FRCS Paediatric Ortho — improved notes
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048. Septic arthritis

visual-inline rebuild1 extracted figuresspeaker notes XML57 study lines8 Q&A

Individual slide images have been cropped from the rendered slide and inserted beside the matching note section. The full slide remains below only for layout/audit.

Clean FRCS notes with inline figures

Unilateral hip pain in child:

Differential diagnosis

•Transient synovitis
•Septic arthritis
•Perthes
•SCFE
•Fracture (NAI)
•JRA
•Hemophilia
•Hip septic arthritis

Cause:

•Hematological spread
•Direct inoculation
•Spread from osteomyelitis
•Neonate with patent transphyseal artery
•In the 4 intracapsular physis – proximal humerus, hip, radial head, distal fibular)

Pathoanatomy in septic arthritis

•Edema and hypertrophy of synovium with fluid production → joint distension
•Frank pus accumulate in joint and destruction of cartilage (marginal and central portions) → joint space narrowing
•Superficial marginal and central bony erosion
•Bony ankylosis

Risk factors:

•Prematurity
•C section

History of invasive trauma

•Recent infection (URTI, UTI)
•Vaccine (esp H influenza)

Management

•Hx of trauma, onset and duration of pain, constitutional symptoms
•Skin for sinus, whether patient can weight bear

Xray to r/o SCFE, Perthes, fracture

•Blood X WBC, CRP, ESR
Clinical photograph
Fig 1. Clinical photographtop left
•+/- MRI to look for osteomyelitis (20%), but difficult to do in baby
•Kocher’s criteria to see the possibility of septic arthritis
•- Unable to bear weight
•Fever > 38.5
•WBC > 12
•ESR > 40
•Chance of septic arthritis: 1: 3%, 2: 40%, 3: 93%, 4: 99.6%
•(Caird modification: CRP >20)
•USG for effusion and aspiration

Free hand technique:

•Palpate femoral artery in line with inguinal ligament
•Insert needle 2.5cm lateral and distal to pulse

Aim 45deg medial and proximal towards hip joint

•Drainage: open anterior hip approach, capsulectomy 1cm2, drill holes at metaphysis (for osteomyelitis), thorough irrigation, hip spica postop for 4-6 weeks (to prevent septic dislocation)
•Discuss with microbiologist for duration and abx
•Monitor clinically and biochemically

FU to monitor complication

Hunka classification

•I Minimal collapse / deformity
•II Head deformity (A: intact physis, B: physeal arrest) → femoral osteotomy
•III Pseudoarthrosis → femoral head viable: BG + valgus osteotomy; femoral head nonviable: resection of head and neck + GT arthroplasty
•IV complete epiphysis destruction (A: neck in acetabulum, B: neck not in acetabulum) → A: adductor tenotomy to increase hip ROM, B: GT arthroplasty to reorient neck to acetabulum
•V complete head and neck loss → conservative

Evidence

•Recent studies Peltola NEJM 2014 have shown that in most case of primary uncomplicated joint sepsis, only a few days of IV (3-5) followed by a short course of oral antibiotics (3 weeks) is sufficient

Direct Q&A

Q1 What are the differential diagnoses for Septic arthritis?

Transient synovitis

•Septic arthritis
•Perthes
•SCFE
•Fracture (NAI)
•JRA
•Hemophilia
•Hip septic arthritis
Q2 What anatomy is relevant to Septic arthritis?

Edema and hypertrophy of synovium with fluid production → joint distension

•Frank pus accumulate in joint and destruction of cartilage (marginal and central portions) → joint space narrowing
•Superficial marginal and central bony erosion
•Bony ankylosis
Q3 What risk factors are listed for Septic arthritis?

Prematurity

•C section
Q4 How is Septic arthritis managed?

Hx of trauma, onset and duration of pain, constitutional symptoms

•Skin for sinus, whether patient can weight bear
Q5 What are the radiographic findings for Septic arthritis?

