how to approach to a patient with joint swelling ? chick the presentation and see

1. 40 YEAR OLD DIABETIC PATIENT
PRESENTED TO ED WITH ACUTELY
PAINFUL SWELLING OF THE R. KNEE FOR 2
DAYS DURATION, ON EXAMINATION THERE
IS MILDPYREXIA, TENDERNESS OVER THE
JOINT AND PASSIVE AND ACTIVE
RESTRICTION OF THE JOINT MOVEMENT,
WHAT IS YOUR WORK UP ?

2. Septic Arthritis
By :
Hard H. Qader
Kirkuk University College Of
Medicine
(KUKOM)

3. • Introduction
• Pathogenesis
• Clinical Features
• Investigations
• Treatment

4. •SEPTIC ARTHRITIS IS INFLAMMATION OF A SYNOVIAL
MEMBRANE WITH PURULENT EFFUSION INTO THE JOINT
CAPSULE, DUE TOINFECTION.
Synovial membrane
Membrane surrounding joint
cavity
Produce synovial fluid
Contain rich capillary network
for phagocytic and
hyaluronate-producing function

5. ETIOLOGY
1.BACTERIAL
I. STAPH. AUREUS 50%, STREP.,
E.COLI, AND PROTEUS…
II. GC ARTHRITIS 20%
2. VIRAL,MYCOBACTERIAL, AND
FUNGAL.

6. ORGANISMS FOUND IN SEPTIC
ARTHRITIS:

7. 1. ARTIFICIAL JOINT IMPLANTS
2. BACTERIAL INFECTION ELSEWHERE IN BODY
3. CHRONIC ILLNESS OR DISEASE (SUCH AS
DIABETES, RHEUMATOID ARTHRITIS, AND SICKLE
CELL DISEASE)
4. INTRAVENOUS (IV) OR INJECTION DRUG USE
5. MEDICATIONS THAT SUPPRESS IMMUNE SYSTEM
6. RECENT JOINT TRAUMA
7. RECENT JOINT ARTHROSCOPY OR OTHER
SURGERY

8. • BACTERIA CAN GAIN ENTRANCE TO A JOINT VIA 3 ROUTES:
Haematogenous
Direct inoculation
Direct spread from
adjacent focal infection

10. Most common form of spread
Usually affect people with underlying medical problem
May result from penetrating trauma
Introduction of organisms during diagnostic and surgical
procedures. For eg arthroscopy and intra-articular injection
More common in children.
Osteomyelitis usually begin in the metaphyseal region,
from which it breaks through the periosteum into the
joint.

11. Synovial membrane is highly vascularised.
↓
Bacteria can easily enter synovial joint via blood stream.
↓
There will be inflammatory reaction with seropurulent exudate and increase
in synovial fluid.
↓
As pus appear in the joint, the articular cartilage is eroded and destroyed.
Partly by the bacterial enzyme, and partly by the enzyme released from
synovium, inflammatory cell and pus
Infant
Destroy the
epiphysis, which is
still largely
cartilaginous.
Children
Vascular occlusion
lead to necrosis of
epiphyseal bone
Adult
Effect confined on
articular cartilage
Extensive erosion
can occur due to
synovial proliferation
and ingrowth

12. a) In the early stage, there is an acute synovitis with a purulent joint effusion
b) Soon the articular cartilage is attacked by bacterial and cellular enzyme.
c) If infection is not arrested , the cartilage may be completely destroyed
d) Healing then leads to ankylosis

13. If left untreated, it will spread to the underlying bone
and out of joint to form abscess and sinus.
Healing with:
1.Complete resolution
2.Partial loss of articular cartilage and fibrosis of
joint
3.Loss of articular cartilage and bony ankylosis
4.Bony destruction and permanent deformity

14. Differ according to age
In new born infants
 More on septicaemia
Rather than joint pain
 Baby is irritable &
refuse to feed
 Tachycardia with fever
 Joints are warmth,
tenderness, resistance
to movement
 Umbilical cord and
inflamed IV site should be
suspicious of source of
infection
In children
o acute pain in single
large joint(esp hip)
o Pseudoparesis
o Child is ill,rapid pulse
and swinging fever
o Overlying skin looks red
& superficial joint swelling
may be obvious
o Local warmth and
marked tenderness
o All movements are
restricted by pain or spasm.
o Look for source of
infection from septic toe or
discharge ear
In adults
 Monoarticular 85% ,
knee – most
common, Other –
hip , wrist, shoulder
& ankle
Sternoclavicular and
sacroiliac joint -
IVDA
 Joints painful, swollen
& inflamed.
 Warmth and marked
local tenderness &
movement restricted.
 look for STD.
 Patient with RA and
those on
corticosteroid may
develop “silent” joint
infection.

