septic arthritis

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• Septic Arthritis
o more common in children
o males are more susceptible.
o Staphylococcus aureus is the
commonest causative organism.
(MCQ)
o Routes of spread
n Haematogenous commonest
route.
• There may be a primary focus of
infection in the form of pyoderma,
throat infection, septicaemia
(MCQ)

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n Secondary to nearby osteomyelitis:
• This is a particularly common route in joints
with intra-articular metaphysis e.g., the hip,
shoulder (MCQ)
n Penetrating wounds: The knee, being a
superficial joint, is often affected via this route.
n Iatrogenic: This may occur following intra-
articular steroid injections in different
arthritis, and during femoral artery punctures for
blood collection.
n Umbilical cord sepsis in infants can travel to
joints.

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• Diagnosis
o The knee is the commonest joint
affected(MCQ)
o Presenting complaints:
n In its typical acute form
• a child with septic arthritis presents with a
severe throbbing pain, swelling and redness
of the affected joint.
• This is associated with high grade fever and
malaise.
• The child is unable to use the affected limb.

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n In its subacute form
• the parents may notice that the child is not
allowing anybody to touch the joint.
• In the lower limbs, a painful limp may be the
first thing to draw attention.
• It may be associated with low grade fever.
o On examination: The affected joint is swollen
and held in the position of ease

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n Investigations
o Radiological Examination:
n Early stage
• X-rays are usually normal.
• increased joint space and a soft tissue
shadow corresponding to the distended
capsule due to swelling of the joint. (MCQ)
n Ultrasound examination is useful in detecting
collection in deep joints such as the hip and
shoulder.

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o Blood shows neutrophilic leucocytosis.
o ESR is markedly elevated.
o A blood culture may grow the causative
organism.
o Joint aspiration is the quickest and the best
method of diagnosing septic arthritis
o Gram staining provides a clue to the type of
organism, till one gets the culture report.

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n Differential diagnosis
o Rheumatic arthritis:
n Commonly a migratory polyarthritis, but may
present with only once joint affected. (MCQ)
n The subsequent fleeting character of the
arthritis, high C-reactive protein levels in the
serum, and joint aspiration helps in its
diagnosis. (MCQ)
o Haemophilia:
o Tubercular arthritis

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o Treatment
o Emprical therapy before culture report : A
combination of Ceftriaxone and Cloxacillin, in
appropriate doses is usually given
o Antibiotics are continued for 6 weeks. (MCQ)
o The joint must be put to rest in a splint or in
traction.
o Whenever pus is aspirated, the joint should
be opened up (arthrotomy), "washed and
closed with a suction drain. The same can be
now done arthroscopically. (MCQ)

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o In late cases, with radiological destruction of
the joint margins, subluxation or dislocation,
it is not possible to expect joint movement.
o In such cases, after an arthrotomy and
extensive debridement of the joint, it is
immobilised in the position of optimum
function, so that as the disease heals,
ankylosis occurs in that position. (MCQ)

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o Complications
o Deformity and stiffness: Bony ankylosis is
the usual outcome of a neglected septic
arthritis. (MCQ)
o Pathological dislocation:
o Posterior dislocation of the hip
o triple displacement of the knee (lateral and
posterior subluxation and lateral rotation)
occur (MCQ)
o Osteoarthritis

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n Septic arthritis in infancy (Tom-Smith
Arthritis)
o This is a septic arthritis of the hip seen in
infants. (MCQ)
o At this age, the head of the femur is
cartilaginous and is rapidly and completely
destroyed by the pyogenic process. (MCQ)
o Onset is acute with rapid abscess formation,
which may burst out or be incised and heals
rapidly.

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o Usually it is mistaken as a superficial
infection and the child presents some time
later with complaint of a limp without any
pain.
o On examination, it is found that the child
walks with an unstable gait.
n The affected leg is shorter and hip
movements are increased in all directions.
n Telescopy test is positive. (MCQ)

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o On X-ray, one finds complete absence of the
head and neck of the femur. (MCQ)
o Differential diagnosis: closely resembles a
congenital dislocation of the hip (CDH) which
also sometimes presents at that age. (MCQ)
n Complete absence of the head and neck,
and a normally developed round acetabulum
differentiate this condition from CDH. In CDH
, acetabulum is shallow.