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Marina Escobar1, Carlos Pedrosa2, Joana Arcângelo2, Mafalda Vital Batista3, Pedro Campos4, André Grenho2, Joana Ovidio5, Catarina Gouveia5, Delfin Tavares5

1. Centro Hospitalar Barreiro Montijo, Barreiro, Portugal
2. Centro Hospitalar Lisboa Central - Hospital Curry Cabral, Lisboa, Portugal
3. Centro Hospitalar de Setúbal - Hospital Ortopédico de Sant'Iago do Outão, Setubal, Portugal
4. Hospital de Vila Franca de Xira, Vila Franca De Xira, Portugal
5. Centro Hospitalar Lisboa Central - Hospital D. Estefania, Lisboa, Portugal

- Poster, Congresso Europeu de Ortopedia, Viena, 29 de Maio a 1 de Junho de 2017

Background: Septic arthritis in children, like osteomyelitis, is usually haematogenous in origin. Septic joints frequently follow upper respiratory or enteric infectious conditions. Seldom does this condition arise from direct inoculation of a joint following trauma. A review of the literature reveals that often this direct inoculation is made by means of a thorn, be it of a palm tree, date tree, rose bush, cactus, or other unidentified plants. This lesions can be difficult to diagnose as some of the smaller children are not able to accurately describe how they got hurt. It is essential to stay alert and, when presented with a case of septic arthritis with an atypical agent or clinical course, to ponder the possibility of this kind of inoculation.
Objectives: We aimed at describing our experience with septic arthritis related to palm torn injury in order to better understand this clinical entity and to identify the specificities of it’s treatment.
Study Design & Methods: We performed a retrospective and descriptive revision of the cases of septic arthritis treated in our institution from 2013 to 2015 to identify all cases with documented palm tree thorn injury as the inoculation route. The identified cases were then studied to evaluate symptoms, identified bacterial agents, treatment responses, complications and recurrences.
Results: three cases were identified. A 3-year-old female and a 11-year-old male with ankle septic arthritis and a 7-year-old male with knee arthritis. The time from inoculation to clinical presentation was 2 months, 4 months and 5 days, respectively. All cases presented themselves with low-grade fever, pain and effusion; the laboratory findings consisted of moderately elevated inflammatory markers. In two cases it was possible to identify the thorn prior to surgical removal in an imaging (ultrasound); in all cases, along with the arthrocentesis, a surgical extraction of the palm thorn was performed. The microbiological exam of the synovial fluid identified a Staphylococcus epidermidis in one patient and a mixed population of Serratia marcescens, Enterococcus casseliflavus and Enterobacter aerogenes in another. In the patient with knee arthritis, no agent was ever identified. After the introduction of the appropriate antibiotics, both ankle arthritis cases evolved to complete resolution of the infection; in the patient with knee arthritis, there was a recurrence of the synovitis 3 months after the clinical resolution of the infection. All patients are currently asymptomatic.
Conclusions: It is necessary a high degree of suspicion to diagnose palm thorn related arthritis. In concordance with the literature, the ankle was the most frequently affected articulation. In the majority of case reports, Pantoea agglomerans is the microorganism identified; our series revealed a different group of agents, with both gram positive and negative bacteria involved. It has become clear to the authors that the removal of the thorn, in association with the identification of the agent, renders the best prognosis.

Palavras-chave: Septic Arthritis, Palm Tree Thorn, Foreign Body