ACUTE SEPTIC ARTHRITIS

AND ACUTE OSTEOMYELITIS

BY
AMR HASSAN ABDEL ATTY
IMRCS ENGLAND,MSc ORTHOPAEDICS

NATIONAL INSTITUTE OF NEUROMOTOR SYSTEM

ACUTE OSTEOMYELITIS
 Definition

• An inflammation of the bone caused by an infective

organism, leading to inflammatory destruction of
bone, necrosis and new bone formation.
 Risk factors
• Systemic:
– Malnutrition.
– Sickle cell anaemia.
– Diabetes.
– Immuno-suppressive conditions.
• Local:
– Trauma.
– Foreign body.
– contiguous infection.
Acute haematogenous
osteomyelitis
Causal organism:

– Staph. aureus 80%.

– Strept., Pneumococcus, H. infleunzae (<2yrs).
– Pseudomonas  heroin addicts.
– Salmonella  sickle cell anaemia.
 Sources fo infection

• Minor skin abrasion, boil, septic tooth.

• Infected umbilical cord.
• Urethral catheterization.
 Pathogenesis
• The organism usually settle in the metaphysis
of :
– Proximal tibia.
– Proximal and distal femur.
– Proximal end of the humerus.
• Acute inflammatory reaction:
– Increase intra-osseous pressure.
– Obstruction to the blood flow.
– Intravascular thrombosis.
• Suppuration:
– Pus forms within the bone in the 2nd and 3rd day.
– Through Volkmann's canal  subperiosteal
abscess forms.
• Bone necrosis:
– By the end of the first week.
– Due to
• infective thrombosis
• Periosteal stripping.
• Bacterial toxin.
• Leucocyte enzymes.
• New bone formation:
By the end of the 2nd week.

• +-Resolution.
Hematogeneous osteomyelitis of children usually begins in the metaphysis of long bones:
The blood-borne bacteria are carried to the marrow space by way of the nutrient artery
 Sinus tracts which drain into the
soft tissue or extend to the skin
surface (fistula or cloaca)
• Impaired the blood supply to
the cortical and medullary
bone  ischemic bone tissue
 necrosis
• After several days a sizeable
portion of the necrotic bone
tissue may separate from the
viable bone as an avascular
bone fragment termed a
sequestrum
– the formation of an
involucrum (coffin)
 Clinical Pictures

• Pain, restless
• Tenderness
• Malaise and fever
• The limb is held still
(pseudo paralysis)
• Sometimes mild or
absent (neonates)
• Lymphadenopathy
Investigation :
Laboratory findings
- Leucocytosis: left ESR ↑ CRP
- Blood culture (50% +ve)
- Bone aspiration (90% +ve)
Conventional x-ray:
- Soft tissue oedema (0-4 days)
- Rarifaction & destruction (4-8 days)
- Periosteal reaction (> 8 days)
Other imaging modalities :
- C.T, MR1
- Radio nuclide scan, U.S.
Radiographs
• Soft tissue swelling

• Periosteal reaction

• Bony destruction
(10-12 days)
Differential Diagnosis

• Acute Septic Arthritis

• Acute monoarticular
rheumatoid arthritis
• Sickle cell crisis
• Cellulitis
• Ewing’s Sarcoma
• Once a clinical diagnosis of A.H.O. is
established bone aspiration is mandatory:
o Establish an accurate bacteriological diagnosis
o Determine whether an abscess is present.
o Can be therapeutic.

• Immediate gram stain is done on any pus

obtained as this provides a good guide to the
nature of the organism even before culture
results.
 Lines of treatment (A.H.O.)
* General * Local
-Antibiotics: -Drainage of the pus:
- Broad spectrum -Aspiration
- Drilling (medulla)
-Incision (soft tissue)

- Supportive measures: -Immobilization of the limb:

- Infusion -Relief pain
- Transfusion - Decrease spasm
- Analgesics - Decrease Spread
- Antipyretics - ↑ local resist
Surgery and antibiotic treatment of A.H.O
are complementary. In some patients,
antibiotic ttt. alone will cure the disease,
in others, prolonged antibiotic ttt. is
doomed to failure with out surgical ttt.
Antibiotic choice :

