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The Journal of Emergency Medicine
Volume 43, Issue 2,
, Pages 316-318
Septic arthritis of the hip is an infrequent disorder that is difficult to diagnose. Traditional methods of obtaining synovial fluid from the hip are not always available in most emergency departments.
To report a case of atypical septic arthritis with the diagnosis and management significantly aided by the use of bedside ultrasound.
An 18-year-old pregnant woman presented with right hip pain, a normal temperature, and elevated inflammatory markers. She had no risk factors for septic arthritis. The differential diagnosis was broad, but the use of bedside ultrasound assisted in rapidly narrowing the differential, as well as guiding the diagnostic procedure.
Bedside ultrasound is a useful tool to evaluate inflammatory disorders of the hip and assists in hip arthrocentesis, a procedure that has not been traditionally performed by most emergency physicians.
Septic arthritis involving the hip is a rare disorder that poses diagnostic challenges to the emergency physician (1). Patients with septic arthritis of native joints typically have risk factors such as immunocompromise or injection drug use. The diagnosis of septic arthritis is a clinical one that relies heavily on synovial fluid analysis. Arthrocentesis of the hip is traditionally performed using fluoroscopic methods by radiologists and orthopedic surgeons and is not immediately available to many emergency departments (EDs), often leading to delays in diagnosis and patient care. Ultrasound-guided hip arthrocentesis has been described in the radiology and orthopedic literature, with fewer reports published in the emergency medicine literature 2, 3, 4, 5, 6. Hip arthrocentesis utilizing bedside ultrasound guidance allows emergency physicians to make a definitive diagnosis more efficiently. We report a case of atypical septic arthritis in an otherwise healthy pregnant patient where the diagnosis and management was significantly aided by the use of bedside ultrasound.
An 18-year-old woman presented to the ED with hip pain of 5 days duration. The pain radiated down the anterior thigh and was made worse with weight-bearing and hip movement. The pain was getting progressively worse to the point that walking was difficult. She denied fevers, chills, nausea, vomiting, or urinary symptoms. There was no flank or abdominal pain, and she denied injury. She denied recent illnesses, upper respiratory or gastrointestinal symptoms, recent dental work, or other invasive
Hip arthrocentesis is a procedure traditionally performed under fluoroscopic guidance by interventional radiologists and orthopedists. It is a procedure that typically requires procedural sedation when performed in children. The use of ultrasound to guide hip arthrocentesis was described in 1989 by Mayekawa and colleagues and has been performed by emergency physicians in mostly pediatric patients, with good results 4, 5, 6, 7. Bedside ultrasound assists in the identification of hip effusions
We report a patient with a final diagnosis of septic arthritis involving the hip joint who presented with normal vital signs and no risk factors for the disease. Even though septic arthritis is an uncommon disorder, rapid diagnosis is essential to minimize complications (8). Left untreated, septic arthritis rapidly destroys the joint space, leading to significant patient morbidity.
Bedside ultrasound is a very useful tool, not only to rapidly identify hip effusion, but also to provide guidance
- J.W. Tsung et al.Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound
J Emerg Med
- K. Freeman et al.Ultrasound-guided hip arthrocentesis in the ED
Am J Emerg Med
(2007)(Video) Point of Care Hip Ultrasound Leads to Expedited Results Amongst Emergency Department Patients...
- D.L. Goldenberg et al.Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis)
Am J Med
- H.T. Harcke
Hip in infants and children
Clin Diagn Ultrasound
There are more references available in the full text version of this article.
- Point-of-Care Ultrasound and the Septic Prosthetic Hip Joint
2019, Journal of Emergency Medicine
Place curvilinear probe over affected hip with transducer orientation aligned transverse, in short axis to the femur and identify the femoral nerve/artery/vein. Rotate the medial aspect of the probe superiomedially toward the umbilicus just below level of inguinal ligament (Figure 2) to identify the femoral head and neck (Figure 3) (8,11). In a native hip, a distance of 0.7 cm or more, or 2 mm asymmetry to the contralateral asymptomatic hip, from the femoral neck to the capsule (see location A-A in Figure 3) identifies an effusion (12).