Blood X WBC, CRP, ESR

•+/- MRI to look for osteomyelitis (20%), but difficult to do in baby
•Kocher’s criteria to see the possibility of septic arthritis
•- Unable to bear weight
•Fever > 38.5
•WBC > 12
•ESR > 40
•Chance of septic arthritis: 1: 3%, 2: 40%, 3: 93%, 4: 99.6%
•(Caird modification: CRP >20)
•USG for effusion and aspiration
Q6 What are the management aims for Septic arthritis?
•Drainage: open anterior hip approach, capsulectomy 1cm2, drill holes at metaphysis (for osteomyelitis), thorough irrigation, hip spica postop for 4-6 weeks (to prevent septic dislocation)
•Discuss with microbiologist for duration and abx
•Monitor clinically and biochemically
Q7 How is Septic arthritis classified here?
•I Minimal collapse / deformity
•II Head deformity (A: intact physis, B: physeal arrest) → femoral osteotomy
•III Pseudoarthrosis → femoral head viable: BG + valgus osteotomy; femoral head nonviable: resection of head and neck + GT arthroplasty
•IV complete epiphysis destruction (A: neck in acetabulum, B: neck not in acetabulum) → A: adductor tenotomy to increase hip ROM, B: GT arthroplasty to reorient neck to acetabulum
•V complete head and neck loss → conservative
Q8 What evidence or study finding is cited for Septic arthritis?
•Recent studies Peltola NEJM 2014 have shown that in most case of primary uncomplicated joint sepsis, only a few days of IV (3-5) followed by a short course of oral antibiotics (3 weeks) is sufficient

Raw speaker-note hierarchy audit

#lvlmarLindentlogicaloriginal note line
10NoneNone0Unilateral hip pain in child:
20NoneNone0DDx:
30171450-1714501Transient synovitis
40171450-1714501Septic arthritis
50171450-1714501Perthes
60171450-1714501SCFE
70171450-1714501Fracture (NAI)
80171450-1714501JRA
90171450-1714501Hemophilia
100NoneNone0Hip septic arthritis
110NoneNone0Cause:
120NoneNone0Hematological spread
130NoneNone0Direct inoculation
140NoneNone0Spread from osteomyelitis
151NoneNone1Neonate with patent transphyseal artery
161NoneNone1In the 4 intracapsular physis – proximal humerus, hip, radial head, distal fibular)
170NoneNone0Pathoanatomy in septic arthritis
180NoneNone0Edema and hypertrophy of synovium with fluid production -> joint distension
190NoneNone0Frank pus accumulate in joint and destruction of cartilage (marginal and central portions) → joint space narrowing
200NoneNone0Superficial marginal and central bony erosion
210NoneNone0Bony ankylosis
220NoneNone0Risk factors:
230228600-2286001Prematurity
240228600-2286001C section
250228600-2286001History of invasive trauma
260228600-2286001Recent infection (URTI, UTI)
270228600-2286001Vaccine (esp H influenza)
280NoneNone0Mx:
290NoneNone0Hx of trauma, onset and duration of pain, constitutional symptoms
300NoneNone0Skin for sinus, whether patient can weight bear
310NoneNone0Xray to r/o SCFE, Perthes, fracture
320NoneNone0Blood X WBC, CRP, ESR
330NoneNone0+/- MRI to look for osteomyelitis (20%), but difficult to do in baby
340NoneNone0Kocher’s criteria to see the possibility of septic arthritis
350NoneNone0- Unable to bear weight
360171450-1714501Fever > 38.5
370171450-1714501WBC > 12
380171450-1714501ESR > 40
390171450-1714501Chance of septic arthritis: 1: 3%, 2: 40%, 3: 93%, 4: 99.6%
400NoneNone0(Caird modification: CRP >20)
410NoneNone0USG for effusion and aspiration
420NoneNone0Free hand technique:
430171450-1714501Palpate femoral artery in line with inguinal ligament
440171450-1714501Insert needle 2.5cm lateral and distal to pulse
450171450-1714501Aim 45deg medial and proximal towards hip joint
460NoneNone0Drainage: open anterior hip approach, capsulectomy 1cm2, drill holes at metaphysis (for osteomyelitis), thorough irrigation, hip spica postop for 4-6 weeks (to prevent septic dislocation)
470NoneNone0Discuss with microbiologist for duration and abx
480NoneNone0Monitor clinically and biochemically
490NoneNone0FU to monitor complication
500NoneNone0Hunka classification
511628650-1714502I Minimal collapse / deformity
521628650-1714502II Head deformity (A: intact physis, B: physeal arrest) → femoral osteotomy
531628650-1714502III Pseudoarthrosis → femoral head viable: BG + valgus osteotomy; femoral head nonviable: resection of head and neck + GT arthroplasty
541628650-1714502IV complete epiphysis destruction (A: neck in acetabulum, B: neck not in acetabulum) → A: adductor tenotomy to increase hip ROM, B: GT arthroplasty to reorient neck to acetabulum
551628650-1714502V complete head and neck loss → conservative
560NoneNone0Evidence
570NoneNone0Recent studies Peltola NEJM 2014 have shown that in most case of primary uncomplicated joint sepsis, only a few days of IV (3-5) followed by a short course of oral antibiotics (3 weeks) is sufficient

