infection
o Late stage - Narrowing and irregularity of joint space
o Plain film findings of superimposed osteomyelitis may develop
(periosteal reaction, bone destruction, sequestrum formation).
 Ultrasonography

• More reliable in revealing a joint effusion in early cases.

• Widening of space between capsule and bone of > 2mm
indicates effusion.
• Echo-free → transient synovitis
• Positively echogenic → septic arthritis
 Treatment
General supportive care
- Analgesics >>> NSAID
- IV fluids
Antibiotics
Treatment is started once the blood and samples are obtained without waiting
for the detail results.
Choice of antibiotic depends on the most likely pathogen
Theraputic arthrocentesis
 Surgical Management

- Surgical Drainage
- Arthroscopic debridement and copious irrigation with normal
saline - more frequently in knee joint septic arthritis
 Complications
• Bone destruction and dislocation of the
joint (esp !Hip)
• Cartilage destruction
- may lead to either fibrosis or bony
ankylosis
- in adult partial destruction of the joint will
result in secondary osteoarthritis
• Growth disturbance
- presenting as either localised deformity or
shortening of the bone