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septic A Seminar.pptx septic A Seminar.pptx
- 1. Septic Arthritis &how to differentiate from Osteomylitis • Presenter Dr. Aydrus GSR3 • Moderator: Dr. Shakur ( Assistant prof of Orthopedic surgery)
- 2. Introduction • Acute septicarthritis results from bacterial invasion of a joint space • Risk factors – • rheumatoid arthritis, • chronic debilitating disorders, • intravenous drug abuse, • immunosuppressive drug therapy and AIDS
- 3. Pathogenesis • A jointcan become infected by: • Direct invasion – penetrating wound, intra-articular wound, arthroscopy • Direct spread – from adjacent bone abscess • Blood spread from distant site • Organisms: • Staph.aureus • H.influenza (1-4 yo, reduced d/t vaccination) • Streptococcus • E.coli • Proteus mirabilis
- 4. Inflammatory reaction increase in synovial fluid& Suppuration Pus appears in the joint Cartilage erosion & destruction Complete resolution Inflammation Suppuration Bone necrosis Reactive new bone formation Resolution and healing OR intractable chronicity Pathogenesis
- 5.
- 6. Clinical Features New-born infants: •Septicaemia • Irritable • Refused to feed • Rapid pulse • Fever • Check for umbilical cord infection, site of infection Children • Single joint pain (commonly hip or knee) with local tenderness • Pseudoparesis • Rapid pulse • Swinging fever Adults • Superficial joint pain (knee, wrist, finger, ankle, toe) + inflammed • Patients with rheumatoid arthritis, and especially those on corticosteroid treatment, may develop a ‘silent’ joint infection.
- 7. Diagnosis Clinical predictor algorithmshave been used to differentiate transient synovitis from septic arthritis in children. A C-reactive protein greater than 20 mg/L and inability to bear weight yielded a 74% probability of septic arthritis Elevated CRP was the strongest independent risk factor for septic arthritis
- 8. Diagnostic Imaging Imaging Features Ultrasonographymost reliable to detect effusion early, compare both joints for comparison Widening of the space between capsule and bone of more than 2 mm - indicative of effusion Echo-free – transient synovitis; positively echogenic – likely septic arthritis Plain x-ray normal early on Soft-tissue swelling, loss of tissue planes, widening of joint space, slight subluxation (due to fluid in the joint) Gas in the joint – E.coli Narrowing and irregularity of joint space – late sign MRI & Radionuclide scanning • good for diagnosis in obscure sites like sacroiliac and sternoclavicular joints
- 9. Investigations • Elevated ESR,WBC, CRP, blood culture maybe positive • Joint aspiration and analysis – much more reliable • In early stage – the fluid may look clear • Normal synovial fluid leukocyte count – less than 300 per mL • Could be more than 10,000 per mL in non-infective inflammatory disorders • More than 50,000 per mL is highly suggestive of sepsis • Gram-positive cocci - probably S. aureus; Gram-negative cocci - either H. influenza or Kingella kingae (in children) or Gonococcus (in adults)
- 10. Differential diagnosis • Acuteosteomyelitis • Psoas abscess, local pelvic infection • Traumatic synovitis or haemarthrosis • Irritable joint • Hemophilic bleed • Rheumatic fever – pain fleets from joint to joint • Juvenile rheumatoid arthritis – onset is more gradual and systemic symptoms less severe • Sickle-cell disease • Gaucher’s disease – because of predisposition for infection, antibiotics should be given • Gout and pseudogout – turbid joint fluid and high cell count, but microscopic examination by polarized light reveals characteristic crystals
- 11. Principles of treatment Aspiratejoint fluid and examine Analgesia and supportive measures Splintage – for resting and prevent dislocation Antibiotics ? IV for 4-7 days then oral for 3 weeks Drainage under anaesthesia
- 13. Drainage • Under anesthesia,open joint with small incision, drain and washout with physiologic saline, leave a small catheter in place and close wound, continue suction-irrigation for another 2-3 days • The above method is advised in very young infants, hip involvement, when aspirated pus is thick • Knee – arthroscopic debridement and copious irrigation • Older children with early (within 3days) presentation except the hip joint – repeated closed aspiration of the joint • Do open drainage if no improvement after 48 hours
- 14. Aftercare Immobilize until itheals Encourage gradual mobility if articular cartilage is preserved If articular cartilage is destroyed, immobilize in functional position until ankylosis formation
- 15. Complications Under 6 yearsold has higher incidence for complications Subluxation and dislocation of the hip Knee instability Damage to the cartilaginous physis/ epiphysis in growing child • Retarded growth • Partial/ complete epiphysis destruction • Joint deformity • Osteonecrosis • Acetabular dysplasia • Pseudoarthrosis of the hip Articular cartilage erosion Joint ankylosis
- 16.
Editor's Notes
- #4 Acute inflammatory reaction with a serous or seropurulent exudate and an increase in synovial fluid Articular cartilage is eroded and destroyed by bacterial enzymes, proteolytic enzymes released from synovial cells, inflammatory cells and pus Infants – epiphysis (largely cartilaginous) maybe severely damaged Children – vascular occlusion – necrosis of epiphyseal bone Adults – confined to articular cartilage Late cases – extensive erosion due to synovial proliferation and ingrowth untreated – spread to underlying bone, burst out of the joint – abscess and sinuses Healing – complete resolution and return to normal, partial loss of articular cartilage and fibrosis of the joint, loss of articular cartilage and joint ankylosis, or bone destruction and permanent deformity of joint
- #7 Clinical predictor algorithms have been used to differentiate transient synovitis from septic arthritis in children. A C-reactive protein greater than 20 mg/L and inability to bear weight yielded a 74% probability of septic arthritis, and patients with neither predictor had a less than 1% probability of septic arthritis (Table 22.2
- #9 Ultrasound – most reliable to detect effusion early, compare both joints for comparison Widening of the space between capsule and bone of more than 2 mm - indicative of effusion Echo-free – transient synovitis; positively echogenic – likely septic arthritis X-ray – normal early on Soft-tissue swelling, loss of tissue planes, widening of joint space, slight subluxation (due to fluid in the joint) Gas in the joint – E.coli Narrowing and irregularity of joint space – late sign MRI and radionuclide imaging – good for diagnosis in obscure sites like sacroiliac and sternoclavicular joints
- #15 Complications Infants under 6 moths of age, mostly over the hip – highest complications Factors – delay in diagnosis and treatment (> 4 days), concomitant OM of proximal femur Subluxation and dislocation of the hip, or instability of the knee Damage to the cartilaginous physis or the epiphysis in the growing child – most serious complication retarded growth, partial or complete destruction of the epiphysis, deformity of the joint, epiphyseal osteonecrosis, acetabular dysplasia and pseudarthrosis of the hip Articular cartilage erosion (chondrolysis) – seen in older patients May result in restricted movement and ankylosis