Septic joints can have an insidious onset and are difficult to diagnosis. Diagnosis can be more complicated in the setting of a distant prosthetic joint. Plain films and inflammatory markers are not specific and magnetic resonance imaging (MRI) is not a timely test in the emergency department. Computed tomography (CT) scan is quick and useful to evaluate for bony changes or signs of inflammation, but lacks the details of MRI, and the prosthetic joint may cause significant artifact. Point-of-care ultrasound (POCUS) is often used in the pediatric population to evaluate for an effusion when there is a concern for a septic native hip joint and is finding a role in adult emergency medicine to evaluate for an effusion in painful native adult hip joints. Even so, ultrasound is not currently included in diagnostic algorithms for diagnosing prosthetic hip joint infections (PJIs). POCUS is, however, readily available in the emergency department. We present a case where POCUS aided in identifying a periprosthetic synovitis and changed the course of the patient's management from previous physical therapy to an investigation toward the final diagnosis of a septic prosthetic hip joint.
- Point-of-care hip ultrasound in a pediatric emergency department
2018, American Journal of Emergency Medicine
In another small case series, Tsung et al. showed that bedside hip ultrasonography is easy to perform as an adjunct to the physical exam and expedited decision-making and disposition in the ED.  In a case report, Minardi et al. illustrated that bedside ultrasound in the ED rapidly identified a hip effusion in an 18 year old pregnant female with acute hip pain and expedited her care . In another case report, Deanehan and colleagues reported that hip ultrasound led to the identification of a hip effusion and an occult femur fracture in a child presenting to the ED with a traumatic limp that initially had negative radiographs .
- Septic Arthritis and Prosthetic Joint Infections in Older Adults
2017, Infectious Disease Clinics of North America
- Success of ultrasound-guided versus landmark-guided arthrocentesis of hip, ankle, and wrist in a cadaver model
2017, American Journal of Emergency Medicine
Perhaps more relevant to emergency medicine (EM), Balint et al. showed that ultrasound improved success rates in aspiration of multiple joints (shoulder, hip, wrist, knee, ankle, and digits) by greater than 60% compared to LM techniques . In the emergency medicine literature, there are multiple case reports of ultrasound-guided (US) arthrocentesis for the hip and ankle [9-13], but only one prospective study evaluating the utility of US arthrocentesis. Wiler et al. compared the success rate of US and LM arthrocentesis of the knee and found no difference, though patients reported less pain and providers found the procedure easier with ultrasound guidance .(Video) Septic Arthritis - Overview (causes, pathophysiology, treatment)
The objectives of this study were to evaluate emergency medicine resident-performed ultrasound for diagnosis of effusions, compare the success of a landmark-guided (LM) approach with an ultrasound-guided (US) technique for hip, ankle and wrist arthrocentesis, and compare change in provider confidence with LM and US arthrocentesis.
After a brief video on LM and US arthrocentesis, residents were asked to identify artificially created effusions in the hip, ankle and wrist in a cadaver model and to perform US and LM arthrocentesis of the effusions. Outcomes included success of joint aspiration, time to aspiration, and number of attempts. Residents were surveyed regarding their confidence in identifying effusions with ultrasound and performing LM and US arthrocentesis.
Eighteen residents completed the study. Sensitivity of ultrasound for detecting joint effusion was 86% and specificity was 90%. Residents were successful with ultrasound in 96% of attempts and with landmark 89% of attempts (p=0.257). Median number of attempts was 1 with ultrasound and 2 with landmarks (p=0.12). Median time to success with ultrasound was 38s and 51s with landmarks (p=0.23). After the session, confidence in both US and LM arthrocentesis improved significantly, however the post intervention confidence in US arthrocentesis was higher than LM (4.3 vs. 3.8, p<0.001).See AlsoAbstracts zum 40. Kongress der Deutschen Gesellschaft für Rheumatologie (DGRh) - PDF Free DownloadL5-S1 Disc Bulge, Slip Disc, Stenosis & SpondylolisthesisBest Golf Grips For Arthritic Hands in 2022
EM residents were able to successfully identify joint effusions with ultrasound, however we were unable to detect significant differences in actual procedural success between the two modalities. Further studies are needed to define the role of ultrasound for arthrocentesis in the emergency department.
