Practical Aspects of septic arthritis in children

Home » » Diseases » Practical Aspects of septic arthritis in children
Diseases No Comments

* Concept

* Epidemiology

* Bacteriology

* Predisposing factors

* Pathogenesis

* Pathology

* Location

* Clinical Manifestations

* Diagnosis

* Differential Diagnosis

* Treatment

* Septic arthritis of the newborn

* Reactive Arthritis

* Transient synovitis

* Arthritis, gonococcal and syphilitic

* Conclusions

* References


“Articulate acute inflammatory process caused by invasion and multiplication of pyogenic organisms.”

Indicates the presence of the infectious organism into the joint and is not associated with adjacent osteomyelitis.

Keywords: arthritis, septic pyogenic infectious, diagnostic, clinical, articular inflammation +, infant, pediatric


* More frequent in childhood than in adulthood

* Increased incidence of 2-6 years.

* In elderly patient due to reduced organic defenses and increased infections in general.

* More common in men than in women (2:1)

* In the male, young adult, gonococcal higher incidence, in the U.S., reaching incidences similar to those produced by Staph.

* More often lower limb joints.

3. Etiology

* More frecuente Staphylococcus (70% to 80%)

* Segundo streptococcus and gonococcus.

* Pneumococcal


  • Mainly under 15 months

    * Hips

    * Fluid culture higher diagnostic method.

    * High percentage with decreased susceptibility to penicillin.

    * Diagnosis and treatment precoz good prognosis articular

    * Gram negative


  • E. Coli, Pseudomonas, Proteus, H. influenza, Serratia

    * Less frequent

    * Newborns and infants in sepsis especialmente

    * Patients aged avanzada in urinary infections and systemic.


    Newborn, community-acquired infection:

    * 52% Group B Streptococcus (birth canal),

    * Staphylococcus 25%

    * Neisseria gonorrhoeae 17%

    Bacilli * G (-) 5%.

    Newborn nosocomial infections:

    * Staphylococcus 62%

    * Yeast 17%

    * Bacilos G (-) 13%,

    * Streptococcus 13%.


    * Before the vaccine and Haemophilus influenza from 1 month to 5 years.

    * As in adults more often staphylococcus.

    Teens: Neisseria gonorrhoeae, Pseudomonas in drug

    5. Predisposing Factors

    * Rheumatoid arthritis

    * Drop

    * Lupus Erythematosus

    * State of immunosuppression, HIV (fungi or mycobacteria) or Deficit complement (C7 and C8)

    * Blood Diseases: Sickle Cell Anemia and hemoglobinopathies

    * Bacteremia transient or persistent

    * Endocarditis.

    * Skin infections.

    * Varicella

    * History of respiratory infection two weeks prior.

    * Trauma or contiguity (osteomyelitis)

    * Joint damage prior

    * Joint prosthesis

    * Joint surgical procedures.

    * Surgery or instrumentation of the urinary tract or bowel.

    * Drug injecting

    * Catheters. Sternoclavicular arthritis (subclavian vein) and arthritis of the hip (femoral)

    6. Pathogenesis

    The germs get into the joint:


  • Hematogenously (the most common).

    * Direct route:

    * Penetrating injury

    * Infected injection

    * Surgical infection.

    * By contiguity:


  • Extension of focus osteomyelitic

    Hip Arthritis child, focus the femoral neck (intracapsular)

    * The remainder of the joints must cross the barrier infection determined by the growth plate and the epiphysis or via periarticular (node).


    * Synovium: bacteria multiplican PMN migration

    * Liberation of proteolytic enzymes (metalloproteinases) and proinflammatory cytokines (IL-1, TNFa) bacteria Phagocytosis

    * Increased Proliferation flow membrane sanguneo sinovial

    * Oozing into space articulate and purulent discharge

    * Increased pressure cavity Articulate cartilage degradation

    * Possible loss of joint integrity.

    7. Pathology

    First etapa “Synovitis”

    * Hyperemia, swelling and leukocyte infiltration of synovial

    * Intraarticular serous effusion, seropurulent, purulent.

    Second etapa “phlegmon capsular>>

    * All joint tissues infiltrated by the exudate.

    * Commitment of articular cartilage, irreparable damage.

    Bone involvement

    * Chondrolysis and osteolysis

    * Permanent joint damage and cartilage loss

    * Contact between bone ends or bony ankylosis fusionan

    * Reparativo is interposed fibrous ankylosis fibrous tissue.


