Septic elbow arthritis in children: Epidemiology and outcome (2022)

Table of Contents
Archives de Pédiatrie Abstract Introduction Methods Results Discussion Conclusion Introduction Section snippets Patients Demographic features Discussion Conclusion Funding Disclosure of interest Acknowledgments References (27) Ann Emerg Med Ann Emerg Med Pediatr Clin North Am Septic arthritis of the elbow with Streptococcus pneumoniae in a 9-month-old girl BMJ Case Rep Elbow septic arthritis in children: clinical presentation management J Pediatr Orthop B Septic arthritis of the shoulder, elbow, and wrist Clin Orthop Relat Res Musculoskeletal infections in children: basic treatment principles and recent advancements Instr Course Lect Does this adult patient have septic arthritis? JAMA Functional evaluation of the elbow and its disorders The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines J Pediatr Orthop Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus J Pediatr Orthop Infections due to Pseudomonas species and related organisms Methicillin-resistant S.aureus infections among patients in the emergency department N Engl J Med Cited by (6) Developments in diagnosis and treatment of paediatric septic arthritis Postoperative early measures and rehabilitation after surgical arthrolysis for elbow stiffness Aspiration or arthrotomy for paediatric septic arthritis of the shoulder and elbow: a systematic review Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills Current Variation in Joint Aspiration Practice for the Evaluation of Pediatric Septic Arthritis Recommended articles (6) FAQs Videos
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Archives de Pédiatrie

Volume 26, Issue 1,

January 2019

, Pages 38-43

Abstract

Introduction

Septic elbow arthritis is a rare disease, especially in children. The aim of this study was to report the functional outcome of our pediatric population with both demographic and microbiological features.

Methods

We retrospectively reviewed all our cases of pediatric septic elbow arthritis between 2007 and 2017. Demographic, microbiological, biological, and radiological features were analyzed. Functional outcome was evaluated according to the Morrey Elbow Performance Score (MEPS).

(Video) Septic Arthritis - Overview (causes, pathophysiology, treatment)

Results

In total, 14 cases were reviewed. The mean age was 9 years. Microbiological findings revealed Staphylococcus aureus in 10 cases. The mean white blood cells count in synovial fluid was 101,306 cells per mm 3. The skin was the most frequently reported entry portal. The mean MEPS score was 86.13 points (excellent in eight cases, good in three cases, fair in two cases, and poor in two cases). Stiffness was observed in three cases. No growth disturbance was reported.

Discussion

Septic elbow arthritis in children is rare. Biological inflammatory markers are sensitive but not specific. White blood cell count in the synovial fluid is specific. S.aureus is the most frequently cultured agent. Treatment is based on surgical debridement, antibiotics, and elbow immobilization. Concomitant osteomyelitis is frequent and should be diagnosed and treated simultaneously. Functional outcomes are usually satisfactory in contrast to osteomyelitis.

Conclusion

Pediatric septic elbow arthritis is rare. It may be primary or secondary to trauma and surgery of the elbow. Demographic, biological, and microbial features are similar to those reported for osteomyelitis; however, functional outcomes are better with a negligible rate of growth disturbance.

Introduction

Septic elbow arthritis is a rare serious infectious disease, especially in children [1]. This infection is dangerous because it may lead to fulminant sepsis [1], [2]. In children, the risk of growth disturbance seems to be higher, explained by the cartilage damage and joint destruction. The elbow may be infected, similarly to the other joints, via three ways: (1) via hematogenous seeding of the joint space from a distant site of infection, (2) via a contiguous infected side, and (3) by direct inoculation after elbow trauma [3]. The outcome depends on the delay of treatment and the effectiveness of antibiotic therapy. Furthermore, the earlier the treatment, the better the outcome [4], [5]. As with the hip or knee, the diagnosis is suspected on the basis of preliminary symptoms such as stiffness, pain, edema, and erythema; laboratory findings may be unreliable given the lack of specificity of the symptoms. Hence, the diagnosis often relies on a heightened index of suspicion by the treating physician [6]. In comparison with both hip and knee septic arthritis, there are few series reporting on the outcome after localization in the elbow, especially in children. Several studies have been found but they comprise mostly adults. The purpose of our study is to report the clinical, microbiological, and radiological features as well as the outcome of septic elbow arthritis in our pediatric population.

