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CME:

Septic
Arthritis
By Syafi’ie Syukri bin Mohammed Faridz
Contents
• Introduction
– Epidemiology
– Pathogenesis

• Clinical Features
• Investigation
• Management
Introduction
• Septic arthritis is inflammation of a synovial membrane with
purulent effusion into the joint capsule, due to infection.

Synovial membrane

Membrane surrounding joint


cavity
Produce synovial fluid
Contain rich capillary network
for phagocytic and hyaluronate-
producing function
Epidemiology
• Most affected joints are knee (~50%) > hip > shoulder >
elbow > ankle > sternoclavicular joint
• Risk factors
– age > 80 years
– medical conditions
• diabetes
• rheumatoid arthritis
• cirrhosis
• HIV
– history of crystal arthropathy
– endocarditis or recent bacteremia
– IV drug user
– recent joint surgery
Epidemiology
Causative Organism
• Child < 2yo : Staphylococcus (most common)
Streptococcus, gram –ve rods
• Child 2-14yo : Staphylococcus (most common)
Streptococcus, Haemophilus
• Adults : Staphylococcus
Streptococcus, Neisseria
• IVDU : Gram –ve organism
• Adults >50yo : Staphylococcus, Streptococcus
Gm-ve bact (Pseudomonas)
Pathogenesis
• Bacteria can gain entrance to a joint via 3 routes:

Direct spread from


adjacent focal
infection

Haematogenous
Direct inoculation
• sd

Acute synovitis Articular Cartilage may Dislocation


cartilage be destroyed Subluxation
attacked
Necrosis
Ankylosis
Clinical Features
In new born infants In children In adults
• More on septicaemia  acute pain in single large  Often in the superficial
Rather than joint pain joint(esp hip) joint(knee, wrist or ankle )

• Baby is irritable &  pseudoparalysis  Joints painful, swollen


refuse to feed & inflamed.
 Child is ill,rapid pulse and
• Tachycardia with fever swingingfever  Warmth and marked
local tenderness &
• Joints are warmth,  Overlying skin looks red & movement restricted.
tenderness, resistance superficial joint swelling
to movement may be obvious  look for gonococcal
infection or drug abuse.
• Umbilical cord and  Local warmth and marked
inflamed IV site should be tenderness  Patient with
suspicious of source of rheumatoid arthritis and
infection  All movements are especially those on
restricted by pain or corticosteroid may
spasm. develop “silent” joint
infection.
 Look for source of
On Examination
• Joints
– Swollen
– Redness
– Warmth
– Diffuse tenderness
– Flactuates

• All movement are grossly restricted and often completely


abolished by pain and spasm (pseudoparesis)
• Extremity tends to be in position of maximum joint volume
– If hip is affected, the limb is held flexed and externally rotated
– If knee is affected, the joint is held 30 degree flexed
Blood Investigation

Investigations Explaination

Full blood count Elevated white blood cell count

ESR > 40 mm/hr

CRP > 20 mg/dL

Blood culture May be positive


Imaging
• X-ray • CT scan
– Early stage – Joint space narrowing
• soft tissue swelling – Blurring of fat planes
• loss of tissue planes – Increased density of fatty
• widening of joint space marrow
• slight sublaxation due to fluid in – Periosteal reaction
the joint
– Late stage – Cortical erosion or destruction
• narrowing and irregularity of – Intraosseous gas
joint space
• Periosteal reaction • MRI
• bone destruction and – Synovial enhancement
sequestrum formation
– Perisynovial edema and joint
• Ultrasound effusion
– Joint effusion – Single or multiple radiolucent
abscesses
• Widening of space more than
2mm – Assessment of the extent of
– Echo free: transient synovitis tissue affected
– Echogenic: probably septic
arthritis
The left hip is subluxated and the soft
tissues are swollen

If the infection persists


untreated, the cartilaginous
epiphysis may be entirely
destroyed, leaving a permanent
pseudarthrosis
Synovial Fluid Analysis
Suspected Appear Viscosity White Crystals Biochemistry Bacteriology
condition ance cells
Normal Clear High Few - As for plasma -
yellow
Septic Purulen Low + - Glucose low +
arthritis t
Tuberculous Turbid Low + - Glucose low +
arthritis
Rheumatoid Cloudy Low ++ - - -
arthritis
Gout Cloudy Normal ++ Urate - -
Pseudogout Cloudy Normal + Pyropho - -
sphate

Osteoarthriti Clear High few Often + - -


s yellow
Management

Analgesic Splinting Empirical ->


C+S

• Neonates to puberty (staphylococcus and


Gram-negative streptococci)
 Flucloxacillin and third-generation
cephalosporin
• Older teenagers and adults
 Flucloxacillin and fusidic acid
Percutaneous
Drainage
Surgical *Antibiotics should be given intravenously for
Drainage 1-2 weeks and then orally for another 4 weeks.

Athroscopic Open
Drainage Drainage
Case Scenario