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1
Q

What is the pathophysiology of septic arthritis?

A

Damage occurs within hours from cartilage degradation by enzymes and bone ischaemia from increased pressure

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2
Q

What is the cause of septic arthritis?

A

Most commonly is haematogenous spread of s aureus

Also can develop from osteomyelitis (esp neonates) infection spreads from metaphysis via transphyseal vessels

or direct inoculation

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3
Q

What are the most common causative organisms in septic arthritis?

A

S aureus (most)

Group B strep
Gram -ve bacilli
Group A step
Strep pneumonia
Neisseria gonorrhoea
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4
Q

Give examples of gram -ve bacilli

A 
E Coli
Salmonella
Shigella
Leigonella
Pseudomonas
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6
Q

What is group A strep?

A

Streptococcus pyogenes

cause strep throat, impetigo

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7
Q

What is group B strep?

A

Streptococcus agalactiae

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8
Q

How does septic arthritis present in children?

A

Easily missed! Infants characteristically do not appear ill and may be confused with more common conditions eg transient synovitis and trauma

Fever (but 50% do not have)
Joint pain
Unwillingness to move affected join (eg limp / refusal to weight bear)
Hot, warm, swollen joint

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9
Q

Group A and B streptococcus are both beta-haemolytic. What are alpha-haemolytic streptococcus?

A

Streptococcus pneumoniae

Streptococcus viridans

(gamma- haemolytic = enterococcus)

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10
Q

What joints are most commonly affected in children with septic arthritis?

A

75% = lower limb

Knee > hip > ankle

Other 25% = upper limb

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11
Q

What investigations are performed for septic arthritis?

A

CRP, synovial WCC, and % of polymorphonuclear cells and lactate = best markers

FBC
Synovial fluid examination
Synovial tissue culture
Blood culture
PCR
Tests for Lyme disease
Immunology
Imaging - plain radiographs, US, CT or MRI
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12
Q

What is the medical and surgical management of septic arthritis?

A

Surgical drainage and lavage of the joint

High dose IV abx

  • Start before results of cultures are known
  • IV for 2-3 weeks then switch PO for 2-4 weeks

1st line : flucloxicillin (clindamycin if allergy)

If MRSA suspected = vancomycin (or teicoplanan)

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13
Q

What would a plain XR show of a septic joint?

A

Usually normal initially

Widened joint spaces suggest effusion

Later signs:

  • Subluxation / dislocation
  • Space narrowing
  • Erosive changes
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14
Q

When would an MRI be used in septic arthritis?

A

If diagnosis in doubt to exclude osteomyelitis

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15
Q

When would a CT be used in septic arthritis?

A

To image sternoclavicular and sacroiliac joints

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16
Q

What other management may improve recovery from septic arthritis?

A

Splintage

  • In position of function
  • Improves pain
  • Allow inflammation to settle

Physiotherapy

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17
Q

Which joint has the worst prognosis in septic arthritis?

A

Septic hip - potential complication is complete destruction of femoral head and capsule, dislocation and 30% loss of growth of potential femur

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18
Q

What is developmental dysplasia of this hip (DDH)?

A

Previously called congenital dislocation of the hip (CDH)

The acetabulum is shallow and does not adequately cover the femoral head, leading to the hip joint being dislocatable or dislocated

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19
Q

What is the spectrum of DDH?

A

Wide spectrum of severity ranging from mild acetabular dysplasia with a stable hip, through more severe forms of dysplasia with neonatal hip instability, to established hip dysplasia with or without later subluxation or dislocation

Not always detectable at birth

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20
Q

How common is DDH?

A

1-3% newborns

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21
Q

Which hip is more commonly dislocated in DDH?

A

Left hip

Possibly due to more common left occiput anterior position in utero, limiting abduction of the left hip

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22
Q

What % of DDH are bilateral?

A

20%

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23
Q

List some RF for DDH (6)

A

1) Breech position (17x inc risk)
2) FH
3) Female sex (80% F)
4) Impaired limb movement eg oligohydraminous or multiple pregnancies
5) Prematurity
6) Neuromuscular disorders eg CP

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24
Q

When is DDH usually picked up?

