CMT 06207

Septic Arthritis
 Learning objectives
By the end of this session, student are expected to be able to:
• Describe Septic Arthritis
• Describe epidemiology of Septic Arthritis
• Explain aetiology/risk factors of Septic Arthritis
• Identify clinical features and complications of Septic Arthritis
• Establish provisional diagnosis and Differential diagnoses Septic
Arthritis
• Request appropriate investigations
• Provide pre-referral treatment to the patient and conduct follow up
services
Septic arthritis of the knee
Activity: Brainstorming
• What is Septic Arthritis?
Definition

• Septic Arthritis-Is the inflammation of a synovial membrane with purulent

effusion into joint capsule due to infection.
• Usually caused by bacteria,viral and fungus.
OR
Is the inflammation of the joints secondary to an infectious etiology such as
bacterial, fungal, mycobacterial, viral, or other pathogens
• If not treated within 24 to 48hours may cause irreversible joint erosion,
septicemia and can be fatal.

• Patients with an infected joint typically present with the triad of fever (40-60%
of cases), pain (75% of cases), and impaired range of motion
 Risk factors
• Abnormal joint architecture seen in patient with rheumatoid
arthritis(the body's immune system is impaired&attacks its own tissue, including joints. In severe
cases, it attacks internal organs.) and osteoarthritis(The wearing down of the protective tissue
at the ends of bones (cartilage) occurs gradually and worsens over time) .

• Diabetics with Charcot arthropathy( progressive destruction of bone and soft tissues at
weightbearing joints) are also at higher risk

• Other notable factors include older age, low socioeconomic status,

intravenous drug abuse, alcoholism(impaires tissue barrier against
microbes), diabetes, previous intra-articular corticosteroid injection,
and cutaneous ulcers.
Rheumatoid arthritis=Autoimmune Osteoarthritis= degenerative joint disease
Charcot arthropathy
 Pathogenesis
Bacteria gain the entrance to joint via three route:
• Haematogenous route-Common form of spread
• Direct inoculation-Result from penetrating
trauma, introduction of organism through
diagnostic or surgical procedure like arthroscopy
and intra articular injection
• Direct spread from adjacent focal infection-
Common in children ,osteomyelitis usually
begin in the metaphyseal region from which,it
breaks through periosteum(the sheath outside
your bones that supplies them with blood, nerves
and the cells that help them grow and heal) into
joint.
Common causative organisms
• If you encounter a patient with septic arthritis, these are the
common causative organism with respect to age;
S/N Age Organism
1 Neonates Streptococcus sp. and Gram-negative organism
2 Infants Staphylococcus aureus, Haemophilus influenza
3 Children Staphylococcus aureus and Samonella
4 Adolescent Staphylococcus aureus and Nesseria gonorrhoea
5 Adult Staphylococcus aureus, Streptococcus sp and
gram-negative organism
6 IV drug abusers Pseudomonas and atypical organism(e.g
Haemophilus haemolyticus)
Activity :Brainstorming

• Mention five (5) clinical feature of septic arthritis

Clinical feature
New born infant Children
• Septicemia • Acute pain in single large
• Tachycardia joint(hip joint)
• Fever • Pseudoparesis (not in full
• Joint warmth, tenderness, range of motion)
resistance to movement • Rapid pulse
• Umbilical cord and inflamed &swinging(Intermittent) fever
iv site should site source of • All movement are restricted
infection by pain and spasms
Clinical feature cont…
Adult
• Joint pain, swollen and inflamed (often in the superficial
joint;-knee, wrist or ankle)
• Warmth and marked local tenderness &movement restricted
• Patient with Rheumatic arthritis and especially those on
corticosteroid may develop silent joint infection
• Look for gonococcal infection or drug abuse
 Clinical feature cont…
Physical Examination
• Lower limb-Antalgic gait (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 muscle around the joint marked
Activity: Brainstorming

• What are differential diagnosis of septic arthritis?

Differential Diagnosis
• Acute osteomyelitis
• Rheumatic fever
• Juvenile rheumatoid arthritis
• Sickle cell disease
• Gaucher’s disease(fatty substances also can build up in bone tissue, weakening the
bone and increasing the risk of fractures.)

• Gout and Pseudo-gout

Activity: Brainstorming
• Mention five (5) investigation you can request for the patient
with septic arthritis
Investigations
Laboratory studies
• Full blood Picture-elevated white blood cell
• Estimated Sedimentation Rate(ESR)-greater than 40mm/hour
• C Reactive protein(CRP)-greater than 20mg/dl
• Blood culture may be positive
Investigation cont…
Synovial fluid Analysis
• Gross examination include-Appearance, volume, Viscosity,
Mucin clotting(In non-inflammatory arthritis e.g Osteoarthritis (good clot). Clot good to
poor = Non-infectious arthritis. The clot is poor = Bacterial arthritis)

• Microscopic exam-leucocyte count, staining of smears,

serum glucose ratio(Patients with joint fluid glucose levels less than 40 mg/dl should
be suspected septic arthritis.), protein

• Culture and sensitivity for definitive diagnosis and treatment

Investigation (continue)

Imaging studies
• X-ray-Early stage normal
• Late stage-Narrowing and irregularity of joint
space,subchondral erosion and sclerosis of femoral head
• Ultrasography-Joint effusion(swelling 2 0 fluid) in early
stage,widening of the space between capsule and bone greater
2mm indicate effusion
• Positive echogenic(from ultrasound waves bouncing back)-
Septic Arthritis
Treatment
General supportive care
• Analgesics esp NSAIDs(Ibuprofen oral 400–600mg three times daily after food or
Naproxen oral 250–500mg twice daily after food. If has PUD give together with PPIs like
Omeprazole oral 20mg each day or Lansoprazole oral 15–30mg each day )

• IV fluid
• Splintage-Joint must rested either on splint or in widely splint plaster
• Antibiotics-Start once the blood sample are obtained without waiting for result.
o Neonates and infants up to 6 months-penicillin (flucloxacillin) plus 3 rd
generation cephalosporin
o Children from 6 months to puberty(treat like neonate)
o Older teenager and adults – Flucloxacillin and Fusidic acid and 3 rd generation
cephalosporin
o Antibiotics given IV for 4-7 days.
 Surgiccal Treatment
• Surgical drainage
• Arthroscopic
debridement and
copious irrigation
(large volumes of irrigant)
with normal
saline
Complication of Septic Arthritis
• Bone destruction and dislocation of
joint (Hip joint)
• Cartilage destruction
• Fibrosis(excessive accumulation of connective
tissue, which eventually contributes to joint stiffness
that results in intense pain during joint movement)
and Ankylosis(stiffness of a joint due to
abnormal adhesion and rigidity of the bones of the joint)

• Growth disturbance
• Presence of either localized
deformity or shortening of bone.
Pannus= extra growth due to synovial tissue proliferation
Key points
• Septic arthritis is the inflammation of a synovial membrane
with purulent effusion into joint capsule due to infection.
• Both, Septic can be managed conservatively or surgically
Evaluation
• Mention three (3) clinical presentation of a patient with septic
arthritis
• Mention four (4) complications of septic arthritis.
• Mention four investigation you can order to the patient septic
arthritis
Reference
• Russell R.C.G., Norman S.W. & Bulstrode C.J.K. (2008).
Bailey and Love’s Short Practice of Surgery (25 th edition.).
London: Hodder Arnold
• Uptodate 2011-2019