Episode 170.0 – Septic Arthritis Core EM - Emergency Medicine Podcast

An overview of septic arthritis.

Hosts:

Audrey Bree Tse, MD

Brian Gilberti, MD







https://media.blubrry.com/coreem/content.blubrry.com/coreem/Septic_Arthritis.mp3







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Tags: Infectious Diseases, Orthopedics











Show Notes

Episode Produced by Audrey Bree Tse, MD



Background



Bacteria enters the joint by hematogenous spread due to absence of basement membrane in synovial space from invasive procedures, contiguous infection (e.g. osteomyelitis, cellulitis), or direct inoculation (e.g. plant thorns, nails)



WBCs migrate into joint → acute inflammatory process → synovial hyperplasia, prevents new cartilage from forming, pressure necrosis on surrounding joint, purulent effusion





Why do we care? 



irreversible loss of function in up to 10% & mortality rate as high as 11%

Cartilage destruction can occur in a matter of hours

Complications include bacteremia, sepsis, and endocarditis







Etiology



Risk factors: extremes of age, RA, DJD, IVDA, endocarditis, GC, immunosuppression, trauma, or prosthesis

Organisms: 



Staph: staph aureus (most common), MRSA, Staph epidermis

N gonorrhea: young healthy sexually active adults

Strep: group A & B

GNRs: IVDA, diabetics, elderly

Salmonella: sickle cell disease

Cutibacterium acnes: prosthetic shoulder infection

Consider mycobacterial & fungal in more indolent courses







Presentation



Typically a single, warm, erythematous, tender joint (#1: knee (50% of cases) → hip, shoulder, ankle)



*Any joint can be involved!

IVDA can involve sacroiliac, costochondral, & sternoclavicular joints 

Classic teaching: very painful with ROM, but this is not always present!

Joint usually held in position of maximum joint volume

Prosthetic joints may have less pain than expected for a septic joint given changed anatomy and disrupted nerve endings





In 10-20% of cases, can see polyarticular involvement



GC typically monoarticular but commonly polyarticular





Often have fever & separate infection as well (only see fever in ~60% of cases)



Diagnostics

Arthrocentesis: 



Gold standard 

Tap joint even if acceptable ROM: septic joints can have normal motion so it does not exclude the diagnosis!

Use ultrasound if possible

Relative contraindications: overlying cellulitis (risk of seeding joint) or severe coagulopathies (weigh risk of creation or worsening of iatrogenic hemarthrosis)

Keep in mind that a “dry tap” may occur due to incorrect needle placement, absent/ minimal joint effusion, ort mechanical obstruction

Note: talk to ortho colleagues if prosthesis present prior to performing arthrocentesis