septica arthritis

7/30/2019 Septica Arthritis

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YUSUF BRILLIANTM.JAUHARIL WAFI


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septic arthritis

is an inflammatory joint diseasecaused by bacterial, viral, andfungal infection.


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Route of infection dissemination of pathogens via the blood, from distant

site. (most common)

dissemination from an acute osteomylitic focus dissemination from adjacent soft tissue infection,

entry via penetrating trauma

entry via iatrogenic means


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Etiology The causal organism is usuallyStaphylococcus aureus.

In children under the age of 3 years Haemophilusinfluenzae is fairly common

gram-negative bacilli (a group of bacteria, includingEscherichia coli, or E. coli)

streptococci (a group of bacteria that can lead to awide variety of diseases)


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Pathology There is an acute synovitis with a purulent joint effusion

and Synovial membrane becomes edematous, swollen andhyperemic, and produces increase amount of cloudy

exudates contains leukocytes and bacteria As infection spread through the joint, articular cartilage is

destroyed by bacterial and cellular enzymes.

If the infection is not arrested the cartilage may be

completely destroyed. Pus may burst out of the joint to form abscesses and

sinuses.

The joint may be become pathologically dislocated.


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With healing there will be:

Complete resolution and return to normal.

Partial loss of cartilage and fibrosis.Bone ankylosis

Bone destruction and permanent deformity.


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Clinical presentation

Typical features are acute pain and swelling in a singlelarge joint ,commonly the hip in children and the knee inadults, however any joint can be affected.

The most commonly involved joint is the knee (50% ofcases), followed by the hip (20%), shoulder (8%), ankle(7%), and wrists (7%). interphalangeal, sternoclavicular,

and sacroiliac joints each make up 1-4% of cases.


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1. Symptoms in newborns or infants:

The emphasis is on septicemia rather than joint pain.

Irritability ,Fever, refuses to feed, rapid pulse.

Unable to move the limb with the infected joint(pseudoparalysis) .

Cries when infected joint is moved (diaper changing)

Infection is usually suspected ,but it could be anywhereso the joints should be carefully felt and moved to elicitthe local signs of warmth ,tenderness and resistance tomovement.

Umbilical cord or the site of injection should beexamined for possible source of infection.

If the baby is distressed and wont move his/her leg thinkof hip infection.


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2. In children:

Acute pain in single large joint.

The joint is swollen (if superficial), warmand tender.

Fever.

All movements are restricted due to musclespasm (Pseudoparesis).


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3. In adult:

Intense joint pain .

Joint swelling .

Joint redness .

Unable to move the limb with the infectedjoint .

Low-grade fever.


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Physical examination

1. Decreased or absent rang of motion.

2. Signs of inflammation: joint swelling, warmth,tenderness and erythema.

3. Joint orientation as to minimize pain (positionof comfort):

Hip: abducted, flexed and externally rotated.

Knee, ankle and elbow: partially f lexed.

Shoulder: abducted and internally rotated


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InvestigationLab studies:

The diagnosis can usually be confirmed by joint aspirationand immediate microbiological investigation of the fluid.

Blood culture may be positive in about 50% of provencases.

Non specific features of acute inflammation-leucocytosis,ESR,CRP-are suggestive but not diagnostic .


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Ask for:

gram stain, culture, leukocyte count withdifferential, and crystal examination

leukocyte count:o generally higher than 50,000/L, with a predominance

of neutrophils more than 75%

gram stain:are positive in approximately 75% of patients withstaphylococcal infections; however, results are positive in only50% of patients with gram-negative infections


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crystal examination: exclude crystal-induced arthritis (may coexist)

culture: The definitive method

for aerobic and anaerobic organisms.

are positive in 85-95%

Synovial fluid glucose, protein, and lactic acidconcentration not specific.


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Imaging studies

1-Plain x-ray:

The appearance of significant x-ray findings depends uponthe duration and virulence of infection.

Plain radiography findings are generally nonspecific andmay reveal only soft tissue swelling ,widening of the jointspace ( due to the effusion), and periarticular osteoporosisduring the first 2 weeks.

Later ,when the articular cartilage is attacked ,the jointspace is narrowed.(persistent subluxation, destructivearthritis).


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Septic arthritis of the hip following group B strep psoas abscess


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Septic arthritis

of the ankle


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2-Ultrasonography

This study is very sensitive in detecting joint effusionsgenerated by septic arthritis.

Ultrasound can be used to define the extent of septic arthritis

and help guide treatment. Ultrasound helps to differentiate septic arthritis from other

conditions (e.g., soft tissue abscesses, tenosynovitis) in whichtreatment may differ.


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DIFFERENTIAL DIAGNOSIS Osteomyelitis: near a joint may be indistinguishable from septic

arthritis ;the safest is to assume that both are present.

An acute haemarthrosis :either post-traumatic or due to a

haemophilic bleed ,can closely resemble infection. The history ishelpful and joint aspiration will resolve any doubt.

Transient synovitis(irritable joint) in children: causessymptoms and signs which are less acute ,but there is always the thatthis is the beginning of an infection.

Gout and pseudogout in adults :aspirated fluid may look turbidbut the presence of urate or pyrophosphate crystals will confirm thediagnosis.

Rheumatic fever


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complication Dislocation: a tense effusion may cause dislocation

Epiphyseal destruction: in neglected infants the largelycartilaginous epiphysis may be destroyed ,leaving an unstable

pseudarthrosis. Growth disturbance: physeal damage may result in shortening or

deformity

Ankylosis: if articular cartilage is eroded healing may lead to

ankylosis Secondary osteoarthritis

Osteomyleitis/abcess/sinus


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Treatment General Measures:

The first priority is to aspirate the joint and examine thefluid, treatment is then started without further delay.

Analgesics and splinting of the involved joint in theposition of maximal comfort alleviate pain.

Fluid replacement and nutritional support may berequired.

Other foci of infection and any coexisting medicalconditions must be identified and treated appropriately.


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Drainage:

Indication of Surgical Drainage:

1-Joints that do not respond to antimicrobial therapy anddaily arthrocentesis

2-. Any joint with limited accessibility, including thesternoclavicular or the hip joint

3-Patients with underlying disease, including diabetes,rheumatoid arthritis, immunosuppression, or other

systemic symptoms, should be treated more aggressivelywith earlier surgical intervention


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septica arthritis

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