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Paediatric Septic 
Arthritis
Contents 
• Introduction 
• Pathophysiology 
• Microbiology 
• Diagnosis 
• History 
• PE 
• Investigations 
• Treatment O...
What is it? 
• An infection of the joint space 
• Monoarticular-90%, Polyarticular, Suppurative and non-suppurative
Routes of Infection 
1. Hematogenous 
• Most common 
• Bacteremia associated with URTI, Skin or GIT infections. Or 
invasi...
Pathogenesis: Acute septic arthritis 
Bacteria deposits in synovium producing inflamation 
↓ 
Spreads to synovial fluid an...
a) In the early stage, there is an acute synovitis with a purulent joint 
effusion 
b) Soon the articular cartilage is att...
Healing 
May occur with/and/or 
1.Complete resolution 
2.Partial loss of articular cartilage and 
fibrosis of joint 
3.Los...
What causes it? 
• Mostly bactireal. Also caused by mycobacteria, 
virus and fungi. (HiB vaccination status 
dependent) 
•...
Clinical Features 
Infants 
• More septicaemia 
• Rather than joint pain 
• Baby is irritable & 
refuses to feed 
• Tachyc...
Position of minimal intrasynovial pressure 
Joint Degrees of flexion 
Wrist 0 
Elbow 40 
Shoulder 0 40 abduction; 0 rotati...
History 
1. Progression 
• Worsens over time, does not wax or wane, and may 
awaken patient at night. 
2. Joint trauma 
• ...
Physical Exam 
• Lower limb  antalgic limp / cannot walk 
• Upper limb  affected part is closely guarded 
• Marked tende...
Investigations 
Bloods Imaging Synovial 
Fluid 
Investigations Explaination 
Full blood count Elevated white blood cell co...
Imaging 
2. Xray: Frog-leg position for hip. 
• Early Stage – Normal 
• Look for soft tissue swelling, loss of 
tissue pla...
Narrowing of joint space and 
irregularity of subchondral bone. 
Joint space loss 
subchondral erosions and 
sclerosis of ...
Synovial Fluid Analysis 
Arthritis Type Appearance Viscosity White 
cells/mm3 
Crystals Biochemistry Culture 
Normal Clear...
Differentials 
Infectious Causes 
of arthritis in 
children
Differentials 
Non- Infectious 
Causes of 
arthritis in 
children
Management 
• Medical 
• General supportive (Fever, pain, hydration) 
• Antibiotics: IV Antibiotics 6-8 weeks 
• Cloxacill...
Parenteral 
antibiotics
Take Home Points 
• Prompt diagnosis and treatment is crucial to preventing bad 
bad sequlae. Esp. if the hip is involved ...
Paediatric Septic Arthritis
Paediatric Septic Arthritis
Paediatric Septic Arthritis
Paediatric Septic Arthritis
Paediatric Septic Arthritis
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Paediatric Septic Arthritis

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Definition, aetiology, Diagnosis, Treatment, Complications and Risk factors for Pediatric Infective Arthritis