    Any joint can be involved,

    * The most common sites of infection are:

    * Knee (children and adolescents)

    * Hips (infants and children)

    * Shoulder and Ankle

    * Elbow

    * Doll

    * Pelvis

    * Column (spondylitis in elderly)

    * Most infections affect only one joint.


    * 80% monoarticular “acute monoarthritis.”


  • Abrupt increase in volume 1 joint with intense pain and local heat.

    * Polyarticular 20%.


  • Patients with pre-existing disease (eg diabetes mellitus) or joints (eg rheumatoid arthritis).


    * Acute onset (hours or days)

    * Febrile syndrome with prostration and loss of appetite.

    * Commitment articulate spontaneous pain, especially joint mobilization, enlargement, erythema, local heat, functional impotence, antalgic position.

    * Can be clear gateway, skin infection (furuncle, Anthrax, impetigo, scabies infected) or the course of a disease (sepsis, staphylococcal pneumonia or other acute tonsillitis, etc.).

    * If there is no gateway obvious: not changed the diagnostic suspicion

    * When there, we probably guidance on origin and etiology.

    * May or may not be evidence of primary outbreaks of skin infection, urinary tract, respiratory or other.


    * Lactantes general manifestations precede the Local Joint box

    * Adultos more attenuated infectious condition, consult a few days later.

    * Tip Superiore child ceases to move your arm, it remains to be touched and, in attempting movilizrselo, crying with pain.

    * Tip Inferiore similar attitude if infant, older child if you stop walking or does so with great difficulty by local pain.

    * Cadera no swelling, joint is a deep, intense pain especially mobilizing internal and external rotation or abduction, limited. Antalgic position: slight flexion and adduction.

    * Rodilla obvious signs of inflammation and joint effusion, iceberg or sign patellar shock. Antalgic position: mild semiflexion.

    Atypical presentations:

    * Preexisting arthropathy: Rheumatoid Arthritis (RA)


  • It can be difficult to recognize

    * It can be confused with peak activity

    * You can drive by mistake increased immunosuppressive therapy.

    * It can be mono or polyarticular.

    * Presentation polyarticular

    * In old and debilitated patients: with fewer symptoms, sometimes afebrile

    * Locations that may go unnoticed: hips, sternoclavicular, sacroiliac

    10. DIAGNOSIS:

    Synovial fluid studies

    * Mandatory

    * Obtaining usually facilitated by increased amount thereof within the involved joint.

    * Inflammation: turbidity of the liquid, cell growth.

    * Other inflammatory diseases may present turbidity chondrocalcinosis (white-milky arthritis crystals of calcium pyrophosphate), rheumatoid arthritis or gout.

    * Confirms get cloudy fluid or pus.

    * WBC and differential

    * Study of crystals

    * Gram stain

    * Crop

    Puncture technique ARTICULAR

    * Measures aseptic

    * Isolation of the field, surgical scrub hands and use sterile gloves.

    * Insert needle into joint cavity and extract the maximum amount of synovial fluid

    * Puncture of the knee or sperointerno outer quadrant, 1 cm. above and outside or inside the bearing.

    * In hip: 1.5cm. inguinal ligament below 1 cm. outside the femoral artery is identified by palpation of the beating.

    * Normal and colorless liquid.

    * Osteoarthritis: beige and septic arthritis: cream or gray.

    * Mucin clot by adding acetic acid


  • Since the amount of protein bound polysaccharide

    * Average in osteoarthritis; friable rheumatoid arthritis or poor, gout and septic arthritis.

    * Viscosity of liquid


  • Relationship presence of hyaluronate, if placing a drop between thumb and forefinger, are separated over one to several centimeters and liquid is held together, is probably normal.

    * Normal joint fluid of osteoarthritis, normal or high.

    * Rheumatoid arthritis, gout or septic, is decreased

    Cell Review


  • Very useful.

    * Normally around 100 leucocitos/mm2.

    * Tubes with anticoagulant (heparin or EDTA) for cell studies.

    * Processes noninflammatory: 1000-2000 cel/mm2.

    * Inflammatory: on 10.000cel/mm2

    * Septic arthritis: on 100.000/mm2 predominantly polymorphonuclear.

    * Normal protein concentration approx. 30% lower serum concentration.

    * Permeability of the synovial inflammatory increased protein content increases.

    * Glucose infectious processes is decreased <50% of the blood, and is lower in septic processes

    * Confirm etiology, causative.

