# 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

(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.

## 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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• D. Purcell

### Minor Injuries; A Clinical Guide

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A psychometric study of the Compassionate Love Scale for Humanity Short version (CLS-H-SF) within a paramedicine student cohort

International Emergency Nursing, Volume 61, 2022, Article 101115

There is a lack of research on compassion within paramedicine practice despite it being a fundamental component of healthcare. Existing studies have focussed primarily on the related concept of empathy. Additionally, the concept of common humanity has been suggested as a core component of compassion, and it informs the assessment scale utilised in the present study.

An Exploratory Factor Analysis (EFA) was performed on the 9-item Compassionate Love Scale for Humanity (CLS-H-SF), using a convenience sample of paramedicine students from an Australian university.

(Video) Rheumatoid Arthritis - Wrist joint

A total of 225 students completed the study (55% response rate). EFA of the CLS-H-SF supported a one-factor solution with all items being retained and accounted for 53.26% of the total explained variance. The Cronbach alpha coefficient for the 9-items was α .909 indicating excellent internal consistency.

Factor analysis supported results from a previous psychometric examination of the CLS-H-SF, indicating that the scale shows strong psychometric properties. The literature has also reported other abridged versions of the original 21-item scale; however, these have not been tested within a paramedicine cohort.

This evaluation suggests that the CLS-H-SF demonstrates robust psychometric characteristics when used in an Australian paramedic student cohort. Although further examination is warranted, it appears that the CLS-H-SF may be a valuable tool to examine compassion within paramedicine students.

• Research article

Influence of transport conditions on infusion pumps performance and triggering alarms: A simulation-based research

International Emergency Nursing, Volume 62, 2022, Article 101144

Critical care transport is an essential component of care system. Inadequacies in equipment, during the interhospital transport can lead to adverse event.

To verify the influence of physical transport conditions in the infusion pumps (IPs) performance and alarm activation.

Simulation-based study about IPs use during interhospital ground transportation. There were 54 simulations (18 flowmetric, 18 volumetric, 18 syringe IPs). The equipment were tested at 01, 05 and 50mL/h infusion flow. Descriptive and inferential statistical analysis, with a 5% significance level was performed.

The effectively infused volume was lower than the expected volume for the 3 IPs types. Vibration was the variable with highest correlation in volume difference. Flowmetric IPs showed higher alarm frequency (50.0%), followed by syringe IPs (27.8%). Free flow predominated in flowmetric IP and airline and occlusion alarms in volumetric and syringe IP. Error percentage of delivered fluid ranged from 2.8% to 25.9% being more evident in flowmeter IPs.

The infusion pumps showed infusion misfunctioning when subjected to physical transport conditions. Syringe IPs were more accurate for low flow administration, while for the administration of solutions at higher flow rate, the volumetric IP showed the highest accuracy.

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International Emergency Nursing, Volume 62, 2022, Article 101169

The reason behind having referral system in Kenya is to have proper distribution of effective health care services to all Kenyans as well as linking and integrating medical services across all levels of healthcare. In Kenya, most of levels of health care lacks specialized manpower and equipment, proper communication strategies, knowledge on referral system and skilled health workers to deal with referral system. Therefore, this study addresses the challenges influencing the proper implementation of quality referral system of health care in Kaloleni sub-county, Kilifi County in Kenya. Specifically, investigating gaps by the health workers, knowledge and communication factors on implementation of quality health care referral system. A cross-sectional research design was used targeting health care workers in public health care facilities. Self- administered questionnaires were used to obtain quantitative data. The data was cleaned, coded and analyzed using SPSS V. 22. The inferential statistics discussed finding from Chi-square showing the significance between independent and dependent variables. According to the results, Communication gap with $p\left(0.18\right)$ showed to have more significant variable affecting the quality referral system followed by knowledge factor with significant of $p\left(0.499\right)$ and finally Nurse’s skills with significant of$p\left(0.99\right)$.

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Subtle oncological emergencies: Nature of illness, clinical characteristics, and outcomes

International Emergency Nursing, Volume 61, 2022, Article 101127

(Video) Septic Arthritis

The primary objective was to assess whether presentation severity at the emergency department (ED) can determine treatment and health outcomes among patients with oncological emergencies.

We conducted a three-year retrospective analysis of accessible records of adult cancer patients admitted with oncological emergencies.

Patients with subtle presentations had longer wait times than patients with severe presentations in all ED timeliness indicators. On average, subtle presentations were significantly associated with 47.5min increase in time to be seen, 33min increase in time to be treated, 42min increase in time to decide on admission and prolonged ED stay by 24min (p<0.05). Subtle presentations were also significantly associated with a four-fold increase in intensive care unit admissions and a three-fold increase in mortality odds.

The severity of the clinical presentations significantly predicted oncological emergencies' treatment and health outcomes. This research raises the importance of emergency triage decision accuracy. Triage health workers should have a solid knowledge base regarding oncological emergencies to improve patients’ early recognition and prioritization. Oncological emergency presentations can be subtle, rendering patients vulnerable extensive delay and inferior outcomes. Therefore, triage nurses should be educated and trained on the multiple available severity scales sensitive to identifying the real urgency. Also, protocols and care pathways should be in place to enable immediate fast-tracking of patients and the provision of timely treatment.

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Road user perceptions of appropriateness of ambulance lights and sirens use in developing countries

International Emergency Nursing, Volume 62, 2022, Article 101157

Ambulance lights and sirens use has traditionally been an important strategy to shorten ambulance travel times. This study explored road users’ perceptions toward the importance and risks of lights and sirens use by ambulances in Jordan.

A cross-sectional survey was used on a sample of 1700 adult road users in Northern Jordan. The questionnaire included 19 items addressing demographics, driving-related characteristics, and perception statements toward lights and sirens use. Continuous variables were summarized as means and standard deviation and categorical variables were reported as frequencies and percentages. Chi-square test was used to assess differences between categorical variable.

A total of 1634 participants completed the questionnaire. The mean age was 32.4 (SD±11.4) years, and 65.4% were males. Most participants agreed on the importance of using lights and sirens for emergency medical services to function effectively (96.5%), and penalizing those who do not yield to emergency ambulances (90.2%). However, around half of the participants perceive that lights and sirens could be over-used by ambulance personnel (48.1%), provoke distraction (48.7%) and create stress (50.3%) for road users. These negative perceptions were reported more often among males, taxi/bus drivers, and novice drivers.

Although the majority of road users, in our region, acknowledge the importance of ambulance lights and sirens use, about half of them perceive that ambulance lights and sirens put them under stress, distraction, and unacceptable risk. Policy-related and educational interventions might be necessary to monitor the use of ambulance lights and sirens and reduce negative road users’ perceptions.

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Self-reported clinical competence before entering advanced level training in acute and prehospital emergency care among registered nurses in Sweden

International Emergency Nursing, Volume 61, 2022, Article 101146

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(Video) Imaging findings of Septic arthritis, Tenosynovitis, Bursitis

## Videos

1. 3 .Septic arthritis
(Clinical Reasoning Pearls)
2. Hip Septic Arthritis Exam Review - Michael Glotzbecker, MD
(Orthobullets)
3. Septic Arthritis by Dr Tim Wright
(The Wonderful World of Orthopaedics)
4. Imaging of Osteomyelitis & Septic Arthritis | 15 Minute Radiology CME
5. Arthritis and Arthrocentesis - Detailed explanation - Emergency Medicine
(Navendu Goyal)
6. Infectious Disease Research in the Emergency Department
(BC Emergency Medicine Network)

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