Section snippets

Patients

The cases of 15 children diagnosed with septic elbow arthritis at Sahloul University Hospital between January 2007 and December 2017 were reviewed retrospectively. After obtaining approval from our institutional review board, the study was undertaken. Inclusion criteria were: age younger than 17 years, confirmed septic elbow arthritis, positive microbial laboratory findings, and presence of patient at final follow-up. Exclusion criteria were: age older than 17 years, culture-negative synovial

Demographic features

This retrospective series included five female and 10 male patients (sex ratio: 2). The mean age of children at time of the infectious event was 9 years (range: 3–13 years). The mean time of symptom development was 4.2 days (range: 1–11 days). The right elbow was affected in eight cases (53%) whereas the left one was affected in seven cases (47%). Concerning the portal of entry, the skin was reported in nine cases (60%); infected granuloma around a K-wire after supracondylar fracture pinning

Discussion

Septic elbow arthritis is a rare localization in children [1], [2]. The number of cases in our series is important and may be considered to be one of the highest in the literature. Septic elbow arthritis has been reported in adults; however, pediatric series are fewer and have not sufficiently characterized the microbiological profile and utility of biological markers in the diagnosis [8]. The aim of this study was to report the biological and microbiological profile as well as the outcomes of

Conclusion

Septic elbow arthritis in the pediatric population is a rare infectious disease. Demographic features in comparison with osteomyelitis are not different: The most commonly reported microbial agent is S.aureus. Reviewing the literature and according to our data, concomitant osteomyelitis is the most frequent situation explained by the high incidence of staphylococcal bone and joint infections in this age. The diagnosis is based on the clinical presentation and the results of physical

Funding

There was no financial support for the study.

Disclosure of interest

The authors declare that they have no competing interest.

Acknowledgments

We thank our colleagues in Sahloul orthopedics department, the participants, the coordinators, and the data reviewers who assisted in this study.

References (27)

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  • B.W. Frazee et al.High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections

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  • G. Frank et al.Musculoskeletal infections in children

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    Septic arthritis of the elbow with Streptococcus pneumoniae in a 9-month-old girl

    BMJ Case Rep

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    Elbow septic arthritis in children: clinical presentation management

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  • P. Mehta et al.

    Septic arthritis of the shoulder, elbow, and wrist

    (Video) Swollen Joint in Children – Pediatrics | Lecturio

    Clin Orthop Relat Res

    (2006)

  • J.J. McCarthy et al.

    Musculoskeletal infections in children: basic treatment principles and recent advancements

    Instr Course Lect

    (2005)

  • M.E. Margaretten et al.

    Does this adult patient have septic arthritis?

    JAMA

    (2007)

  • B.F. Morrey et al.

    Functional evaluation of the elbow and its disorders

  • O.A. Gafur et al.

    The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines

    J Pediatr Orthop

    (2008)

  • S.R. Arnold et al.

    Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus

    J Pediatr Orthop

    (2006)

  • C.A. Ohl et al.

    Infections due to Pseudomonas species and related organisms

  • G.J. Moran et al.

    Methicillin-resistant S.aureus infections among patients in the emergency department

    N Engl J Med

    (2006)

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    FAQs

    Septic elbow arthritis in children: Epidemiology and outcome? ›

    Conclusion: Pediatric septic elbow arthritis is rare. It may be primary or secondary to trauma and surgery of the elbow. Demographic, biological, and microbial features are similar to those reported for osteomyelitis; however, functional outcomes are better with a negligible rate of growth disturbance.

    Why are children at higher risk of septic arthritis? ›

    Which children are at risk for septic arthritis? Septic arthritis may occur without any known risk factors. But children who have an open skin wound and a weakened immune system may be at greater risk. A weakened immune system can be caused by diabetes, kidney disease, HIV infection, or cancer.

    What is septic arthritis of the elbow? ›

    Septic arthritis is an infection in the joint (synovial) fluid and joint tissues. Different types of bacteria, viruses, and fungi can infect a joint. Symptoms include fever, joint pain, swelling, redness, and warmth. Quick treatment with antibiotics is needed to halt the risk of joint damage.

    What is the most common bacterial cause of septic arthritis in infants? ›

    Bacterial infection with Staphylococcus aureus (staph) is the most common cause.

