1. Dr chiranjeevi ortho pg
RMC, KAKINADA
SEPTIC ARTHRITIS IN CHILDREN

2. SEPTIC ARTHRITIS
 A joint inflammation due to an infection usually
involving synovial joints.
 More common than osteomyelitis
 Common age group 1month to 5 yrs
 50% of cases- children less than 5 years.
 30% of cases- children less than 2 years.
 Single joint involvement 94% of cases

3. Common site of involvement
CHILDREN
 Hip 41%
 Knee 23%
 Ankle 12%
 Wrist 4%
 Shoulder 4%

4. causatives
 Staph. aureus m/c
 Hemophilus influenza
 Streptococcus
 E. coli
 N.gonrrhoeae
 K.kingae
 Proteus
 M.tuberculosis--- septic sacroiliitis

5. Predisposing factors
LOCAL FACTORS GENERAL FACTORS
 Previous joint
trauma.
 H/o arthritis to the
same joint.
 Degenerative joint
disease.
 Crystal induced joint
disease.(gout and
pseudogout)
 Rheumatoid arthritis.
 SLE
 Immunosuppressive
drug therapy.
 Diabetes mellitus.
 Immunodeficiency
disorders.
 Chronic debilitating
disorders- liver failure
and renal failure

6. Mode of spread
1. Hematogenous
spread m/c
2. Direct invasion.
3. Aspiration , surgery,
injection.
4. osteomyelitis.
5. Local spread from
adjacent tissues.
6. Spread from
metaphyseal.

7. Pathophysiology
 Bacteria rapidly gains access to the joint cavity and
settles in the synovial membrane.
 Acute inflammatory reaction occurs with formation of
serous or seropurulent exudate.
 Articular cartilage is eroded and destroyed due to the
action of bacterial toxins and by enzymes released
from the synovium and inflammatory cells.
 In late cases- extensive erosion due to synovial
proliferation and ingrowth.
 If untreated- spread to the underlying bone or burst
out of the joint to form abscesses and sinuses.

8.  HEALING PROCESS
1. Complete resolution.
2. Partial loss of cartilage and fibrosis of joint.
3. Loss of articular cartilage and bony ankylosis.
4. Bone destruction and permanent deformity of
the joint

9. Clinical features
COMMON symptoms
 Fever
 Pain over joint.
 Reluctance to move
joint(pseudoparesis).
In neonates:
 Few clinical signs.
 Child may not have fever.
 Loss of spontaneous movement of
extremity.
 Hip-flexion, abduction, and external
rotation.

10. IN CHILDREN:
 signs of local inflammation are present.
 Rapid pulse and swinging fever.
 Overlying skin-red.
 Swelling may be present.
 Local rise of temperature and marked tenderness
over joint.
 All movements of joint- restricted.
IN ADULTS:
 Often a superficial joint( knee, wrist or ankle).
 Joint is painful, swollen, and inflamed.
 Movements are restricted.

11. Physical examination
1. Decreased or absent ROM.
2. Signs of inflammation: joint
swelling, warmth, tenderness
and erythema.
3. 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

12. D/D WITH OSTEOMYELITIS
 warm joint with painful gentle passive motion–
septic arthritis
 joint motion usually doesn’t exacerbate
symptoms in O.M
D/D WITH TRANSIENT SYNOVITIS

13. TRANSIENT SYNOVITIS
 m/c/c of hip pain in children
 Kocher and collegues identified 4 independent
predictors to d/d b/w septic arthritis v/s transient
synovitis
1. Fever >38.5 C (best predictor)
2. h/o non weight bearing
3. WBC > 12000cell / mm3
4. ESR > 40 mm/ hr
USG and arthrocentesis are best for diagnosis

14. Investigations
1. Blood investigations
2. X- ray
3. USG
4. Diagnostic aspiration
5. MRI

15. BLOOD INVESTIGATIONS
Leucocytosis >12,000.
ESR>40 mm/hr.
CRP- elevated.
Blood culture-may be positive.

16. X-ray
In early stages- usually
normal.
Later on- joint space
widening may be present and
subluxation of the joint may
be present.
In late stages- irregularity of

17.  Hip Ankle

18. USG
 Can be used to detect even the
smallest amount of joint effusion.
 Non invasive, inexpensive and easy
to use.
 Can be used to guide joint
aspiration.

19. JOINT ASPIRATION
 In early cases- fluid may be clear.
 Sample sent for Gram staining,
microscopy, culture, and antibiotic
sensitivity.
 Normal synovial fluid leucocyte count: <
200/ml.
 Leucocyte count>50,000 per ml with 90%
PMN- strongly suggestive of septic
arthritis.

20. s

21. MRI
 Can detect infection and extent of infection.
 Useful in diagnosing infections that are difficult to
access.
 Also useful in differentiating between bone and
soft tissue infections and in detecting joint
effusion.

22. Differential Diagnosis
 Acute osteomyelitis.
 Trauma
 Transient synovitis
 Hemophilic joint.
 Rheumatic fever
 Gout and pseudogout

23. Treatment
 Joint must be rested either on splint or in a widely
split plaster.
 ANTIBIOTICS
Broad spectrum IV antibiotics are started
immediately and then depending on
microbiological investigations, specific
antimicrobial therapy is started.
First line antibiotics: Benzyl penicillin,
flucloxacillin, and augmentin.
Second line antibiotics: Vancomycin,
Clindamycin, Fusidin, and Teicoplanin.
Hemophilus infection- cephalosporins.

24.  Duration of treatment: IV antibiotics given for
minimum of 2 weeks.
 Oral antibiotics:
Children-2-4 weeks.
Adults- 4-6 weeks.

25. 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, R.A, immunosuppression, or other
systemic symptoms

26. Drainage
 In septic arthritis of hip- surgical drainage is
always done.
 Best approach-anterolateral
 Joint is opened through a small incision and
washed with normal saline.
 Small drain is left in place after incision is
closed.
 Suction-irrigation is continued for another 2 or 3
days.
 In knee- arthroscopic debridement and copious
irrigation.
 In adults- repeated closed aspiration of joint

27. Complications
 Joint Destruction
 Coxa magna
 Pathological Dislocation
 Acute Osteomyelitis
 Septicemia
 Secondary osteoarthritis
 Avascular necrosis

28. TOM SMITH ARTHRITIS
 Septic arthritis of the hip.
 Seen in infants.
 Head of femur is completely destroyed by the
pyogenic process.
 Transphyseal vessels are present in early
infancy before the formation of the growth
plate This may account for the frequency of
septic arthritis of the hip in the neonate

29. Clinical features
 Onset is acute with rapid abscess formation.
 Can be mistaken for a superfical infection.
 Can present later with complaints of limp without
any pain.
 O/E: Affected leg is shorter and hip movements
are increased in all directions.
 Telescopy test-positive.

30.  X-ray- complete absence of the head and neck of
femur.
 Condition resembles DDH; complete absence of
head and neck and normally developed round
acetabulum.

31. Treatment
 Acute surgical emergency.
 Open drainage of hip joint is the most effective
method of treatment in septic arthritis of the hip.
 Arthroscopic drainage can also be attempted.

32. THANK YOU