septic arthritis management

1. Click to edit Master title style
1
SEPTIC ARTHRITIS
DR.FAROUQ MAKKIE ALYOUZBAKI
ORTHOPEDIC SPECIALIST
NINEVAH MEDICAL COLLEGE
5TH STAGE LECTURE

2. Click to edit Master title style
2
1 - SEPTIC ARTH R ITIS( D EFIN ITION ,C L IN C AL
FEATU R ES,D IAGN OSIS,TR EATMEN T AN D
PR OGN OSIS)
2- TU BER C U LOU S ARTH R ITIS(C LIN IC AL
FEATU R ES AN D TR EATMEN T )
3 - BR U C EL L OSIS ARTH R ITIS ( C L IN IC AL
FEATU R ES AN D TR EATMEN T)
2
OBJECTIVES

3. Click to edit Master title style
3 3
SEPTIC ARTHRITIS
DEFINITION
it is an inflamtion of the synovial tissue leading to purulent
discharge and cartilage destruction.

4. Click to edit Master title style
4
Septic Arthritis
4
Usually hematogenous but may also
result from contiguous spread or direct
inoculation
Occurs in all age groups
Most common in children
Usually monoarticular
Polyarticular in less than 10% of pediatric
cases and less than 20% of adult cases
Hip and knee are most frequently
affected

5. Click to edit Master title style
5
EPIDEMIOLOLGY
 most commonly affected
joints in descending order:
 knee
 hip
 elbow
 ankle
 stenoclavicular joint

6. Click to edit Master title style
6
PATHOANATOMY
6
3 etiologies of bacterial seeding of joint
bacteremia
 direct inoculation from trauma or surgery
 contiguous spread from adjacent
osteomyelitis (like hip and ankle joint)
 septic arthritis causes irreversible
cartilage destruction in an involved joint
release of proteolytic enzymes from
inflammatory cells (PMNs)

7. Click to edit Master title style
7 7

8. Click to edit Master title style
8
MICROBIOLOGY
8
 staphylococcus species
 staphyloccus aureus (most common, >50%
cases) MRSA
 staphylococcus epidermis
 neisseria gonorrhea most common organism in
otherwise healthy sexually active adolescents
and young adults knee most commonly involved
streptococcus
 salmonella seen in patients with sickle cell
disease

9. Click to edit Master title style
9
CLINICAL FEATURES
9
SYMPTOMS
 pain in affected joint
 fevers
 may appear toxic o inability to bear
weight (limping )
 inability to tolerate PROM

10. Click to edit Master title style
10
CLINICAL EXAMINATION
10
Physical exam o involved joint will have
 warmth, erythema, and tenderness
 effusion
 joint motion causes extreme pain extremity
tends to be in position of maximum joint
volume
 hip would be in FABER position (flexed,
abducted, externally rotated)

11. Click to edit Master title style
1111
• Septic arthritis of the hip joint in children
• The hip joint is flexed abducted and externally rotated

12. Click to edit Master title style
12
IMAGING
12
 Radiographs may show joint space
widening or effusion
 Ultrasound may help in confirming joint
effusion in large joint such as hip
 can be used in guiding aspirations
 MRI o detects joint effusion, and may
detect adjacent bone involvement such
as osteomyelitis

13. Click to edit Master title style
13
INVESTIGATIONS
13
 elevated serum WBC >10K , ESR >30,
and CRP >5
 ESR is often elevated but may be normal
early in process
 rises within 2 days of infection and can
rise 3-5 days after initiation of
appropriate antibiotics, and returns to
normal 3-4 weeks
 CRP is most helpful , best way to judge
efficacy of treatment, as CRP rises within
few hours of infection, and may
normalize within 1 week of treatment

14. Click to edit Master title style
14
JOINT FLUID ASPIRATION
14
 gold standard for treatment and allows
directed antiobiotic treatment should be
analyzed for
 cell count with differential
 gram stain
 culture
 glucose level
 crystal analysis

