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Septic Arthritis: Myth Busting

What's the big deal with septic arthritis? It's not really an emergency is it? Within days of onset, septic arthritis destroys cartilage and can leave the joint with permanent joint disability occurring in 25-50% of the cases. The mortality rate for in-hospital septic arthritis ranges from 7% to 15%, despite antibiotic use.

Ok ok. So that's pretty bad. How do I make sure I don't miss a septic arthritis?

Unfortunately, there are no physical examination findings or maneuvers, such as range of motion or degree of swelling, that have been studied that can help the clinician discriminate between etiologies of the monoarthritis.

Basically…

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  The Red Hot Joint

... we should first think about the worst-case scenario; only when that has been ruled out can a more benign diagnosis be considered. In the case of the “red-hot joint,” the most serious threat is septic arthritis.

Articles of Interest

What is Useful in the ED to Help Diagnose or Rule Out Septic Arthritis?

sWBC > 50,000 - essentially rules IN septic arthritis, sWBC < 50,000 - unhelpful for clinical diagnosis, Gram Stain: useful when positive, unhelpful when negative, Culture: not available when we need it in the ED, Lactate >10 - essentially rules IN septic arthritis.

Atraumatic Septic Arthritis of the Elbow in a Young Immunocompetent Host Secondary to Distant Hematogenous Spread

S eptic arthritis is a surgical emergency. Diagnosis and treatment have to proceed in expeditious manner. History and a high index of suspicion are important in making the correct and timely diagnosis.1 We report a case of elbow septic arthritis caused by hematogenous spread of Methicillin-sensitive Staphylococcus aureus (MSSA).

Back to Basics: Swollen Joint

Suspect gonococcal if sexually active young adults; infection will typically have a prodromal phase of migratory arthritis and tenosynovitis before symptoms settle in one or more joints.

Basics of Knee Aspiration

Due to the necessity for diagnosis there exist no absolute contraindications to arthrocentesis.

Diagnosing Septic Arthritis

One pitfall in the management of septic arthritis is the use of serum tests to exclude the need for joint aspiration. Synovial fluid is key to diagnosis. Serum blood tests do not rule out septic arthritis. If concern for septic arthritis exists, synovial fluid is required.

Emergency Department Management of Pediatric Septic Arthritis and Osteomyelitis

Neonates and infants with SA present acutely with septicemia, cellulitis, or fever without a source; older children most commonly present with acute fever, joint pain/limited range of motion, and/or refusal to bear weight.

Episode 16: Acute Monoarthritis

Most Common Causes of Acute Mono-arthritis: Crystal Arthritis (Gout & Pseudogout), Septic Arthritis, Occult Trauma.

Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department

Septic arthritis is a potentially deadly condition that unfortunately does not always present classically. The red, hot, swollen joint mandates consideration of septic arthritis. No physical examination finding can rule out the condition, and serum blood tests should not be used to exclude septic arthritis. Diagnostic aspiration is required, with the sample sent for synovial WBC, Gram stain, culture, and lactate. Synovial lactate and culture are the best laboratory tests, as some patients can present with normal synovial WBC and Gram stain.

Paucis Verbis card: Septic Arthritis

I was surprised to learn that only about 50% of patients with septic joints have a fever. Note that a hip or knee prosthesis PLUS an overlying skin infection pretty much equals a septic joint (LR = 15.0).

Septic Arthritis in a Patient with a Confounding History

Septic arthritis should be considered in all individuals with non-traumatic joint pain.

Septic Arthritis: Staph is back, back again

The real money is in the bedside arthrocentesis.

Septic joint: Reminders, Updates, and Pitfalls

Septic arthritis typically involves one joint, but can be polyarticular in up to 20% of cases. A predilection for large joints exists with as many as 60% of cases involving the knee or the hip (

The Speed of Sound

Septic Hip? Ultrasound is Faster and Easier

Resources

Core EM

60-90% of cases are Gram positive (S. aureus = 50-70%)