A

6-8 week baby checks

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25
Q

What is DDH associated with?

A

Tallipes

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26
What is important to include in an examination for DDH?
1) Observation of symmetrical skin creases and leg length 2) Ortolani test 3) Barlow test
27
What is the Ortolani test?
Abduct the hips to try to relocate hip Fingers push femur forwards into acetabulum A dislocated hip will not abduct fully, and 'clunks' as it relocates into the acetabulum
28
What is the Barlow test?
Pushing backwards to try and dislocate the hip Feeling a clink as dislocatable hip slips out of the acetabulum
29
What investigations may be performed in DDH?
Dynamic USS to assess hip stability and acetabular development in infants US used in <4.5 months but pelvic X-rays used more in older infants and children - once femoral head ossification centre as developed +/- CT / MRI Athrography used peri-operatively when deciding between open and closed reduction
30
What is the Galeazzi sign?
Child lies supine with hips and knees flexed to 90 degrees and the height of each knee compared
31
How may DDH present in an older child?
Limited abduction when fully flexed May walk on toes on affected side or present with a painless limp
32
How may bilateral DDH present?
Often a waddling gait with hyperlordosis Difficult to diagnosis as: - Absent Galeazzi sign - Absent asymmetrical thigh and skin folds - Absent asymmetrical decreased abduction
33
What is the management of DDH?
Early diagnosis important for good prognosis Most unstable hips stabilise spontaneously by 2-6 weeks of age and any hip that remains dislocatable or pathologically unstable after this time requires prompt treatment 1st line = bracing Surgery for those where bracing fails or in children diagnosed >6 months
34
What bracing is used for DDH?
A dynamic flexion-abduction orthosis (Pavlik harness) and splinting - used to maintain hip reduction Start ASAP Adjust harness as child grows and hip stabilises
35
How successful is bracing for DDH?
Very effective If started within 90 days of age, only approx 5% need any further treatment
36
What are some risks of bracing for DDH?
Avascular necrosis Temporary femoral nerve palsy Pavlik harness contraindicated if child >4.5-6 months and when hip irreducible
37
What is the surgical management of DDH?
Closed reduction with adductor or psoas tenotomy (to decrease adduction contracture) Followed by 3-4 months in a plaster cast or abduction brace
38
What are potential long term complications of DDH?
Premature degenerative joint disease and low back pain DDH accounts for 9% of all primary hip replacements and 29% of those 60yr or over Follow up required until hip clinically stable and normal imaging
39
List some causes of leg pain and limp in children
Organic: - Transient synovitis - Septic arthritis - Legg-Calvé-Perthes disease - Slipped capital femoral epipysis - Trauma - Osteomyelitis - Neoplastic disease - Systemic disease Non-organic: - Growing pains
40
What is the most common cause of a limp?
Transient synovitis Important to distinguish from septic arthritis which can lead to obstruction of joint
41
What is transient synovitis?
Self-limiting condition in which there is inflammation in the synovial of the capsule of the hip joint
42
What age group / sex is transient synovitis more common in?
Boys aged 2-8 years
43
How does transient synovitis present?
Sudden onset of limp No systemic symptoms Single joint pain No pain on passive movement Often preceded by URTI
44
What do investigations show in transient synovitis?
Diagnosis of exclusion Normal investigations and radiographs Infection screen and joint aspiration performed to exclude bacterial infection May show signs of preceding infection eg raised WCC, CRP, pyrexia
45
What does fever, swelling, erythema and tenderness in a child presenting with a limp?
Osteomyelitis
46
What may investigations show in osteomyelitis?
High CRP and WCC Diagnosis using radiography, bone scan or MRI
47
What is Legg-Perthes disease?
Osteochondritis leading to avascular necrosis of femoral head
48
In which population is Legg-Perthes disease more common?
4:1 M:F Ages 4-11 years, peak 4-7 years
49
What can Legg-Perthes disease follow?
Transient synovitis
50
How does Legg-Perthes disease present?
Initially painless Pain and limp when feature occurs
51
How is Legg-Perthes disease diagnosed?
Radiography or MRI
52
In which population do slipped capital femoral epiphysis tend to occur?