    * Study direct Gram stain morphology without waiting seed crop

    * Positive culture in 90% of nongonococcal bacterial arthritis

    * Growing medium


  • Usual blood agar

    * Neisseria gonorrhea, haemophilus: chocolate agar

    * Fungi Sabouraud

    * Mycobacteria: specific means.


    * Method secondary early diagnosis.

    * Radiographic late, do not help in acute, but after 10 to 15 days.

    * Allows:


  • Knowing joint precondition

    * Pesquisar possibility of other diagnoses

    * Rate after disease progression.

    Radiologic Signs

    * Increased periarticular soft

    * Decreased joint space: commitment cartilage

    * (Chondrolysis)

    * Increase joint fluid increased joint space.

    * Subchondral and epiphyseal bone demineralization

    * Effacement and irregularity of contour articulate and

    * Progressive destruction of articular surfaces.

    * Skeletal scintigraphy: Concentration in coordination abnormal radiopharmaceutical diagnostic value suspect is in initial stages. Technetium 99, increased uptake in affected joint. (+) In 24 hours.

    * Joints difficult to locate and / or to puncture is useful and CT or MRI.

    * MRI. Reveals abnormalities of bone marrow and soft tissues within 24-48 hours. Demonstrates increased infection and edema fluid around. Typically: focal area, well defined with much edema extending to adjacent soft tissues.


    * For joint space and can recognize early periosteal elevation.

    * Intraarticular fluid is easily detectable.

    * Can assess edema as areas of high echogenicity.

    * You can not rate structures intraosseous

    Other laboratory tests

    * Blood cultures: (+) in 50% of nongonococcal bacterial arthritis

    * CBC: leukocytosis and increased neutrophil.

    * Elevation of ESR and C-reactive protein


    * Active rheumatic disease (migratory arthritis).

    * Arthritis crystals (gout or pseudogout).

    * Mono-articular rheumatoid arthritis.

    * Traumatic arthritis.

    * Infectious processes periarticular soft tissue.

    * Acute osteomyelitis.

    * Toxic synovitis (also called (irritable hip, reactive or transient synovitis)

    * Epiphyseal osteomyelitis.

    * Viral arthritis (varicella zoster, parvovirus B19, rubella and others).

    * Arthritis by fungi and mycobacteria.

    * Traumatic arthritis.

    * Bacterial endocarditis.

    * Villonodular synovitis.

    * Leukemia.

    * Cellulite deep.

    * Serum sickness.

    * Ulcerative colitis.

    * Granulomatous colitis.

    * Schnlein-Henoch.

    * Traumatic arthritis.

    * Fracture.

    * Legg-Calv-Perthes disease.

    * Epiphysiolysis of the femoral head.

    * Metabolic diseases that affect the joints


    * You must be urgent and early

    * Purulent secretion condroltica has a powerful action will destroy the joint from the functional viewpoint

    * It is a septic focus with the consequences that can derive from it (sepsis).

    * Mandatory bedrest patient to top

    * Rehabilitation to achieve a joint anatomically and functionally normal.

    * Recommended early mobilization to prevent contractures.

    Antibiotic Treatment

    * According to: causative organism, clinical and bacteriology with Gram, culture and sensitivity.

    * Majority: Staph aureus, oxacillin intravenous dose of 150 to 200 mg / kg or 1 gr. every 6 hours in adults.

    * Penicillin G estreptococo Gonococcus or 100-200 mg / kg or 2 million units every 6 hours EV in adults.

    * EV are administered for 14 days followed by oral treatment for another 14 days.

    * No need intrarticulacin, concentrations achieved in synovial intravenously are sufficient.

    Drainage of exudate

    * Arthrotomy, repeated punctures or Arthroscopy articular aspirational.

    * Method of choice: surgical drainage system leaving joint lavage with saline for 5-10 days.

    * Insufficient articular punctures and not indicated in staph infections or arthritis very aggressive.

    * Mandatory and urgent, hip, destruction is imminent for cartilage damage and necrosis of the femoral head vascular damage

    * In the infant, the destruction of the femoral head and neck with distension of the joint capsule can cause dislocation of the hip, bad functional prognosis.

    13. NEWBORN septic arthritis

    * Difficulty of diagnosis: clinical scarcity and nonspecific

    * Etiology: unusual microorganisms

    * May be involved etiological agents Staphylococcus, Streptococcus and Enterobacteriaceae.

    * Also been reported for Candida albicans and gonococcus.

    * Gonococcal: is polyarticular, 1-5 weeks after birth.

    * DX and catastrophic consequences if not early Tto

    * It may affect more than one joint.

