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Septic Arthritis (other than Hip)

Septic arthritis (other than hip)
Objectives
  1. Describe diagnostic features of joint sepsis in children
  2. Describe the natural history of joint sepsis in children
  3. Describe the organisms most likely to result in joint sepsis in your location
  4. Describe treatment for joint sepsis in children, excluding the hip joint

Discussion
Septic arthritis is a common childhood condition. Seeding of the joint occurs from one of the transient bacteremias that accompany everyday life, even from brushing teeth. The reason for seeding a particular joint at any particular time remains mysterious. Once seeded, the chain of reactions leasing proteolytic enzymes from the leucocytes is begun, which prior to the antibiotic era could result in joint destruction or even death. The outlook today for most cases of septic arthritis promptly treated is for complete recovery. The hip joint, with its particularly vulnerable blood supply is a more emergent condition when septic than other joints, although the shoulder has similarities; the sequelae may be less obvious as the shoulder is not a weightbearing joint. The septic joint is painful, and the child will hold the joint in the most comfortable position, usually at the midrange of motion, and vigorously resist painful motion. Sequential measurements of active and passive range of motion is an excellent clinical measure of response to treatment. Most joints of the limbs are superficial and can thus be easily examined, and easily aspirated. The SI joint is an exception, and must be examined indirectly by maneuvers designed to place stress on the joint; aspiration of a painful SI joint requires anesthesia. If the patient is febrile, blood cultures may be helpful. It is not at all uncommon to have a negative culture of an obviously cloudy joint aspirate, in such cases blood cultures may identify an organism. If an organism is not identified, treatment is based on the prevalent organisms for the age of the patient in the local environment. In the United States, it is no longer considered necessary to provide antibiotic coverage for hemophilus influenza. Kingella is becoming much more prevalent in the young population.

Special imaging for most cases of septic arthritis should not be necessary. Ultrasonography of the adjacent bone may be helpful to determine if osteomyelitis is also present when swelling is severe. Scintigraphy is only helpful when one is unsure of the site of infection (SI joint). MRI and CT can be helpful for detecting abscesses about the pelvis.

The basic treatment plan for septic arthritis is to make the diagnosis, isolate the organism if possible, remove the purulent effusion, and deliver an appropriate antibiotic. There are published reports of treating septic arthritis by arthrotomy, arthroscopy, and early septic joints by aspiration and lavage alone (all with intravenous antibiotics). Whatever method is used, it is important that a clinical response be noted within 24 hours, or another diagnosis (or inadequate drainage) is responsible. Sequential levels of C reactive protein (CRP) provide a more rapid indicator of clinical response than the ESR. After a clear clinical response is documented, antibiotics may be continued orally. There is no scientific endpoint for discontinuing coverage for uncomplicated joint sepsis, the trend is for lesser total durations of therapy. 3 weeks is a cookbook answer for most uncomplicated cases.

If diagnosis is delayed, or an immediate response to treatment is not attained, there is either another nidus of infection or osteomyelitis complicating the arthritis must be suspected, and a longer duration of therapy will be necessary. Indications for operative intervention are then the same as those for osteomyelitis.

References
  1. Aprin H, Turen C. Pyogenic sacroiliitis in children. Clinical Orthopaedics & Related Research 1993( 287): 98-106.
  2. Birgisson H, Steingrimsson O, Gudnason T. Kingella kingae infections in paediatric patients: 5 cases of septic arthritis, osteomyelitis and bacteraemia. Scandinavian Journal of Infectious Diseases 1997; 29( 5): 495-8.
  3. Bos CF, Mol LJ, Obermann WR, Tjin a Ton ER. Late sequelae of neonatal septic arthritis of the shoulder. Journal of Bone & Joint Surgery -British Volume 1998; 80( 4): 645-50.
  4. Herndon WA, Knauer S, Sullivan JA, Gross RH. Management of septic arthritis in children. Journal of Pediatric Orthopedics 1986; 6( 5): 576-8.
  5. Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR. American Journal of Roentgenology 1995; 165( 2): 399-403.
  6. Lejman T, Strong M, Michno P, Hayman M. Septic arthritis of the shoulder during the first 18 months of life. Journal of Pediatric Orthopedics 1995; 15( 2): 172-5.
  7. Luhmann JD, Luhmann SJ. Etiology of septic arthritis in children: an update for the 1990s. Pediatric Emergency Care 1999; 15( 1): 40-2.
  8. Lundy DW, Kehl DK. Increasing prevalence of Kingella kingae in osteoarticular infections in young children. Journal of Pediatric Orthopedics 1998; 18( 2): 262-7.
  9. Lyon RM, Evanich JD. Culture-negative septic arthritis in children. Journal of Pediatric Orthopedics 1999; 19( 5): 655-9.
  10. Peltola H, Kallio MJ, Unkila-Kallio L. Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b vaccination. Implications for treatment. Journal of Bone & Joint Surgery -British Volume 1998; 80( 3): 471-3.
  11. Peters W, Irving J, Letts M. Long-term effects of neonatal bone and joint infection on adjacent growth plates. Journal of Pediatric Orthopedics 1992; 12( 6): 806-10.
  12. Reilly JP, Gross RH, Emans JB, Yngve DA. Disorders of the sacro-iliac joint in children. Journal of Bone & Joint Surgery -American Volume 1988; 70( 1): 31-40.
  13. Sanchez AA, Hennrikus WL. Arthroscopically assisted treatment of acute septic knees in infants using the Micro-Joint Arthroscope. Arthroscopy 1997; 13( 3): 350-4.
  14. Skyhar MJ, Mubarak SJ. Arthroscopic treatment of septic knees in children. Journal of Pediatric Orthopedics 1987; 7( 6): 647-51.
  15. Strong M, Lejman T, Michno P, Hayman M. Sequelae from septic arthritis of the knee during the first two years of life. Journal of Pediatric Orthopedics 1994; 14( 6): 745-51.
  16. Strong M, Lejman T, Michno P. Septic arthritis of the wrist in infancy. Journal of Pediatric Orthopedics 1995; 15( 2): 152-6.
  17. Unkila-Kallio L, Kallio MJ, Peltola H. The usefulness of C-reactive protein levels in the identification of concurrent septic arthritis in children who have acute hematogenous osteomyelitis. A comparison with the usefulness of the erythrocyte sedimentation rate and the white blood-cell count. Journal of Bone & Joint Surgery -American Volume 1994; 76( 6): 848-53.
  18. Yagupsky P, Bar-Ziv Y, Howard CB, Dagan R. Epidemiology, etiology, and clinical features of septic arthritis in children younger than 24 months. Archives of Pediatrics & Adolescent Medicine 1995; 149( 5): 537-40.

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