Overweight teenage boys
53
How do slipped capital femoral epiphysis present?
Gradual onset of pain in groin or knee
54
How is slipped capital femoral epiphysis diagnosed?
Radiography
55
What characteristics of pain suggest organic and inorganic causes of leg pain?
Organic: - Day and night - Interrupts play - Unilateral - Located in joint - Limp or refusal to walk Non-organic: - Only at night - Primarily school days - No interference with normal activities - Located between joints - Bilateral - Normal gait
56
What features of a history suggest organic and inorganic causes of leg pain?
Organic: - Weight loss - Fever - Night sweats - Rash - Diarrhoea Inorganic: - Otherwise healthy child
57
What features on examination suggest organic and inorganic causes of leg pain?
Organic: - Point tenderness - Redness - Swelling - Limitation of movement - Muscle weakness or atrophy - Fever, rash, pallor, LN, organomegaly Inorganic: - Normal examination or minor changes such as coolness or mottling of leg
58
Where does pain in the hip refer to?
The knee - so must do full examination of leg and groin
59
What may children with transient synovitis go on to develop?
Reactive arthritis aka post-infectious arthritis Form of arthritis that occurs during or shortly after extra-articular infection
60
How is irritable hip / reactive arthritis / transient synovitis managed?
Symptomatic - paracetamol and NSAIDs Improvement occurs within days
61
What does reactive arthritis have a genetic association with?
HLA-B27
62
When does reactive arthritis occur and is it common in children?
Secondary to a GI or genitourinary infection Not common in children
63
What is juvenile idiopathic arthritis (JIA)?
A group of conditions that present in childhood with joint inflammation lasting 6 weeks r which no other cause is found
64
How common is JIA?
One of the most common rheumatic diseases of children and is a major cause of chronic disability
65
How is JIA characterised?
Synovitis or peripheral joints with soft tissue swelling and effusion
66
What are the 3 main patterns of presentation of JIA?
1) Systemic 2) Polyarticular 3) Pauciarticular
67
How common is systemic JIA?
= Still's disease Rarest form of JIA
68
How may systemic JIA present?
Diagnostic puzzle as may not have joint symptoms initially Child looks ill with: - Remitting fever - Variable rash - Hepatosplenomegaly - Anaemia - Weight loss - Abdo pain
69
How is systemic JIA confirmed?
Difficult No characteristic laboratory findings, RF negative Sepsis and malignant are often considered as ddx
70
How do children with polyarticular JIA present?
Painful swelling and restricted movement of both large and small joints Commonly symmetrically distributed Systemic features not prominent but poor weight gain and mild anaemia may occur Morning stiffness common and young children may be irritable
71
What may be found on bloods of polyarticular JIA?
RF negative | Antinuclear antibodies may be positive
72
What is the prognosis of polyarticular JIA?
Good
73
Who does pauciarticular JIA usually affect?
Girls under the age of 4
74
What joints does pauciarticular JIA involve?
Fewer than 5 joints Commonly knees, ankles and elbows
75
How does pauciarticular JIA present?
Joints identical to those in polyarticular JIA Systemic symptoms minimal
76
How are polyarticular and pauciarticular JIA distinguished from eachother?
1) Number of joint affected : - Pauciarticular = <5 2) Risk of chronic iridocyclitis: - In pauciarticular arthritis, inflammation of the inner structures of the eye can lead to loss of vision and potentially permanent blindness - Changes are only detectable by slit lamp examination this regular ophthalmological exams necessary
77
What are the main aims of JIA management? (3)
1) Reduce joint inflammation 2) Maintain funciton 3) Prevent deformity
78
How is joint inflammation reduced in JIA?
NSAIDs Corticoseteroids in severe systemic disease unresponsive to other therapies Steroid injection into selected joints (but should not be routine) Hydroxychloroquine, penicillamine, gold injections, MTX and immune regulatory drugs in severe disease
79
How is joint function maintained in JIA?
Physical and occupational therapy Daily exercises, hydrotherapy, day and night splints COULD GO MORE INTO MTX??
80
What age group / sex does septic arthritis most commonly affect in children?
Preschool infants Toddlers Half present in first 2 years Twice as common in M

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