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SEPTIC ARTHRITIS
&
TOM SMITH ARTHRITIS
Introduction
 A joint inflammation due to an
infection usually involving synovial
joints.
 50% of cases- children less than 5
years.
 30% of cases- children less than 2
years.
Common sites(Adults)
 Knee- 53%
 Hip- 20%
 Elbow- 17%
 Shoulder- 10%
Common sites(Children)
Knee- 39%
 Hip- 32%
CAUSATIVE ORGANISMS
Staphylococcus aureus
Hemophilus influenza
Streptococcus
E. coli
Proteus
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septicarthritis-140504005810-phpapp01.pdf

  • 2. Introduction  A joint inflammation due to an infection usually involving synovial joints.  50% of cases- children less than 5 years.  30% of cases- children less than 2 years.
  • 3. Common sites(Adults)  Knee- 53%  Hip- 20%  Elbow- 17%  Shoulder- 10%
  • 5. CAUSATIVE ORGANISMS Staphylococcus aureus Hemophilus influenza Streptococcus E. coli Proteus
  • 7. MODES OF SPREAD 1. Direct invasion. 2. Local spread from adjacent tissues. 3. Spread from metaphyseal osteomyelitis. 4. Hematogenous spread.
  • 8. Predisposing Factors-General factors  Rheumatoid arthritis.  SLE  Immunosuppressive drug therapy.  Diabetes mellitus.  Immunodeficiency disorders.  Chronic debilitating disorders- liver failure and renal failure.
  • 9. Predisposing factors- Local factors Previous joint trauma. H/o arthritis to the same joint. Degenerative joint disease. Crystal induced joint disease.(gout and pseudogout)
  • 10. PATHOLOGY  Bacteria rapidly gains access to the joint cavity and settles in the synovial membrane.  Acute inflammatory reaction occurs with formation of serous or seropurulent exudate.  Articular cartilage is eroded and destroyed due to the action of bacterial toxins and by enzymes released from the synovium and inflammatory cells.  In late cases- extensive erosion due to synovial proliferation and ingrowth.
  • 11.  If untreated- spread to the underlying bone or burst out of the joint to form abscesses and sinuses.  With healing: 1. Complete resolution. 2. Partial loss of cartilage and fibrosis of joint. 3. Loss of articular cartilage and bony ankylosis. 4. Bone destruction and permanent deformity of the joint.
  • 12. Clinical Features- Symptoms  Fever  Pain over joint.  Reluctance to move joint(pseudoparesis).
  • 13. Signs  In neonates: Few clinical signs. Child may not have fever. Loss of spontaneous movement of extremity. Hip-flexion, abduction, and external rotation.
  • 14.  In children: signs of local inflammation are present.  Rapid pulse and swinging fever.  Overlying skin-red.  Swelling may be present.  Local rise of temperature and marked tenderness over joint.  All movements of joint- restricted.
  • 15.  In adults: Often a superficial joint( knee, wrist or ankle). Joint is painful, swollen, and inflamed. Movements are restricted.
  • 16. PHYSICAL EXAMINATION 1. Decreased or absent range of motion. 2. Signs of inflammation: joint swelling, warmth, tenderness and erythema. 3. Joint orientation as to minimize pain (position of comfort):  Hip: abducted, flexed and externally rotated.  Knee, ankle and elbow: partially flexed.  Shoulder: abducted and internally rotated
  • 17. Investigations 1. Blood investigations 2. X- ray 3. USG 4. Diagnostic aspiration 5. MRI
  • 18. BLOOD INVESTIGATIONS  Leucocytosis >12,000.  ESR>40 mm/hr.  CRP- elevated.  Blood culture-may be positive.
  • 19. X-ray In early stages- usually normal. Later on- joint space widening may be present and subluxation of the joint may be present. In late stages- irregularity of the joint.
  • 22. USG  Can be used to detect even the smallest amount of joint effusion.  Non invasive, inexpensive and easy to use.  Can be used to guide joint aspiration.
  • 23. JOINT ASPIRATION  In early cases- fluid may be clear.  Sample sent for Gram staining, microscopy, culture, and antibiotic sensitivity.  Normal synovial fluid leucocyte count: under 300/ml.  Leucocyte count>50,000 per ml with 90% PMN- strongly suggestive of septic arthritis.
  • 27. MRI  Can detect infection and extent of infection.  Useful in diagnosing infections that are difficult to access.  Also useful in differentiating between bone and soft tissue infections and in detecting joint effusion.
  • 28. Differential Diagnosis  Acute osteomyelitis.  Trauma  Irritable joint  Hemophilic joint.  Rheumatic fever  Gout and pseudogout  Gaucher’s disease.
  • 29. Treatment  IV fluids- to prevent dehydration.  Analgesics- for pain.  Joint must be rested either on splint or in a widely split plaster.
  • 30. Antibiotics  Broad spectrum IV antibiotics are started immediately and then depending on microbiological investigations, specific antimicrobial therapy is started.  First line antibiotics: Benzyl penicillin, flucloxacillin, and augmentin.  Second line antibiotics: Vancomycin, Clindamycin, Fusidin, and Teicoplanin.  Hemophilus infection- cephalosporins.
  • 31.  Duration of treatment: IV antibiotics given for minimum of 2 weeks.  Oral antibiotics: Children-2-4 weeks. Adults- 4-6 weeks.
  • 32. Drainage: Indication of Surgical Drainage: 1-Joints that do not respond to antimicrobial therapy and daily arthrocentesis 2-. Any joint with limited accessibility, including the sternoclavicular or the hip joint 3-Patients with underlying disease, including diabetes, rheumatoid arthritis, immunosuppression, or other systemic symptoms, should be treated more aggressively with earlier surgical intervention
  • 33. Drainage  In septic arthritis of hip- surgical drainage is always done.  Best approach-anterolateral  Joint is opened through a small incision and washed with normal saline.  Small drain is left in place after incision is closed.  Suction-irrigation is continued for another 2 or 3 days.
  • 34.  In knee- arthroscopic debridement and copious irrigation.  In adults- repeated closed aspiration of joint may be done.  But if no improvement within 48 hours- open drainage is necessary.
  • 35. Complications  Joint Destruction  Coxa magna  Pathological Dislocation  Acute Osteomyelitis  Septicemia  Secondary osteoarthritis  Avascular necrosis
  • 37.  Septic arthritis of the hip.  Seen in infants.  Head of femur is completely destroyed by the pyogenic process.
  • 38.  Transphyseal vessels are present in early infancy before the formation of the growth plate This may account for the frequency of septic arthritis of the hip in the neonate  In children, about a third of long-bone osteomyelitis is associated with septic arthritis of the adjacent joint.
  • 39. Clinical features  Onset is acute with rapid abscess formation.  Can be mistaken for a superfical infection.  Can present later with complaints of limp without any pain.  O/E: Affected leg is shorter and hip movements are increased in all directions.  Telescopy test-positive.
  • 40.  X-ray- complete absence of the head and neck of femur.  Condition resembles DDH; complete absence of head and neck and normally developed round acetabulum.
  • 41. Treatment  Acute surgical emergency.  Open drainage of hip joint is the most effective method of treatment in septic arthritis of the hip.  Arthroscopic drainage can also be attempted.