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40 YEAR OLD DIABETIC PATIENT PRESENTED TO ED WITH ACUTELY PAINFUL SWELLING OF THE R. KNEE FOR 2 DAYS DURATION, ON EXAMINATION THERE IS MILD PYREXIA, TENDERNESS OVER THE JOINT AND PASSIVE AND ACTIVE RESTRICTION OF THE JOINT MOVEMENT, WHAT IS YOUR WORK UP ?
Septic ArthritisBy :
Hard H. QaderKirkuk University College Of
Medicine (KUKOM)
• Introduction
• Pathogenesis
• Clinical Features
• Investigations
• Treatment
•SEPTIC ARTHRITIS IS INFLAMMATION OF A SYNOVIAL MEMBRANE WITH PURULENT EFFUSION INTO THE JOINT
CAPSULE, DUE TO INFECTION.
Synovial membrane
Membrane surrounding joint cavityProduce synovial fluidContain rich capillary network for phagocytic and hyaluronate-producing function
ETIOLOGY 1.BACTERIAL
I. STAPH. AUREUS 50%, STREP., E.COLI, AND PROTEUS…
II. GC ARTHRITIS 20%2. VIRAL,MYCOBACTERIAL, AND FUNGAL.
ORGANISMS FOUND IN SEPTIC ARTHRITIS:
1. ARTIFICIAL JOINT IMPLANTS2. BACTERIAL INFECTION ELSEWHERE IN BODY3. CHRONIC ILLNESS OR DISEASE (SUCH AS
DIABETES, RHEUMATOID ARTHRITIS, AND SICKLE CELL DISEASE)
4. INTRAVENOUS (IV) OR INJECTION DRUG USE5. MEDICATIONS THAT SUPPRESS IMMUNE SYSTEM6. RECENT JOINT TRAUMA7. RECENT JOINT ARTHROSCOPY OR OTHER SURGERY
• BACTERIA CAN GAIN ENTRANCE TO A JOINT VIA 3 ROUTES:
Haematogenous
Direct inoculation
Direct spread from adjacent focal infection
Most common form of spreadUsually affect people with underlying medical problem
May result from penetrating traumaIntroduction of organisms during diagnostic and surgicalprocedures. 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.
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 cartilageExtensive erosion can occur due to
synovial proliferation and
ingrowth
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
If left untreated, it will spread to the underlying bone and out of joint to form
abscess and sinus.
Healing with:1.Complete resolution2.Partial loss of articular cartilage and fibrosis of joint3.Loss of articular cartilage and bony ankylosis4.Bony destruction and permanent deformity
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 childreno acute pain in single large joint(esp hip)o Pseudoparesiso Child is ill,rapid pulse and swinging fevero 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.
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.
Investigations ExplainationFull blood count Elevated white blood cell count
ESR >40 mm/hrCRP >20 mg/dL
Blood culture May be positive
Synovial fluid analysisAseptic 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.
Suspected
condition
Appearance
Viscosity
White cells
Crystals
Biochemistry
Bacteriology
Normal Clear yellow
High Few - As for plasma
-
Septic arthritis
Purulent Low + - Glucose low
+
Tuberculous
arthritis
Turbid Low + - Glucose low
+
Rheumatoid arthritis
Cloudy Low + + - - -
Gout Cloudy Normal ++ Urate - - Pseudogo
utCloudy Normal + Pyrop
hosphate
- -
Osteoarthritis
Clear yellow
High few Often +
- -
X ray 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).
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
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
CT, MRI, AND BONE 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 OF INFLAMMATION.
• 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
• 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
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