- Whether or not surgical drainage is necessary

antibiotics are begun immediately.
- The Initial choice of antibiotics is made on a best
guess basis.
- At least 90% of the cases are caused by staph.
Aureus.
- After all culture are obtained the proper
antibiotic is used.
The need for surgery :

There are three main indications for surgery in

A.H.O.:
- The presence of an abscess requiring
drainage.
- Failure of improvement despite IV
antibiotic treatment.
- Joint involvement.
Surgery:
• The objective: Drain any abscess cavity and
remove all non viable or necrotic tissue
• Subperiosteal abscess in an infant-several small
holes drilled through the cortex into the
medullary canal
• If intramedullary pus is found, a small window
of bone is removed
• Skin is closed loosely over drains and the limb
splinted
• Generally a 6 week course of intravenous
antibiotics is given.

• Orthopedic and infectious disease

followup is continued for at least 1 year.
Complications
• Septicaemia.
• Metastatic infection ( infants).
• Suppurative arthritis.
• Altered bone growth.
• Chronic osteomyelitis.
ACUTE SEPTIC ARTHRITIS
 Definition
• Inflammation of a synovial membrane with
purulent effusion into the joint capsule, often
due to bacterial infection.
A Big Problem
• Despite advances in diagnostic studies, powerful
antibiotics, and early drainage, significant joint
destruction commonly occurs.
• Why?
– Lack of clinical suspicion .

– Delay in definitive diagnostic needle aspiration.

– Failure to adequately drain the joint.

Etiology
• Staph aureus.

• Streptococci.

• In all age groups, 80% due to gram-positive aerobes,

20% due to gram-negative anaerobes.
• Neonates and infants < 6months- S aureus and gram-
negative anaerobes.
• Incidence of H. influenzae has decreased due to the vaccine
Infection Sources
Pathophysiology

• Adults
– Knee 40-50 %
– Hip 20-25 %
– Infants and young children
• Hip 95 %
Pathological changes :

- Synovitis  oedema, congestion, thickening.

- Effusion & rapid pus formation.

- Destruction of articular cartilage & ligaments.

- Abscess (soft tissue)(extra-capsular).

- Dislocation (pathological) (e.g. the Hip).

- End result  ankylosis (Bony).

 Clinical Presentation: “red,
hot, painful joint”
• Fever.
• Erythema.
• Edema.
• Heat.
• Pain.
• Markedly decreased passive and active ROM.
Differential Diagnosis:

• Acute osteomyelitis.

• Transient synovitis of the hip (<10).

• Acute rheumatic fever.

• Haemoarthrosis.

• Haemophilic arthritis .
Differentiation from transient synovitis

4 independent variables:

-History of fever.

-Non-weight-bearing.

-ESR > 40mm/h.

-WBC > 12,000/uL.

Investigations :

* Laboratory * Radiological ex.

- Leucocytosis - Early haziness
- ESR, CRP - Late narrow J. space
- Blood cultures: + in 50% S aureus - New bone formation
- AspirationAspiration: if WBC >50,000with >90% PMNLs suspect septic arthritis even if culture is
negative.

* Other methods
Ultra-sonography
MRI, Isotopic scan
Treatment of acute case :

* Antibiotics & supportive I.V. 2-4w

- Broad spectrum.
- Analgesic & antipyritic.

* Joint support
- Splint in the best position of function.
- Frequent observation.
* Joint Aspiration (needle or arthroscopy)
- Remove pus, decrease tension and pain.
- Sample for culture sensitivity.
- Local injection of antibiotic.
- Can be repeated.

* Incision drainage(arthrotomy):
- If aspiration failed or get thick pus.
- Rapid pus collection.

* PT
Take home message
• The key to successful management is early diagnosis
and appropriate surgical and antimicrobial
treatment.
• The diagnosis of A.H.O. depends on high index of
suspicion. Child with acute bone pain and systemic
signs of sepsis should be considered to has A.H.O.
until proved other wise.
Thank you for not sleeping
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