15. PHYSICAL EXAMINATION:
• LOWER LIMB  ANTALGIC LIMP / CANNOT WALK
• UPPER LIMB  AFFECTED PART IS CLOSELY GUARDED
• MARKED TENDERNESS, ACTIVE AND PASSIVE RANGE OF
MOTION ARE LIMITED
• EXAMINE FOR SYNOVIAL EFFUSION, ERYTHEMA, HEAT AND
TENDERNESS.
• SPASM OF MUSCLES AROUND THE JOINT MAY BE MARKED.
• PATIENT MAY HOLD THE JOINT IN A POSITION TO REDUCE THE
INTRA-ARTICULAR PRESSURE TO MINIMIZE PAIN.

16. Investigations Explaination
Full blood count Elevated white blood cell count
ESR <40mm/hr
CRP <20mg/dL
Blood culture May be positive

17. Synovial fluid analysis
Aseptic technique.
Avoid taken from infected site of skin.
The fluid is then analyzed by gross and microscopic
examination and culture.
Gross examinations include appearance, volume,
viscosity.
Microscopic examinations include leucocyte count,
staining of smears, serum glucose ratio, protein.
Finally, culture and sensitivity for definitive diagnosis
and treatment.

18. Suspected
condition
Appearanc
e
Viscosit
y
White
cells
Crystal
s
Biochemistr
y
Bacteriolog
y
Normal Clear
yellow
High Few - As for
plasma
-
Septic
arthritis
Purulent Low + - Glucose low +
Tuberculou
s arthritis
Turbid Low + - Glucose low +
Rheumatoi
d arthritis
Cloudy Low + + - - -
Gout Cloudy Normal ++ Urate - -
Pseudogou
t
Cloudy Normal + Pyroph
osphat
e
- -
Osteoarthri
tis
Clear
yellow
High few Often+ - -

19. Xray
 Early Stage – Normal
 Late stage – Narrowing and irregularity of joint space
(destruction of articular cartilage, followed by destruction
of subchondral bone)
 Plain film findings of superimposed osteomyelitis may
develop (periosteal reaction, bone destruction, sequestrum
formation).

20. Narrowing of joint space and irregularity
of subchondral bone.
Joint space loss
subchondral erosions and
sclerosis of the femoral
head
osteonecrosis and
complete collapse of
the femoral head

21. ULTRASONOGRAPHY
• MORE RELIABLE IN REVEALING A JOINT EFFUSION IN
EARLY CASES.
• WIDENING OF SPACE BETWEEN CAPSULE AND BONE OF <
2MM INDICATES EFFUSION.
• ECHO-FREE  TRANSIENT SYNOVITIS
• POSITIVELY ECHOGENIC  SEPTIC ARTHRITIS

23. CT, MRI, ANDBONE SCANS
• CT SCANS – SOFT TISSUE SWELLING,
JOINT EFFUSIONS, ABSCESS FORMATION,
GUIDE JOINT ASPIRATION, MONITOR
THERAPY AND PLANNING OPERATIVE
APPROACHES.
• MRI – EXTENT OF INFECTION, DIAGNOSING
INFECTIONS THAT ARE DIFFICULT TO
ACCESS, BETTER ANATOMICAL DETAIL.
• BONE SCANS- DETECT LOCALIZED AREAS

25. • GENERAL SUPPORTIVE CARE
- ANALGESICS
- IV FLUIDS
• SPLINTAGE
• ANTIBIOTICS
• SURGICAL DRAINAGE
• ARTHROSCOPIC DEBRIDEMENT AND COPIOUS IRRIGATION WITH
NORMAL SALINE – MORE FREQUENTLY IN KNEE JOINT SEPTIC
ARTHRITIS

27. • BONE DESTRUCTION AND DISLOCATION OF
THE JOINT (ESP HIP)
• CARTILAGE DESTRUCTION
- MAY LEAD TO EITHER FIBROSIS OR BONY
ANKYLOSIS
• - IN ADULT PARTIAL DESTRUCTION OF THE
JOINT WILL RESULT IN SECONDARY
OSTEOARTHRITIS
• GROWTH DISTURBANCE
• - PRESENTING AS EITHER LOCALISED
DEFORMITY OR SHORTENING OF THE BONE