15. Click to edit Master title style
15
JOINT FLUID ANALYSIS
15
 characteristic findings
 joint fluid appears cloudy or purulent
 cell count with WBC > 50,000 is considered
diagnostic for septic arthritis, however lower
counts may still indicate infection
 gram stains only identifies infective organism 1/3
of time
 glucose less than 60% of serum level

16. Click to edit Master title style
16
Joint fluid analysis
16

17. Click to edit Master title style
17
DIFFERENTIAL DIAGNOSIS IN KIDS
17
1. Osteomyelitis
2. JRA
3. Transient synovitis
4. Legg-Calvé-Perthes disease
5. Slipped capital femoral epiphysis
6. Rheumatic fever

18. Click to edit Master title style
18
DIFFERNTIAL DIAGNOSIS IN ADULT
18
1. Osteomyelitis
2. Gout
3. Pseudogout
4. Reiter’s syndrome
5. Psoriatic arthritis
6. Arthritis associated with
inflammatory bowel disease and
ankylosing spondylitis
7. Traumatic hemarthrosis

19. Click to edit Master title style
19
TREATMENT
19
 IT IS considered an orthopaedic surgical
emergency operative irrigation and drainage of
the joint
 indications technique may be performed open
or arthroscopically ,remove all purulent fluid and
irrigate joint synovectomy can be performed as
needed obtain joint fluid and tissue for culture

20. Click to edit Master title style
20
complications
20
• 1-osteomyelitis
• 2-sepsis
• 3-ankylosis
• 4-partial or complete destruction of the
epiphysis
• 5-retarded growth

21. Click to edit Master title style
21
Skeletal Tuberculosis
21
it affect chiefly large joints and spine
“Tertiary lesion”
Predisposing factors; chronic
debilitating disorders, IV drug abuse,
corticosteroid medication, AIDS,..
Look for primary lung lesion.

22. Click to edit Master title style
22
Pathology
22
Cold abscess formation.
Synovial pannus formation.
Articular cartilage erosion.
Secondary pyogenic infection.
Healing by:
Resolution. Or,
Fibrous ankylosis.

23. Click to edit Master title style
2323

24. Click to edit Master title style
24
Clinical features
24
History of pulmonary TB or contact with TB
patient.
Pain and swelling.
Fever, lassitude and weight loss.
Muscle wasting and synovial thickening.
All movements are restricted.

25. Click to edit Master title style
25
TB Spine
25
Chronic Dull pain.
Abscess in groin or lumbar region.
Localized kyphosis due to spine
collapse.
Peripheral weakness or
paraesthesia.

26. Click to edit Master title style
26
X-Ray
26
Soft tissue swelling.
Peri-articular osteoporosis.
Narrowing of joint space.
Bone erosion.
Vertebral collapse and deformity
(kyphosis).

27. Click to edit Master title style
2727

28. Click to edit Master title style
28
Investigations
28
1. ESR increased with relative
lymphocytosis.
2. Synovial fluid aspiration for Acid-
fast bacilli identification and
culture.
3. Synovial biopsy is more sensitive.

29. Click to edit Master title style
29
Tuberculen test (PPD)
purified protein dereviative derivative
29

30. Click to edit Master title style
30
Treatment
30
• Rest and splintage.
• Chemotherapy:
• Rifampicine, isoniazid and
ethambutol (or pyrazinamide) for 8
wks.
• Then rifampicine and isoniazid for 6-
12 months.
• Operation:
• Cold abscess drainage.
• Arthrodesis or arthroplasty for
destructed painful joints.

31. Click to edit Master title style
31
Brucellosis
31
Chronic or subacute granulomatous infection in bone and joint.
Microorganism:
1. Brucella melitensis; from sheeps.
2. Brucella abortus; from cattle.
3. Brucella suis; from pigs.
Etiology: drinking unpasturised milk or dealing with infected meat.

32. Click to edit Master title style
32
Clinical features
32
Localized to single large joint
(usually hip or knee) or vertebra.
Positive brucella agglutination
test is diagnostic.

33. Click to edit Master title style
33
Treatment
33
Antibiotics: tetracycline and streptomycine
(with or withour refampicine) for 3-4 wks.

34. Click to edit Master title style
3434