ACUTE SUPPURATIVE ARTHRITIS

A joint can become infected by: (1) direct invasion through a penetrating
wound, intra-articular injection or arthroscopy; (2) direct spread from an
adjacent bone abscess; or (3) blood spread from a distant site. In infants
it is often difcult to tell whether the infection started in the metaphyseal
bone and spread to the joint or vice versa. In practice it hardly matters
and in advanced cases it should be assumed that the entire joint and the
adjacent bone ends are involved.
The causal organism is usually Staphylococcus aureus; however, in
children between 1 and 4 years old, Haemophilus inuenzae is an
important pathogen unless they have been vaccinated against this organism. Occasionally other microbes, such as Streptococcus, Escherichia
coli and Proteus, are encountered.
Predisposing conditions are rheumatoid arthritis, chronic debilitating
disorders, intravenous drug abuse, immunosuppressive drug therapy and
acquired immune deciency syndrome (AIDS).
Pathology
The usual trigger is a haematogenous infection which settles in the
synovial membrane; there is an acute inammatory reaction with a
serous or seropurulent exudate and an increase in synovial uid. As pus
appears in the joint, articular cartilage is eroded and destroyed, partly by
bacterial enzymes and partly by proteolytic enzymes released from
synovial cells, inammatory cells and pus. In infants the entire
epiphysis, which is still largely cartilaginous, may be severely damaged;
in older children, vascular occlusion may lead to necrosis of the
epiphyseal bone. In adults the effects are usually conned to the articular
cartilage, but in late cases there may be extensive erosion due to
synovial proliferation and ingrowth.
If the infection goes untreated, it will spread to the underlying bone or
burst out of the joint to form abscesses and sinuses.
With healing there may be: (1) complete resolution and a return to
normal; (2) partial loss of articular cartilage and brosis of the joint; (3)

loss of articular cartilage and bony ankylosis; or (4) bone destruction and
permanent deformity of the joint.
Clinical features
The clinical features differ somewhat according to the age of the patient.
In newborn infants the emphasis is on septicaemia rather than joint pain.
The baby is irritable and refuses to feed; there is a rapid pulse and
sometimes a fever. Infection is often suspected, but it could be
anywhere! The joints should be carefully felt and moved to elicit the
local signs of warmth, tenderness and resistance to movement. The
umbilical cord should be examined for a source of infection. An
inamed intravenous infusion site should always excite suspicion. The
babys chest, spine and abdomen should be carefully examined to
exclude other sites of infection.
Special care should be taken not to miss a concomitant
osteomyelitis in an adjacent bone end.
In children the usual features are acute pain in a single large joint
(commonly the hip or the knee) and reluctance to move the limb
(pseudoparesis). The child is ill, with a rapid pulse and a swinging
fever. The overlying skin looks red and in a supercial joints welling
may be obvious. There is local warmth and marked tenderness. All
movements are restricted, and often completely abolished, by pain and
spasm. It is essential to look for a source of infection a septic toe, a
boil or a discharge from the ear.
In adults it is often a supercial joint (knee, wrist, a nger, ankle or toe)
that is painful, swollen and inamed. There is warmth and marked local
tender-ness, and movements are restricted. The patient should be
questioned and examined for evidence of gonococcal infection or drug
abuse. Patients with rheumatoid arthritis, and especially those on
corticosteroid treatment, may develop a silent joint infection. Suspicion
may be aroused by an unexplained deterioration in the patients general
condition; every joint should be carefully examined.

Imaging
Ultrasonography is the most reliable method for revealing a joint
effusion in early cases. Both hips should be examined for comparison.
Widening of the space between capsule and bone of more than 2 mm is
indicative of an effusion, which may be echofree (perhaps a transient
synovitis) or positively echogenic (more likely septic arthritis).
X-ray examination is usually normal early on but signs to be watched for
are soft-tissue swelling, loss of tissue planes, widening of the
radiographic joint space and slight subluxation (because of uid in the
joint). With E. coli infections there is sometimes gas in the joint.
Narrowing and irregularity of the joint space are late features.
MRI and radionuclide imaging are helpful in diagnosing arthritis in
obscure sites such as the sacroiliac and sterno clavicular joints.
Investigations
The white cell count and ESR are raised and blood culture may be
positive. However, special investigation take time and it is much quicker
(and usually more re-liable) to aspirate the joint and examine the uid. It
maybe frankly purulent but beware! In early cases the uid may look
clear. A white cell count and Gram stain should be carried out
immediately: the normal synovial uid leucocyte count is under 300 per
mL; it may be over 10 000 per mL in non-infective inammatory disorders, but counts of over 50 000 per mL are highly suggestive of sepsis.
Gram-positive cocci are probably S. aureus; Gram-negative cocci are
either H. inuenzae or Kingella kingae (in children) or Gonococcus (in
adults). Samples of uid are also sent for full micro -biological
examination and tests for antibiotic sensitivity.
Differential diagnosis
Acute osteomyelitis
In young children, osteomyelitis
may be indistinguishable from septic arthritis; often one must assume
that both are present.
Other types of infection

Psoas abscess and local infection

of the pelvis must be kept in mind. Systemic featureswill obviously be
the same as those of septic arthritis.
Trauma
Traumatic synovitis or haemarthrosis may be
associated with acute pain and swelling. A history of injury does not
exclude infection. Diagnosis may remain in doubt until the joint is
aspirated.
Irritable joint
At the onset the joint is painful and lacks
some movement, but the child is not really ill and there are no signs of
infection. Ultrasonography may help to distinguish septic arthritis from
transient synovitis.
Haemophilic bleed
An acute haemarthrosis closely
resembles septic arthritis. The history is usually conclusive, but
aspiration will resolve any doubt.
Rheumatic fever
Typically the pain its from joint to
joint, but at the onset one joint may be misleadingly inamed. However,
there are no signs of septicaemia.
Juvenile rheumatoid arthritis
This may start with pain and swelling of a single joint, but the onset is
usually more gradual and systemic symptoms less severe than in septic
arthritis.
Sickle-cell disease
The clinical picture may closely
resemble that of septic arthritis and indeed the bone nearby may
actually be infected! So this condition should always be excluded in

communities where the disease is common.

