Approach Considerations
Hospitalize all children presumed to have septic arthritis (SA) for empiric intravenous antibiotic therapy. After 2-3 days of immobilization, encourage early passive range of motion.
The optimal duration of antibiotic therapy is not defined, and recommendations vary from 1-6 weeks. Thus, institutional practices will prevail. In general, 3-4 weeks of antibiotic therapy is used to treat S aureus,H influenzae type B, or S pneumoniae infections, whereas gonococcal infections are treated for 7-10 days.
Consultations
Consultation may be indicated with an orthopedic surgeon. Septic arthritis of the hip requires emergent irrigation and drainage to minimize risk of aseptic necrosis of the femoral head. Consultation with an infectious diseases specialist is particularly indicated if the diagnosis is uncertain or if the microbiology is unusual.
Splinting and Antibiotics
Splint the affected joint in a functional position for the first few days after a diagnosis of septic arthritis (SA). Encourage early passive range of motion to stretch tendons and prevent contractures.
Once an organism is identified, an appropriate antibiotic is selected, and the child is demonstrating a good clinical response, continue outpatient therapy with either high-dose oral antibiotics or parenteral antibiotics. Antibiotics readily enter the joint fluid in high concentrations after oral administration. Frequent revisits to the physician to ensure compliance and good clinical response are essential.
Aspiration, Arthrotomy, and Drainage
No studies have compared outcomes for children with SA undergoing arthrotomy versus aspiration alone. Traditionally, for uncomplicated septic arthritis involving joints other than the hip or shoulder, serial needle aspirations are performed. These may be discontinued once fluid no longer reaccumulates. Failure to reach this goal is an indication for arthrotomy and open drainage.
Urgent arthrotomy and open drainage is usually performed in septic arthritis of the hip or shoulder, septic arthritis of other joints if no improvement occurs within 3 days of starting antimicrobial therapy, or if a large amount of pus or debris is aspirated during diagnostic arthrocentesis. However, in one study of 62 children with septic arthritis of the hip, 50 were treated successfully with aspiration and antibiotics alone. [22]
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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.
