Septic arthritis 179

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D: Joint inflammation due to intra-articular infection.

A: Bacteria enter the joint directly, e.g. penetrating wound, by haematogenous spread, systemic sepsis, adjacent osteomyelitis or a contaminated prosthesis. The most common causative organisms in < 3 years are Staphylococcus aureus, Haemophilus influenzae or coliforms, and S. aureus and Neisseria gonorrhoeae in adults.

A/R: Those with diabetes, corticosteroid use, IV drug abuse, immunocompromise or chronic joint disease (e.g. rheumatoid arthritis) are at " risk of septic arthritis.

_E: Incidence ~6/100000, 50% of cases in children <3 years. ^^

H: Pain in a joint or limb, malaise, fever.

Commonly affects a single large joint; e.g. the hip in infants and children, present with a limp and refusing to weight bear. The knee is often affected in nIrlor rhIIrlran anrl arliiltc althnunh It maw affort ami inint older children and adults, although it may affect any joint.

A red swollen joint; if a hip, the leg is held flexed and slightly externally rotated (slackens ligaments and reduces joint pressure).

Diffuse joint tenderness with severe reduction in its range of movement due to pain. If gonococcal arthritis, there may be associated skin pustules nearthe joint and evidence of urethral discharge.

Bloods: FBC, blood cultures, ESR, CRP.

Joint aspiration and microscopy, culture and sensitivity: Aspirate usually turbid with > 50 x 103/ml white blood cells, 90% neutrophils, culture to identify causative organism.

Joint radiograph: Shows " in joint space, soft tissue swelling and in late cases, subchondral bone destruction.

Bone scan: " uptake is seen in joint region.

USS: To identify a joint effusion, may guide aspiration.

Bacteria in the joint incite an inflammatory response, with the release of inflammatory mediators and attraction of leucocytes into the joint. Activation of neutrophils, macrophages results in release of proteolytic enzymes, together with bacterial toxins cause damage to the articular cartilage. " permeability and fluid secretion result in a joint effusion that may contribute to damage by " pressure and # synovial blood supply. During recovery, healing of the raw articular surfaces may result in fibrosis and bony ankylosis.

Surgical: In most cases, surgical washout of the joint should be carried out to remove pus and infected material. May be performed by arthroscopy or open procedure (arthrotomy). Sepsis in a prosthetic joint requires removal of the prosthesis before full eradication of infection is possible. Medical: Antibiotics initially, e.g. ceftriaxone or flucloxacillin, IV for 1-2 weeks followed by oral for an additional 4-6 weeks. Analgesics should be given and the joint should be splinted for pain reduction. Physiotherapy is provided to prevent fibrosis and maintain joint mobility.

Joint subluxation or dislocation, avascular necrosis of epiphysis, growth disturbance, ankylosis, joint destruction or secondary osteoarthritis.

Outcomes are dependent on the virulence of the organism, duration of infection prior to diagnosis, the premorbid condition of the patient and the joint affected, e.g. knees have better outcomes than ankles. With early appropriate treatment prognosis is usually good.

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