Septic arthritis of the wrist and the hand: – An Emergency department case study (2022)

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International Emergency Nursing

Volume 62,

May 2022

, 101150

https://doi.org/10.1016/j.ienj.2022.101150Get rights and content

(Video) Septic Arthritis - Overview (causes, pathophysiology, treatment)

Abstract

Joint pain is a common presentation in the Emergency department. There are countless potential causes for pain and swelling in a joint. Septic arthritis is a true joint emergency as it can lead to rapid, irreversible destruction of the joint. If not diagnosed early this infection can lead to considerable functional deficit. Our case is unique in that our patient presented to the Emergency department requesting referral to the fracture clinic for continued management of a suspected scaphoid bone fracture but was found to have Neisseria gonorrhoea causing septic arthritis of the joint. This case highlights the importance of accurate history taking, clinical examination and assessment of the patients presenting with joint pain.

Section snippets

Background

Septic Arthritis (SA) can be mono-articular or polyarticular, the latter being less common. Globally, the incidence of SA is reported to be between 4 and 60 cases per 100,000 population per annum [1]. Bacterial infection causes an inflammatory process and micro-organisms enter the joint space and normally sterile synovial fluid. The combination of the bacteria and the host inflammatory response causes tissue ischemia and can result in significant and rapid destruction of the joint [2]. Risk

Case presentation

A 26-year-old male presented to the Emergency department (ED) with a Plaster of Paris cast on his left wrist requesting follow up for a prior injury that occurred during a recent international holiday. He was assessed, using the Australian triage scale as a Category 5 presentation and streamed to the ambulatory care area for Nurse Practitioner review. Two weeks prior, the patient had consumed a large amount of alcohol and the next day his hand and wrist were painful, presumed injured. Further

Investigations

The ‘look, feel, move’ framework was used for musculoskeletal examination of the wrist [7]. As soon as the cast was removed the patient held his hand supporting the wrist very firmly, holding it very still to prevent movement. The wrist and hand were not red but were hot to touch. There was swelling over the wrist and dorsum of hand, capillary refill was less than 2s. There was tenderness over the radial aspect of the carpal bones and wrist joint but most significantly the anatomical snuffbox.

Discussion of findings

Evidence suggests that physical examination and medical history results are not adequate to establish an accurate diagnosis of SA [9]. However, clinical suspicion of SA should be raised in the presence of fever, malaise, swelling, pain and restricted movement to a joint [9]. Fever is not a reliable indicator of an infected joint as 45% of patients with SA have a normal temperature, including this case [10]. The fact that this patient had presented three times before a diagnosis could be made

Conclusion of case

The rapid, irreversible destruction of bone and cartilage seen in this case demonstrates the devastating impact this disease can have. The timeline clearly highlights the impact this disease process had on the patient in terms of disability and activities of daily living with prolonged treatment and irreversible destruction of the wrist and hand. Patient prognosis from delayed diagnosis with potential long-term impact on range of movement and joint function.

Learning points

Acute onset of joint pain is not always traumatic.

High suspicion for SA is needed in a hot, swollen joint with restricted movement with or without systemic symptoms such as fever.

SA is a debilitating disease and can lead to irreversible loss of limb function and even death if left untreated.

In mono-arthritis or polyarthritis of joints in a sexually active person with no other risk factors always consider Neisseria Gonorrhoea – and ask about sexual history.

Gram stain and culture of synovial

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    (Video) Wrist Joint Arthrocentesis Procedure

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