Practice Easily Missed?

Septic arthritis in children

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4407Easily (Published 27 August 2010) Cite this as: BMJ 2010;341:c4407
  1. Andrew Howard, consultant paediatric orthopaedic surgeon1,
  2. Mary Wilson, family practitioner2
  1. 1Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G1X8
  2. 2Marathon Family Health Team, Marathon, ON, Canada
  1. Correspondence to: A Howard andrew.howard{at}sickkids.ca
  • Accepted 9 July 2010

A differential diagnosis of septic arthritis in children can be difficult, but early treatment of joint infections avoids potentially disabling complications

Septic arthritis accounts for a small minority of the myriad musculoskeletal problems in childhood which primary care doctors will evaluate. Joint infections are best treated early to avoid potentially disabling complications. The earlier the presentation, the more difficult it is to distinguish an infection from benign, self limited conditions such as transient synovitis of the hip.

Case scenario

A 5 year old boy is brought to the accident and emergency department with pain in his left leg. The previous day he limped markedly and now he refuses to walk. History is negative for injury and positive for fever in a previously well, immunised child who is developmentally normal. Concerned about septic arthritis, the junior doctor requests a blood count, erythrocyte sedimentation rate, and C reactive protein concentration, and requests review by the paediatric team.

How common is it?

  • Transient synovitis is a common idiopathic inflammatory condition of the child’s hip which presents in a similar manner to the “do not miss” diagnosis of septic arthritis

  • Transient synovitis was diagnosed in 43 Norwegian children per 100 000 annually, compared with only five cases of septic arthritis per 100 0001

  • Septic arthritis in children affects the hip in a third of cases, the knee in a third, and other joints in the remaining third2

  • Septic arthritis can occur at any age in childhood but is most common among infants, toddlers, and children of preschool age2

Why is it missed?

Joint infections overlap in presentation with transient synovitis, unexplained symptoms, and minor trauma, all of which are common. Musculoskeletal infections in very young children and in very ill children can be …

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