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Pediatric Septic Arthritis Clinical Presentation

  • Author: Richard J Scarfone, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Jun 09, 2016
 

History

Joint pain or swelling

Acute joint inflammation marked by severe pain and swelling is the hallmark of septic arthritis (SA). Joint pain results from stretching of the fibrous joint capsule. If lower extremity joints are involved, parents often report that children cannot bear weight and that they resist all efforts to move the involved joint.

Children typically have involvement of a single joint; lower extremity joints, especially the knee and hip, account for most cases. The elbow is the most common upper extremity joint to become infected. Neonates are more likely to have infection in multiple joints (polyarticular disease).

Pseudoparalysis

A septic joint is so painful that most children do not tolerate any range of motion, resulting in pseudoparalysis. If the knee or hip is involved, an ambulatory child refuses to walk or bear weight on the affected limb.

If supported by a physical examination of the joint, this history helps to distinguish SA from less painful causes of arthralgia, such as transient synovitis of the hip, postinfectious or reactive arthritis, or traumatic hemarthrosis.

Septic arthritis versus transient synovitis

One retrospective series determined that a history of fever and difficulty of bearing weight on a limb, along with an erythrocyte sedimentation rate greater than 40 mm/h and a peripheral white blood cell (WBC) count of more than 12,000 cells/μL, were independent variables that best distinguished SA from transient synovitis.[3] The probability of SA was 99.6% for children with all 4 factors and 93.1% for those with any 3 factors. In another series, none of the children with transient synovitis had fever, and fever was found to be the most influential predictor in distinguishing between the 2 conditions.[4]

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Physical Examination

Decreased or absent range of motion, joint tenderness, swelling, warmth, and erythema are common physical signs of septic arthritis (SA). However, because of the deep location of the hip joint, there may be no erythema or swelling noted. Children orient an affected joint in such a way as to minimize the pain. The hip is flexed, abducted, and externally rotated. The knee, ankle, and elbow are partially flexed, whereas the shoulder is adducted and internally rotated. (See the image below.)

Emergency room photograph of an infant with septic Emergency room photograph of an infant with septic arthritis of the left hip. The child holds his hip rigidly in the classic position of flexion, abduction, and external rotation, a position that maximizes capsular volume. The patient is relatively comfortable as long as the hip joint remains immobile in this position.

In one study, among 82 children with septic arthritis of the hip, 78 (95%) were unable to bear weight on the affected limb at presentation.[3]

Diagnosis is suspected in children who present with monoarthritis of a lower extremity. In a series of 95 children with septic arthritis (1975-1985), over 90% had involvement of a single joint of a lower extremity.[1] One notable exception is gonococcal septic arthritis. This results from the hematogenous spread of the organism, with fever, chills, rash, tenosynovitis, and migratory polyarthritis, which often leads to monoarticular infection.

Fever

In a series of 95 children with SA, most had a low-grade fever, but one third were afebrile at presentation.[1] In another study, 83% of children with SA had a recent fever, but only half were febrile at emergency department presentation.[2] Absence of fever should not sway the clinician from the diagnosis.

On the other hand, the presence or absence of fever may be helpful in distinguishing SA from transient synovitis of the hip. Each condition presents as an acutely irritable hip in a young child and may be associated with an effusion. In general, children with transient synovitis are afebrile, while those with SA have more diminished range of motion.

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Contributor Information and Disclosures
Author

Richard J Scarfone, MD Associate Professor, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Attending Physician, Division of Emergency Medicine and Medical Director of Emergency Preparedness, The Children's Hospital of Philadelphia

Richard J Scarfone, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

References
  1. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: a review of 95 cases. Pediatr Infect Dis. 1986 Nov-Dec. 5(6):669-76. [Medline].

  2. Thompson A, Mannix R, Bachur R. Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics. 2009 Mar. 123(3):959-65. [Medline].

  3. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec. 81(12):1662-70. [Medline].

  4. Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006 Jun. 88(6):1251-7. [Medline].

  5. Kaplan SL. Challenges in the evaluation and management of bone and joint infections and the role of new antibiotics for gram positive infections. Adv Exp Med Biol. 2009. 634:111-20. [Medline].

  6. Taekema HC, Landham PR, Maconochie I. Towards evidence based medicine for paediatricians. Distinguishing between transient synovitis and septic arthritis in the limping child: how useful are clinical prediction tools?. Arch Dis Child. 2009 Feb. 94(2):167-8. [Medline].

  7. [Guideline] Fordham L, Gunderman R, Blatt ER, et al. Limping child--ages 0-5 years. American College of Radiology (ACR). 2007. 5. [Full Text].

  8. Mistry RM, Lennon D, Boyle MJ, Chivers K, Frampton C, Nicholson R, et al. Septic Arthritis and Acute Rheumatic Fever in Children: The Diagnostic Value of Serological Inflammatory Markers. J Pediatr Orthop. 2014 Aug 13. [Medline].

  9. Horton DB, Strom BL, Putt ME, Rose CD, Sherry DD, Sammons JS. Epidemiology of Clostridium difficile Infection-Associated Reactive Arthritis in Children: An Underdiagnosed, Potentially Morbid Condition. JAMA Pediatr. 2016 May 16. e160217. [Medline].

  10. Deanehan JK, Kimia AA, Tan Tanny SP, Milewski MD, Talusan PG, Smith BG, et al. Distinguishing Lyme from septic knee monoarthritis in Lyme disease-endemic areas. Pediatrics. 2013 Mar. 131(3):e695-701. [Medline].

  11. Kelly JC. Septic Arthritis in Children Ruled Out by New Test. Medscape. Available at http://www.medscape.com/viewarticle/779584. Accessed: September 17, 2014.

  12. Carter K, Doern C, Jo CH, Copley LA. The Clinical Usefulness of Polymerase Chain Reaction as a Supplemental Diagnostic Tool in the Evaluation and the Treatment of Children With Septic Arthritis. J Pediatr Orthop. 2015 Apr 7. [Medline].

  13. Pääkkönen M, Kallio MJ, Peltola H, Kallio PE. Pediatric septic hip with or without arthrotomy: retrospective analysis of 62 consecutive nonneonatal culture-positive cases. J Pediatr Orthop B. 2010 May. 19(3):264-9. [Medline].

  14. Fogel I, Amir J, Bar-On E, Harel L. Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics. 2015 Oct. 136 (4):e776-82. [Medline].

 
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Emergency room photograph of an infant with septic arthritis of the left hip. The child holds his hip rigidly in the classic position of flexion, abduction, and external rotation, a position that maximizes capsular volume. The patient is relatively comfortable as long as the hip joint remains immobile in this position.
 
 
 
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