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JAUHARIL WAFI
septic arthritis
is an inflammatory joint disease caused by bacterial, viral, and
fungal infection.
Route of infection
dissemination of pathogens via the blood, from distant
site. (most common) dissemination from an acute osteomylitic focus dissemination from adjacent soft tissue infection, entry via penetrating trauma entry via iatrogenic means
Etiology
The causal organism is usually Staphylococcus aureus. In children under the age of 3 years Haemophilus
influenzae is fairly common gram-negative bacilli (a group of bacteria, including Escherichia coli, or E. coli) streptococci (a group of bacteria that can lead to a wide variety of diseases)
Pathology
There is an acute synovitis with a purulent joint effusion
and Synovial membrane becomes edematous, swollen and hyperemic, and produces increase amount of cloudy exudates contains leukocytes and bacteria As infection spread through the joint, articular cartilage is destroyed by bacterial and cellular enzymes. If the infection is not arrested the cartilage may be completely destroyed. Pus may burst out of the joint to form abscesses and sinuses. The joint may be become pathologically dislocated.
Complete resolution and return to normal. Partial loss of cartilage and fibrosis. Bone ankylosis Bone destruction and permanent deformity.
Clinical presentation
Typical features are acute pain and swelling in a single large joint ,commonly the hip in children and the knee in adults, however any joint can be affected.
The most commonly involved joint is the knee (50% of
cases), followed by the hip (20%), shoulder (8%), ankle (7%), and wrists (7%). interphalangeal, sternoclavicular, and sacroiliac joints each make up 1-4% of cases.
1.
2. In children:
Acute pain in single large joint. The joint is swollen (if superficial), warm and tender. Fever. All movements are restricted due to muscle spasm (Pseudoparesis).
3.
In adult:
Intense joint pain . Joint swelling . Joint redness . Unable to move the limb with the infected joint . Low-grade fever.
Physical examination
1. 2. 3.
Decreased or absent rang of motion. Signs of inflammation: joint swelling, warmth, tenderness and erythema. Joint orientation as to minimize pain (position of comfort):
Hip: abducted, flexed and externally rotated. Knee, ankle and elbow: partially flexed. Shoulder: abducted and internally rotated
Investigation
Lab studies:
The diagnosis can usually be confirmed by joint aspiration
and immediate microbiological investigation of the fluid. Blood culture may be positive in about 50% of proven cases. Non specific features of acute inflammationleucocytosis,ESR,CRP-are suggestive but not diagnostic .
Ask for: gram stain, culture, leukocyte count with differential, and crystal examination leukocyte count:
o generally higher than 50,000/L, with a predominance
culture:
The definitive method for aerobic and anaerobic organisms. are positive in 85-95%
Synovial fluid glucose, protein, and lactic acid
Imaging studies
1-Plain x-ray:
The appearance of significant x-ray findings depends upon
the duration and virulence of infection. Plain radiography findings are generally nonspecific and may reveal only soft tissue swelling ,widening of the joint space ( due to the effusion), and periarticular osteoporosis during the first 2 weeks. Later ,when the articular cartilage is attacked ,the joint space is narrowed.(persistent subluxation, destructive arthritis).
2-Ultrasonography
This study is very sensitive in detecting joint effusions generated by septic arthritis. Ultrasound can be used to define the extent of septic arthritis and help guide treatment. Ultrasound helps to differentiate septic arthritis from other conditions (e.g., soft tissue abscesses, tenosynovitis) in which treatment may differ.
joint. (may help in difficult site as sacroiliac & sternoclavicular joints 4- CT scan: This study may help to diagnose sternoclavicular or sacroiliac joint infections. 5-MRI: MRI is most useful in assessing the presence of periarticular osteomyelitis as a causative mechanism.
DIFFERENTIAL DIAGNOSIS
Osteomyelitis: near a joint may be indistinguishable from septic
arthritis ;the safest is to assume that both are present.
Rheumatic fever
complication
Dislocation: a tense effusion may cause dislocation
Epiphyseal destruction: in neglected infants the largely
cartilaginous epiphysis may be destroyed ,leaving an unstable pseudarthrosis.
Secondary osteoarthritis
Osteomyleitis/abcess/sinus
Treatment
General Measures:
The first priority is to aspirate the joint and examine the fluid, treatment is then started without further delay. Analgesics and splinting of the involved joint in the position of maximal comfort alleviate pain. Fluid replacement and nutritional support may be required. Other foci of infection and any coexisting medical conditions must be identified and treated appropriately.
started as soon as joint fluid and blood sample have been taken for culture. If gram positive organisms are identified ,Flucloxacillin is suitable . If in doubt ,a third generation cephalosporin will cover both game+ and gram- organisms. Children less than 4 yr( if suspicion of H.Infl) treated with Ampicillin. Once the bacterial sensitivity is known the appropriate drug is substituted. Intravenous administration is continued for several weeks and is followed by oral antibiotics for a further 2 or 3 weeks.
Drainage:
Indication of Surgical Drainage: 1-Joints that do not respond to antimicrobial therapy and daily arthrocentesis 2-. Any joint with limited accessibility, including the sternoclavicular or the hip joint 3-Patients with underlying disease, including diabetes, rheumatoid arthritis, immunosuppression, or other systemic symptoms, should be treated more aggressively with earlier surgical intervention
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