    Is septic arthritis more common in males or females? ›

    Septic arthritis is more common in males5 and the large joints are more often involved, of which the knee is the most commonly involved joint5. The risk is higher when the joint is traumatized. The causative organisms are diverse in septic arthritis, but Staphylococcus aureus infection is the most common6.

    How common is septic arthritis? ›

    Approximately 20,000 cases of septic arthritis occur in the United States each year (7.8 cases per 100,000 person-years), with a similar incidence occurring in Europe. The incidence of arthritis due to disseminated gonococcal infection is 2.8 cases per 100,000 person-years.

    What are the complications of septic arthritis? ›

    Complications of septic arthritis can include:
    • Chronic pain.
    • Osteomyelitis (inflammation or swelling in the bone).
    • Osteonecrosis (bone tissue dies due to lack of blood flow).
    • A difference in leg length.
    • Sepsis (widespread inflammation in the body).
    • Death.

    How does a child get septic arthritis? ›

    These bacteria can enter a child's body in a variety of ways, including: Infection that spreads from another source inside the body, such as a skin or bone infection adjacent to a joint. Infected wounds. Open fractures, or bones that penetrate through the skin.

    What is the differential diagnosis of septic arthritis? ›

    When evaluating a patient with suspected septic arthritis, also consider conditions such as primary rheumatologic disorders (eg, vasculitis, crystalline arthritides), drug-induced arthritis, and reactive arthritis (eg, postinfectious diarrhea syndrome, postmeningococcal and postgonococcal arthritis, arthritis of ...

    How is septic arthritis diagnosed? ›

    How Is Septic Arthritis Diagnosed? A procedure called arthrocentesis is commonly used to make an accurate diagnosis of septic arthritis. This procedure involves a surgical puncture of the joint to draw a sample of the joint fluid, known as synovial fluid.

    How do you prevent septic arthritis? ›

    It is possible to prevent septic arthritis by avoiding infections, puncture wounds, and damage to the skin.

    What antibiotics are used for septic arthritis? ›

    Septic arthritis medicine include intravenous vancomycin, ceftriaxone and ceftazidime. Treatment can then be changed to oral antibiotics such as cefixime or ciprofloxacin for at least one week.

    What is the most common cause of sepsis? ›

    Bacterial infections cause most cases of sepsis. Sepsis can also be a result of other infections, including viral infections, such as COVID-19 or influenza.

    Which bacteria causes arthritis? ›

    Most cases of infectious arthritis are caused by bacteria. The most common of these is Staphylococcus aureus (staph), a bacterium that lives on healthy skin. Infectious arthritis can also be caused by a virus or a fungus.

    Is septic arthritis the same as arthritis? ›

    Infectious arthritis, also called septic arthritis, involves a sudden, severe infection of a joint. It is a type of inflammatory arthritis that can cause swelling, pain, and tissue damage. Infectious arthritis usually affects just one joint, but it can spread.

    Is septic arthritis an emergency? ›

    Acute nongonococcal septic arthritis is a medical emergency that can lead to significant morbidity and mortality. Therefore, prompt recognition, rapid and aggressive antimicrobial therapy, and surgical treatment are critical to ensuring a good prognosis.

    What's the difference between septic and sepsis? ›

    ANSWER: Sepsis is a serious complication of an infection. It often triggers various symptoms, including high fever, elevated heart rate and fast breathing. If sepsis goes unchecked, it can progress to septic shock — a severe condition that occurs when the body's blood pressure falls and organs shut down.

    What is the difference between osteomyelitis and septic arthritis? ›

    Osteomyelitis is an infection of the bone that can include the periosteum, medullary cavity, and cortical bone. Septic arthritis is an infection of surface of the cartilage that lines the joint and the synovial fluid that lubricates the joint.

    Does septic arthritis require surgery? ›

    Septic arthritis can also cause many complications, including osteomyelitis, bony erosions, fibrous ankylosis, sepsis, and even death. Treatment consists of a combined medical and surgical approach.

    What are the pathological changes of septic arthritis? ›

    In septic arthritis the joints are swollen, hot, sore, and pus-filled; the condition may occur following infection by such bacteria as Streptococcus, Staphylococcus, Pneumococcus, Gonococcus, or Meningococcus.