Gauchers disease
In this rare condition acute joint pain and fever can occur without any
organism being found (pseudoosteitis). Because of the predisposition
to true infection, antibiotics should be given.
Gout and pseudo gout
In adults, acute crystal induced synovitis may closely resemble infection.
On aspiration the joint uid is often turbid, with a high white cell count;
however, microscopic examination by polarized light will show the
characteristic crystals.
Treatment
The rst priority is to aspirate the joint and examine the uid. Treatment
is then started without further delay and follows the same lines as for
acute osteomyelitis. Once the blood and tissue samples have been
obtained, there is no need to wait for detailed results before giving
antibiotics. If the aspirate looks purulent, the joint should be drained
without waiting for laboratory results (see below).GENERAL
SUPPORTIVE CARE Analgesics are given for pain and intravenous
uids for dehydration. SPLINTAGE The joint should be rested, and for
neonates and infants this may mean light splint age; with hip infection,
the joint should be held abducted and 30 degrees exed, on traction to
prevent dislocation. ANTIBIOTICS Antibiotic treatment follows the
same guidelines as presented for acute haematogenous osteomyelitis
(see page 35). The initial choice of antibiotics is based on judgement of
the most likely pathogens.
Neonates and infants up to the age of 6 months should be protected
against staphylococcus and Gram-negative streptococci with one of the
penicillinase -resistant penicillins (e.g. ucloxacillin) plus a third
generation cephalosporin.
Children from 6 months to puberty can be treated similarly. Unless they
had been immunized there is a risk of Haemophilus infection.

Older teenagers and adults can be started on ucloxacillin and fusidic

acid. If the initial examination shows Gram negative organisms a third
generation cephalosporin is added. More appropriate drugs can be
substituted after full microbiological investigation.
Antibiotics should be given intravenously for 47
days and then orally for another 3 weeks. DRAINAGE Under
anaesthesia the joint is opened through a small incision, drained and
washed out with physiological saline. A small catheter is left in place
and the wound is closed; suctionirrigation is continued for another 2or
3 days. This is the safest policy and is certainly advisable (1) in very
young infants, (2) when the hip is involved and (3) if the aspirated pus is
very thick. For the knee, arthroscopic debridement and copious irrigation
may be equally effective. Older children with early septic arthritis
(symptoms for less than 3days) involving any joint except the hip can
often be treated successfully by repeated closed aspiration of the joint;
however, if there is no improvement within48 hours, open drainage will
be necessary. Haemophilic bleed An acute haemarthrosis closely
resembles septic arthritis. The history is usually conclusive, but
aspiration will resolve any doubt.
Rheumatic fever
Typically the pain its from joint to joint, but at the onset one joint may
be misleadingly inamed. However, there are no signs of septicaemia.
Juvenile rheumatoid arthritis
This may start with pain and swelling of a single joint, but the onset is
usually more gradual and systemic symptoms less severe than in septic
arthritis.
Sickle-cell disease
The clinical picture may closely resemble that of septic arthritis and
indeed the bone nearby may actually be infected! So this condition
should always be excluded in communities where the disease is

common.
Gauchers disease
In this rare condition acute joint pain and fever can occur without any
organism being found (pseudoosteitis). Because of the predisposition
to true infection, antibiotics should be given.
Gout and pseudogout
In adults, acute crystal-induced synovitis may closely resemble
infection. On aspiration the joint uid is often turbid, with a high white
cell count; however, microscopic examination by polarized light will
show the characteristic crystals.
AFTERCARE
Once the patients general condition is satisfactory and the joint is no
longer painful or warm, further damage is unlikely. If articular cartilage
has been pre-served, gentle and gradually increasing active movements
are encouraged. If articular cartilage has been destroyed the aim is to
keep the joint immobile while ankylosis is awaited. Splint age in the
optimum position is therefore continuously maintained, usually by
plaster, until ankylosis is sound.
Complications
Infants under 6 months of age have the highest incidence of
complications, most of which affect the hip. The most obvious risk
factors are a delay in diagnosis and treatment (more than 4 days) and
concomitant osteomyelitis of the proximal femur.
Subluxation and dislocation of the hip, or instability of the knee should
be prevented by appropriate posturing or splint age.
Damage to the cartilaginous physis or the epiphysis in the growing child
is the most serious complication. Sequelae include retarded growth,
partial or complete destruction of the epiphysis, deformity of the joint,
epiphyseal osteonecrosis, acetabular dysplasia and pseudo arthrosis of
the hip.
Articular cartilage erosion (chondro lysis) is seen in older patients and

this may result in restricted movement or complete ankylosis of the

joint.