    * Hip: clinic 1-28 days after venipuncture (differentiate femoral thrombosis). Fever and leukocytosis septic appearance. Progression of localized infection spontaneous drainage path along the inner shutter and giving rise to a mass above the inguinal canal.

    * Treatment and antibiotics to cover S. aureus, Enterobacteriaceae, Streptococcus group B and gonorrhea Neiserria the following treatment regimens according to age:

    – Under 7 days: antipenicilinasa penicillin (cloxacillin + cefotaxime).

    – From 7 days to 28 days: cloxacillin + cefotaxime

    – Over 28 days: cloxacillin + cefotaxime

    * Duration: 3 to 4 weeks

    * Will parenteral, or oral and supplemented parenteral start.

    * Perform radiography before stopping treatment because up to two thirds of patients have been observed in addition to arthritis, bone involvement.

    14. Reactive arthritis

    * Caused by an immune mechanism,

    * Have been described in connection with Shigella infections, Chlamydia trachomatis, Salmonella and Yersinia.

    * Joint swelling postinfectious more often in people with HLA-B27 (+).

    * Symptoms: from days to weeks after infection, resolved in 7 to 10 days regardless of the use of antimicrobials

    15. Transient synovitis

    * Characterized: fever, pain and loss of function of the joint.

    * Probable viral

    * Regression spontaneously within a few days.

    * Differential diagnosis with pyogenic arthritis.

    * Facing Dudae hip arthrotomy before leaving evolve pyogenic arthritis

    * Once drained the joint should be immobilized in a cast, brace or be a pelvipedio if the knee or hip respectively.

    16. Gonococcal arthritis

    * More common in young adults

    * Days a few weeks after gonococcal urethritis treated improperly.

    * Oligoarticular or monoarticular.

    * Characteristics of acute pyogenic arthritis.

    * Gram can show Gram negative diplococcus

    * Growing difficult.

    * Antibiotic of choice is penicillin

    * It is conservatively without surgical drainage.

    * Immobilization in functional position is imperative.

    Syphilitic arthritis

    * Exceptional.

    * View syphilitic mother newborns.

    * Tertiary syphilis can cause Charcot arthropathy in adults.


    * Increased incidence of 2-6 years and more common in men than in women (2:1)

    * Most common etiologic agent is Staphylococcus (70% to 80%)

    * In a newborn, community-acquired infection: 52% Group B Streptococcus (birth canal) but it is a nosocomial infections: Staphylococcus 62%,

    * The germs get into the joint: hematogenously (the most common).

    * Pathology: First stage: “Synovitis” Stage “capsular phlegmon” Then commitment articular cartilage damage by ltino irreparable.y: bone involvement: chondrolysis and osteolysis with definitive joint damage and cartilage loss.

    * The most common sites of infection are: Knee (children and adolescents) and Hip (infants and children)

    * Presented as monoarticular 80%

    * In Infants general manifestations precede the local joint box Adults differences where it occurs as an infection more attenuated.

    * The study is mandatory synovial fluid confirms the diagnosis established etiology and guides to specific treatment.

    * Plain radiography is a method for early diagnosis secondary radiographic signs are late, and do not help in acute, but after 10 to 15 days.

    * Treatment should be urgent and early include: antibiotics, analgesics, anti-inflammatory, joint exudate drainage, physiotherapy and rest then.


    * Tiddia F, Cherchi GB, Pacific L. (1994) Yersinia enterocolitica Causing suppurative arthritis of the shoulder.J Clin Pathol 47 (8): 760,

    * The-Gabalawy HS, Duray P, Goldbach-Mansky R. (2000) Evaluating patients with arthritis of recent onset: studies in pathogenesis and prognosis. JAMA, 284: 2368-2373.

    * Perlman MH, MJ Patzakis, Kurmar PJ. (2000) The Incidence of joint Involvement with adjacent osteomyelitis in pediatric patients. J Pediatr Orthop, 20: 40-43.

    * Perry CR. Septic arthritis. (1999) Am J Orthop; 28:168-178.

    * Cardinal, E., Bureau, N., Aubin, b., Chhem, R., (2001) Role of Ultrasound in Musculoskeletal Infections, Radiol Clin North Am; 39:191201.

    * Roldn-Valadez E, Lima-Davalos R, Shangri-Pinto G, Solorzano-Morales S, Hernandez-Ortiz J (2004) Imaging of acute septic arthritis of the hip. Gac Med Mex, 140 (1): 93-96

    * Goldenberg D. Septic arthritis. (1998) Lancet, 351: 197-202