Orthopaedic

1. SEPTIC ARTHRITIS
&
TOM SMITH ARTHRITIS

2. Introduction
 A joint inflammation due to an
infection usually involving synovial
joints.
 50% of cases- children less than 5
years.
 30% of cases- children less than 2
years.

3. Common sites(Adults)
 Knee- 53%
 Hip- 20%
 Elbow- 17%
 Shoulder- 10%

4. Common sites(Children)
Knee- 39%
 Hip- 32%

5. CAUSATIVE ORGANISMS
Staphylococcus aureus
Hemophilus influenza
Streptococcus
E. coli
Proteus

7. MODES OF SPREAD
1. Direct invasion.
2. Local spread from adjacent
tissues.
3. Spread from metaphyseal
osteomyelitis.
4. Hematogenous spread.

8. Predisposing Factors-General
factors
 Rheumatoid arthritis.
 SLE
 Immunosuppressive drug therapy.
 Diabetes mellitus.
 Immunodeficiency disorders.
 Chronic debilitating disorders- liver
failure and renal failure.

9. Predisposing factors- Local
factors
Previous joint trauma.
H/o arthritis to the same joint.
Degenerative joint disease.
Crystal induced joint disease.(gout
and pseudogout)

10. PATHOLOGY
 Bacteria rapidly gains access to the joint cavity and
settles in the synovial membrane.
 Acute inflammatory reaction occurs with formation
of serous or seropurulent exudate.
 Articular cartilage is eroded and destroyed due to
the action of bacterial toxins and by enzymes
released from the synovium and inflammatory cells.
 In late cases- extensive erosion due to synovial
proliferation and ingrowth.

11.  If untreated- spread to the underlying bone or burst
out of the joint to form abscesses and sinuses.
 With healing:
1. Complete resolution.
2. Partial loss of cartilage and fibrosis of joint.
3. Loss of articular cartilage and bony ankylosis.
4. Bone destruction and permanent deformity of the
joint.

12. Clinical Features- Symptoms
 Fever
 Pain over joint.
 Reluctance to move joint(pseudoparesis).

13. Signs
 In neonates:
Few clinical signs.
Child may not have fever.
Loss of spontaneous movement of extremity.
Hip-flexion, abduction, and external rotation.

14.  In children: signs of local inflammation are present.
 Rapid pulse and swinging fever.
 Overlying skin-red.
 Swelling may be present.
 Local rise of temperature and marked tenderness
over joint.
 All movements of joint- restricted.

15.  In adults:
Often a superficial joint( knee, wrist or ankle).
Joint is painful, swollen, and inflamed.
Movements are restricted.

16. PHYSICAL EXAMINATION
1. Decreased or absent range of motion.
2. Signs of inflammation: joint swelling, warmth,
tenderness and erythema.
3. Joint orientation as to minimize pain (position of
comfort):
 Hip: abducted, flexed and externally rotated.
 Knee, ankle and elbow: partially flexed.
 Shoulder: abducted and internally rotated

17. Investigations
1. Blood investigations
2. X- ray
3. USG
4. Diagnostic aspiration
5. MRI

18. BLOOD INVESTIGATIONS
 Leucocytosis >12,000.
 ESR>40 mm/hr.
 CRP- elevated.
 Blood culture-may be positive.

19. X-ray
In early stages- usually normal.
Later on- joint space widening
may be present and subluxation
of the joint may be present.
In late stages- irregularity of the
joint.

21. Septic arthritis
of the ankle

22. USG
 Can be used to detect even the smallest
amount of joint effusion.
 Non invasive, inexpensive and easy to
use.
 Can be used to guide joint aspiration.

23. JOINT ASPIRATION
 In early cases- fluid may be clear.
 Sample sent for Gram staining, microscopy, culture,
and antibiotic sensitivity.
 Normal synovial fluid leucocyte count: under
300/ml.
 Leucocyte count>50,000 per ml with 90% PMN-
strongly suggestive of septic arthritis.

24. streptococci

25. H. influenzae

27. MRI
 Can detect infection and extent of infection.
 Useful in diagnosing infections that are difficult to
access.
 Also useful in differentiating between bone and soft
tissue infections and in detecting joint effusion.

28. Differential Diagnosis
 Acute osteomyelitis.
 Trauma
 Irritable joint
 Hemophilic joint.
 Rheumatic fever
 Gout and pseudogout
 Gaucher’s disease.

29. Treatment
 IV fluids- to prevent dehydration.
 Analgesics- for pain.
 Joint must be rested either on splint or in a widely
split plaster.

30. Antibiotics
 Broad spectrum IV antibiotics are started
immediately and then depending on microbiological
investigations, specific antimicrobial therapy is
started.
 First line antibiotics: Benzyl penicillin, flucloxacillin,
and augmentin.
 Second line antibiotics: Vancomycin, Clindamycin,
Fusidin, and Teicoplanin.
 Hemophilus infection- cephalosporins.

31.  Duration of treatment: IV antibiotics given for
minimum of 2 weeks.
 Oral antibiotics:
Children-2-4 weeks.
Adults- 4-6 weeks.

32. Drainage:
Indication of Surgical Drainage:
1-Joints that do not respond to antimicrobial therapy and daily
arthrocentesis
2-. Any joint with limited accessibility, including the sternoclavicular
or the hip joint
3-Patients with underlying disease, including diabetes, rheumatoid
arthritis, immunosuppression, or other systemic symptoms, should
be treated more aggressively with earlier surgical intervention

33. Drainage
 In septic arthritis of hip- surgical drainage is always
done.
 Best approach-anterolateral
 Joint is opened through a small incision and washed
with normal saline.
 Small drain is left in place after incision is closed.
 Suction-irrigation is continued for another 2 or 3
days.

34.  In knee- arthroscopic debridement and copious
irrigation.
 In adults- repeated closed aspiration of joint may
be done.
 But if no improvement within 48 hours- open
drainage is necessary.

35. Complications
 Joint Destruction
 Coxa magna
 Pathological Dislocation
 Acute Osteomyelitis
 Septicemia
 Secondary osteoarthritis
 Avascular necrosis

36. TOM SMITH ARTHRITIS

37.  Septic arthritis of the hip.
 Seen in infants.
 Head of femur is completely destroyed by the
pyogenic process.

38.  Transphyseal vessels are present in early infancy
before the formation of the growth plate This may
account for the frequency of septic arthritis of the
hip in the neonate
 In children, about a third of long-bone
osteomyelitis is associated with septic arthritis of the
adjacent joint.

39. Clinical features
 Onset is acute with rapid abscess formation.
 Can be mistaken for a superfical infection.
 Can present later with complaints of limp without
any pain.
 O/E: Affected leg is shorter and hip movements are
increased in all directions.
 Telescopy test-positive.

40.  X-ray- complete absence of the head and neck of
femur.
 Condition resembles DDH; complete absence of
head and neck and normally developed round
acetabulum.

41. Treatment
 Acute surgical emergency.
 Open drainage of hip joint is the most effective
method of treatment in septic arthritis of the hip.
 Arthroscopic drainage can also be attempted.