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Septic Arthritis: Differential Diagnosis

- Diff Dx:
    - reactive transient synovitis (toxic synovitis)
           - in the report by Kocher MS et al., the authors sought to distinguish transient synovitis vs sepsis on the basis of lab data and patient history;
                 - independent clinical predictors between septic arthritis and transient synovitis included history of fever, non-wt-bearing, ESR of at least forty mm/hr, and serum WBC of more than 12,000;
                 - the predicted probability for septic arthritis were 93% if three of these variables were present and were over 99% if all 4 predictors were present;
                 - the authors recommend careful observation without aspiration if none of the four independent predictors are present;
           - reference:
                  - Differentiating Between Septic Arthritis and Transient Synovitis of the Hip in Children: An Evidence-Based Clinical Prediction Algorithm.
                  - Legg-Calve-Perthes disease
    - slipped capital femoral epiphysis
           - psoas abscess:
                  - note that these patients will hold the hip in flexion and in internal rotation (which is also seen in septic arthritis of the hip);
                  - look for atypical features, such as femoral nerve neurapraxia or bladder irritability along with hip pain;
                  - references:
                         - Psoas abscess in children. Schwaitzberg SD. J Pediatr Surg. 1985;20:339-342.
                         - Differentiation of Psoas Muscle Abscess From Septic Arthritis of the Hip in Children. Song J. Clin Orthop Rel Res 2001;391:258-265
           - obturator internus pyomyositis:
                  - patients may demonstrate rectal pain and swelling during an examination;
                  - in the report by Orlicek SL, et al, the authors describe 4 cases of obturator internus muscle (OIM) abscess in children, including their clinical presentations and treatment;
                         - common presenting features were fever, limp, and hip pain;
                         - CT or MRI was diagnostic in all 4 patients, and staph aureus was the causative agent in each;
                         - all the patients recovered, one after surgical drainage and the other three after antimicrobial therapy alone or with needle aspiration;
                         - presentation of OIM pyomyositis is similar to that of psoas muscle pyomyositis and other infectious processes of the pelvis and hip;
                         - most patients can be managed without open surgical drainage, but needle aspirations may be helpful both therapeutically and diagnostically;
                 - references:
                       - Case Report. Obturator Internus Pyomyositis
                       - Obturator Internus Muscle Abscess in Children
           - acetabular osteomyelitis
           - pyogenic sacroiliitis
           - vertebral/disc space infections
           - proximal femoral osteomyelitis (see above)
           - sickle cell anemia;
           - juveline rheumatoid arthritis
           - neuroblastoma
                  - uncommon but should be considered in the differential diagnosis;
                  - abdominal ultrasonography may serve as a screening examination

Primary Pyomyositis of the Pelvis in Children: A Retrospective Review of 8 Cases

Suppurative arthritis of the hip in children.

Long-term follow-up of infantile hip sepsis

Sequelae and reconstruction after septic arthritis of the hip in infants.  

Evaluation of treatment modalities for septic arthritis with histologic grading and analysis of levels of uronic acid, neutral protease, and interleukin-1.  

Acute haematogenous osteomyelitis and septic arthritis in childhood: A 10 year review and follow up

Acute septic arthritis of the hip joint in infancy and childhood.

Pyogenic arthritis associated with adjacent osteomyelitis: identification of the sequelae prone child

The Role of Pelvic Magnetic Resonance in Evaluating Nonhip Sources of Infection in Children With Acute Nontraumatic Hip Pain.