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Paediatric Septic Arthritis

  1. 1. Paediatric Septic Arthritis
  2. 2. Contents • Introduction • Pathophysiology • Microbiology • Diagnosis • History • PE • Investigations • Treatment Options
  3. 3. What is it? • An infection of the joint space • Monoarticular-90%, Polyarticular, Suppurative and non-suppurative
  4. 4. Routes of Infection 1. Hematogenous • Most common • Bacteremia associated with URTI, Skin or GIT infections. Or invasive procedures. 2. Direct Inoculation • Joint contamination by foreign object 3. Contiguous spread • Osteomyelitis due to several factors in infants
  5. 5. Pathogenesis: Acute septic arthritis Bacteria deposits in synovium producing inflamation ↓ Spreads to synovial fluid and multiplies ↓ Products of inflamation destroys joint components (Swollen, painful joint) ↓ Sequlae Infant Destroy the epiphysis, which is still largely cartilaginous. Children Vascular occlusion lead to necrosis of epiphyseal bone
  6. 6. 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) Sequlae include necrosis, sublaxation, dislocation and ankylosis.
  7. 7. Healing May occur with/and/or 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
  8. 8. What causes it? • Mostly bactireal. Also caused by mycobacteria, virus and fungi. (HiB vaccination status dependent) • Gram positive 70-80% of which 40% is S. aureus • Gram negative 9-20% • Kingella kingae, N. gonorrhoeae
  9. 9. Clinical Features Infants • More septicaemia • Rather than joint pain • Baby is irritable & refuses to feed • Tachycardia with fever • Joints are inflamed • Pseudoparalysis • Check umbilical cord and IV site for infection Children • Acute pain in single large joint(esp hip) • Pseudoparesis • Child is ill, rapid pulse and swinging fever • Overlying skin looks red & superficial joint swelling may be obvious • Local warmth and marked tenderness • All movements are restricted by pain or spasm. • Look for source of infection
  10. 10. Position of minimal intrasynovial pressure Joint Degrees of flexion Wrist 0 Elbow 40 Shoulder 0 40 abduction; 0 rotation Hip 40 15 abduction; 15 external rotation Knee 40 Ankle 15
  11. 11. History 1. Progression • Worsens over time, does not wax or wane, and may awaken patient at night. 2. Joint trauma • Falls, bites, cuts. 3. Skin lesions 4. Recurrent or concurrent illness 5. Recent onset of menses 6. MCH card (Immunization status) 7. Family history of rheumatologic disease
  12. 12. Physical Exam • 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.
  13. 13. Investigations Bloods Imaging Synovial Fluid Investigations Explaination Full blood count Elevated white blood cell count ESR > 40 mm/hr CRP > 20 mg/dL Blood culture May be positive Ultrasound Xray Synovial Fluid
  14. 14. Imaging 2. Xray: Frog-leg position for hip. • Early Stage – Normal • Look for soft tissue swelling, loss of tissue planes, widening of joint space and slight subluxation due to fluid in joint. Gas may be seen with E. coli infection • Late stage – Narrowing and irregularity of joint space, erosion of epiphysis or metaphysis • Plain film findings of superimposed osteomyelitis may develop (periosteal reaction, bone destruction, sequestrum formation). 1. USS • 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
  15. 15. 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
  16. 16. Synovial Fluid Analysis Arthritis Type Appearance Viscosity White cells/mm3 Crystals Biochemistry Culture Normal Clear yellow High Few - As per plasma - Septic arthritis Purulent Low >>50,000 - Glucose low + Tuberculous arthritis Turbid Low <2000 - Glucose low + Rheumatoid arthritis Cloudy Low >2000 - - - Gout Cloudy Normal >2000 Urate NBF - - Pseudogout Cloudy Normal >2000 Pyrophos phate PBF - - Osteoarthritis Clear yellow High <2000 Often + - -
  17. 17. Differentials Infectious Causes of arthritis in children
  18. 18. Differentials Non- Infectious Causes of arthritis in children
  19. 19. Management • Medical • General supportive (Fever, pain, hydration) • Antibiotics: IV Antibiotics 6-8 weeks • Cloxacillin, Flucloxicillin, gentamycin and rifampicin for mycobacterium and ceftriaxone for gonorrhoea • Surgical • Percutaneous arthrocentesis • Arthroscopic of open surgical drainage • Rehabilitation • Physiotherapy: Rapid mobilizaton
  20. 20. Parenteral antibiotics
  21. 21. Take Home Points • Prompt diagnosis and treatment is crucial to preventing bad bad sequlae. Esp. if the hip is involved • Treatment goals are sterillisation and decompression of joint space and removal of debris • Follow-up must be scheduled to ensure a growing child won’t be affected the rest of her/his life. Veenaka 

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