    What age can you get septic arthritis? ›

    The incidence varies between studies, but septic arthritis has a predilection towards children under the age of 4 years. Septic arthritis occurs most commonly in the hip and knee joints. Other joints commonly affected include the shoulder and ankle, but septic arthritis can occur in any synovial joint in the body.

    How long does it take to recover from septic arthritis? ›

    The average stay in hospital if you have septic arthritis is about 2 weeks. Most people start feeling better quickly once they are given antibiotics.

    What is the most common clinical presentation of a patient with septic arthritis? ›

    Patients will most commonly present with a single swollen joint causing severe pain. Pyrexia will be in around 60% of affected individuals (although its absence should not rule out septic arthritis).

    Can you see septic arthritis on xray? ›

    Conventional radiograph is the initial screening imaging modality for the detection of septic arthritis, although it has low sensitivity and specificity for acute infection. In the early stage, the simple radiograph can appear normal, and this does not rule out infection.

    Can septic arthritis be misdiagnosed? ›

    Mortality rates can be significant, ranging from 3–25%. Despite the severity of illness, septic arthritis may be subtle, with many patients lacking the classic signs, symptoms, or laboratory findings. There are also a large number of conditions that may mimic septic arthritis, further confounding the diagnosis.

    Why is septic arthritis considered a surgical emergency? ›

    Septic arthritis is considered a surgical emergency. Diagnosis and prompt drainage is required to avoid continued joint damage, which can result in early onset arthritis. Septic arthritis typically occurs related to adjacent osteomyelitis (infection of the bone).

    Can septic arthritis be treated with oral antibiotics? ›

    * Following joint drainage, the typical duration of antibiotic therapy for treatment of septic arthritis is three to four weeks; we typically administer parenteral antibiotics for at least 14 days followed by oral therapy for an additional 14 days.

    What antibiotics are used for septic bursitis? ›

    Septic bursitis is a medical emergency that requires prompt treatment with broad-spectrum antibiotics (e.g., cephalosporins, clindamycin, or vancomycin).

    Can septic arthritis migrate? ›

    Adults with suspected gonococcal arthritis are usually young, healthy and sexually active. On physical examination, they may have dermatitis, tenosynovitis, non-erosive arthritis and a migratory pattern of arthritis.

    What are the 5 signs of sepsis? ›

    Symptoms of severe sepsis or septic shock
    • feeling dizzy or faint.
    • a change in mental state – like confusion or disorientation.
    • diarrhoea.
    • nausea and vomiting.
    • slurred speech.
    • severe muscle pain.
    • severe breathlessness.
    • less urine production than normal – for example, not urinating for a day.

    What are the 4 signs of sepsis? ›

    What are the symptoms of sepsis?
    • Rapid breathing and heart rate.
    • Shortness of breath.
    • Confusion or disorientation.
    • Extreme pain or discomfort.
    • Fever, shivering, or feeling very cold.
    • Clammy or sweaty skin.
    Jun 20, 2021

    What are the 3 stages of sepsis? ›

    There are three stages of sepsis:
    • Sepsis. An infection gets into your bloodstream and causes inflammation in your body.
    • Severe sepsis. The infection and inflammation is severe enough to start affecting organ function.
    • Septic shock.

    Do antibiotics help arthritis? ›

    Antibiotics will not treat reactive arthritis itself but are sometimes prescribed if you have an ongoing infection – particularly if you have an STI. Your recent sexual partner(s) may also need treatment.

    How does a child get osteomyelitis? ›

    In children, an infection in the blood is a common cause of osteomyelitis. This is because a child's growing bones have an increased blood supply. That makes it easier for the bacteria to get into the bone. An infection from nearby soft tissue or from a wound may also lead to osteomyelitis.

    What is reactive arthritis kids? ›

    Reactive arthritis occurs when the body's immune system reacts to a recent infection, usually within the past four to six weeks, with joint swelling and pain. The child has recovered from the infection and, several weeks later, develops the signs of reactive arthritis.

    How common is juvenile rheumatoid arthritis? ›

    Juvenile rheumatoid arthritis (JRA), often referred to by doctors today as juvenile idiopathic arthritis (JIA), is a type of arthritis that causes joint inflammation and stiffness for more than six weeks in a child aged 16 or younger. It affects approximately 50,000 children in the United States.

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