Improved semantic hierarchy used for the study notes

#semantic levelsection?rewritten line
10yesUnilateral hip pain in child:
20yesDifferential diagnosis
31Transient synovitis
41Septic arthritis
51Perthes
61SCFE
71Fracture (NAI)
81JRA
91Hemophilia
101Hip septic arthritis
110yesCause:
121Hematological spread
131Direct inoculation
141Spread from osteomyelitis
151Neonate with patent transphyseal artery
161In the 4 intracapsular physis – proximal humerus, hip, radial head, distal fibular)
170yesPathoanatomy in septic arthritis
181Edema and hypertrophy of synovium with fluid production → joint distension
191Frank pus accumulate in joint and destruction of cartilage (marginal and central portions) → joint space narrowing
201Superficial marginal and central bony erosion
211Bony ankylosis
220yesRisk factors:
231Prematurity
241C section
250yesHistory of invasive trauma
261Recent infection (URTI, UTI)
271Vaccine (esp H influenza)
280yesManagement
291Hx of trauma, onset and duration of pain, constitutional symptoms
301Skin for sinus, whether patient can weight bear
310yesXray to r/o SCFE, Perthes, fracture
321Blood X WBC, CRP, ESR
331+/- MRI to look for osteomyelitis (20%), but difficult to do in baby
341Kocher’s criteria to see the possibility of septic arthritis
351- Unable to bear weight
361Fever > 38.5
371WBC > 12
381ESR > 40
391Chance of septic arthritis: 1: 3%, 2: 40%, 3: 93%, 4: 99.6%
401(Caird modification: CRP >20)
411USG for effusion and aspiration
420yesFree hand technique:
431Palpate femoral artery in line with inguinal ligament
441Insert needle 2.5cm lateral and distal to pulse
450yesAim 45deg medial and proximal towards hip joint
461Drainage: open anterior hip approach, capsulectomy 1cm2, drill holes at metaphysis (for osteomyelitis), thorough irrigation, hip spica postop for 4-6 weeks (to prevent septic dislocation)
471Discuss with microbiologist for duration and abx
481Monitor clinically and biochemically
490yesFU to monitor complication
500yesHunka classification
512I Minimal collapse / deformity
522II Head deformity (A: intact physis, B: physeal arrest) → femoral osteotomy
532III Pseudoarthrosis → femoral head viable: BG + valgus osteotomy; femoral head nonviable: resection of head and neck + GT arthroplasty
542IV complete epiphysis destruction (A: neck in acetabulum, B: neck not in acetabulum) → A: adductor tenotomy to increase hip ROM, B: GT arthroplasty to reorient neck to acetabulum
552V complete head and neck loss → conservative
560yesEvidence
571Recent studies Peltola NEJM 2014 have shown that in most case of primary uncomplicated joint sepsis, only a few days of IV (3-5) followed by a short course of oral antibiotics (3 weeks) is sufficient
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