Septic arthritis

Introduction
Half the cases of septic arthritis occur
in children aged below 3 years.
 The hip joint is most commonly
involved in infants, whereas
the knee joint is more common in
older children.
10% of childhood cases have
polyarticular involvement.

2
septic arthritis

An acute infectious process of a joint space

THE DIAGNOSIS NOT TO MISS

Aetiology
risk factor Likely pathogen(s) involved

Arthritis (esp. RA) S. aureus

trauma S. aureus, Streptococci &

neighbouring OM same as that causing the bone

sickle--cell anaemia Salmonella spp. and Strep. pneumoniae

sexual activity N. gonorrhoeae

IVDU Pseudomonas, Serratia spp. and S.aureus

dog/cat bite Pasteurella multocida

human bite Eikenella corrodens

tick exposure Borrelia burgdorfori

exposure to marine life Mycobacterium marinum

4
 ClinicalFeatures
Patient complains of fever,
chilli/rigors, joint pain, swelling and
immobility.
The joint is fixed in the position of
ease. (Knee flexed; hip flexed,
externally rotated and abducted).
Signs include heat, tenderness and
possibly a joint effusion.

5
Pathogenesis
Direct infection of the joint -
penetration through trauma or a
diagnostic/therapeutic procedure OR
local extension of a neighbouring
focus of infection (eg. epiphyseal or
metaphyseal osteomyelitis) OR
Haematogenous spread of
organisms (usually Streptococci,
Staphylococci)

6
In Neonates -Streptococcus the most common
followed by - staphylococcus
- Candida
- Gm negative bacillus (esp. in
hospitalized neonates)
In children – H. Influenzae (Under 2 years)
In adults - N- gonorrhea
- Staph aurous
-Hips and knees - frequent sites
Pathogenesis :
Bacterial presence incites intense local
reaction - in synovial membrane
-Hyperemia
-Edematous -> then form purulent
fluid

-Articular destruction (Proteolytic

enzymes pressure, nutrition)
Infection spreads to-
Underlying bone -destroys growth plate
-> growth disturbance
-> angular deformities
-Joint dislocation - distension , Cartilage
destruction, Ligament disruption ,and
muscle spasm
-Multiple sinuses - in neglected cases
In newborn / Infants
- Cartilaginous femoral head destroyed -
Hypermobile joint
In young children – results is bony
ankylosis
In adolescent and adults > bony or fibrous
ankylosis
Investigations
CBC, ESR
Blood cultures before instituting antibiotic
treatment
X-ray
CT, MRI, isotope scans
Diagnostic aspiration and analysis of
synovial fluid
- send for cytology, biochemistry and
microbiology

11
Synovial Fluid
=> If WBC count >50,000/uL (with >90% PMNLs)
suspect septic arthritis
(Even if culture is negative)
=> Usually glucose is down and protein is up
Important: examine fluid for crystals (urate or CaPP)
Gram stain and culture / sensitivities

12
Imaging

 X-ray
compare with other joint
- Early - rarefaction
- ST swelling
-Late - Bony erosions
- Joint space narrowing
Differential Diagnosis
In children
◦ transient synovitis of the hip (commonest cause of
irritable hip in kids <l0yrs)
◦ Perthes' disease - excluded by history and MRI
◦ Acute rheumatic fever
◦ Henoch-Schonlein purpura
In children and adults
◦ Acute osteomyelitis · RA, OA
◦ Crystal arthropathies

15
Treatment principles
 Pus evacuation - aspiration
- arthroscopy
- arthrotomy
Joint sterilization
-Systemic antibiotics - empirically and on C/S-
results
-Until afebrile and ESR lowers, then oral for
4-6 weeks.
Splintage - rest and prevent deformity
Treatment is initially parenteral, followed
by an oral regime, in total 4-6 weeks.
Aspiration is both diagnostic and
therapeutic.
Open surgical debridement and drainage

17
complications

Sequel of septic arthritis

- ankylosis
- Instability
- Degenerative OA
- Contractures and deformities
- Sepsis and death
Prognosis
Itis curable and recurrences are not
common.
 However, complications of chronic
infection include
◦ loss of articular cartilage,
◦ pathological joint dislocation,
◦ epiphyseal necrosis.
In the long term
◦ joint stiffness and bony ankylosis
◦ Degenerative osteoarthritis is almost
guaranteed.

19
Bone TB

Pott disease
◦ Lower thoracic and upper lumbar
◦ Begins with infl of anterior aspect of
intervertebral joints
◦ Gibbus deformity
TB arthritis
◦ Hip or knee
TB osteomyelitis
 Treatment :-
Medical
Surgical
 synovectomy arthrotomy and biopsy
 curettage of bone erosion + bone grafting
Joint resection( arthroplasty)
Bone resection
Arthrodesis (fusion)
Amputations