- Pediatric emergency ultrasound
2014, Ultrasound Clinics
Sonographic features of hip effusions are listed in Box 12, pearls and pitfalls associated with POCUS for hip effusions are provided in Box 13, and key points regarding hip effusions are listed in Box 14. Several case reports demonstrate the ability of PEM physicians to use POCUS to detect hip effusions, diagnose transient synovitis and septic arthritis,25–27 and guide arthrocentesis to obtain synovial fluid for analysis.27,28 Most recently, a prospective study evaluating 28 children who required hip ultrasound as part of their PED management showed that PEM physicians with focused training in hip POCUS were able to detect hip effusions with a sensitivity of 85% and specificity of 93%, suggesting that positive findings may be used to rule in the diagnosis of hip effusion, and negative findings may prompt further evaluation or observation.29
- Ultrasonography in musculoskeletal disorders
2014, Ultrasound Clinics
Research articleCan mechanical devices be tested during CPR? Does it matter?
Resuscitation, Volume 158, 2021, pp. 273-274(Video) How to detect joint effusions with ultrasound
Research articleCisplatin-induced bradycardia: Cardiac toxicity or cardiac hypersensitivity and Kounis syndrome?
International Journal of Cardiology, Volume 202, 2016, pp. 817-818
Research articleWhat Is the Utility of Ultrasonography for the Identification of Skin and Soft Tissue Infections in the Emergency Department?
Annals of Emergency Medicine, Volume 70, Issue 4, 2017, pp. 580-582
Research articleTreatment of septic hip in a pediatric ED: a retrospective case series analysis
The American Journal of Emergency Medicine, Volume 34, Issue 3, 2016, pp. 602-605
A pediatric septic hip is a serious condition that must be recognized and treated as early as possible. We describe the clinical course of children with septic hip that were treated with aspiration of the hip joint in the emergency department (AHED).
This was a retrospective case series analysis.
Between January 1, 2007, and December 31, 2014, 17 children with septic hip were diagnosed by emergency physicians using point-of-care ultrasonography. All were treated with AHED. During hospital admission, a median of 2 (interquartile range [IQR], 2-3) follow-up sonographic examinations per patient was performed; 10 (59%) patients did not have another hip aspiration, and 7 (41%) had a median of 1 (IQR, 1-3) hip joint aspiration under sedation. Median length of antibiotic treatment was 28days (IQR, 21-40). No patient underwent arthrotomy, and all recovered without disability in up to 4 years of follow-up.
The results of this cohort suggest that AHED with repeated aspirations as needed is an effective treatment for children with septic hip.
Research articleRunning in Circles
The Journal of Emergency Medicine, Volume 57, Issue 1, 2019, pp. 119-120
Research articleReply to: ‘Bystander hit by leakage current from S-ICD’(Video) Hips Don't Lie: Hip Ultrasound in the Evaluation of the Limping Child
Resuscitation, Volume 138, 2019, p. 299
Copyright © 2012 Elsevier Inc. All rights reserved.
Since 1895, when Wilhelm Röntgen produced his first x-ray (of his wife’s hand), physicians have used imaging to
Joint aspiration, or arthrocentesis , is one of the most commonly performed procedures in the evaluation and treatment of joint diseases.. Effusions - Diagnosis and aspiration of joint and tendon sheath effusions. Using a 25- or 27-gauge needle, begin by making a subcutaneous skin wheal using an anesthetic (eg, 1% lidocaine without epinephrine) and then inject an additional 1-3 mL of anesthetic into the subcutaneous tissue overlying the chosen needle insertion site.. Appropriate transducer (probe). Anterior approach to visualizing a knee effusion with ultrasonography.. While conventional x-rays require up to 5 mL of synovial fluid before an ankle effusion can be detected, ultrasonography requires as little as 2 mL of fluid.. An ankle effusion appears as an anechoic region in the anterior recess between the tibia and talus (see image below).. See the images below.. Synovial fluid is often not visualized by ultrasonography in a normal joint.. The approach most often used to examine a hip effusion is the anterior approach with the patient in a supine position and the hip in slight flexion and internal rotation.. Emergency Ultrasound .. Knee Ultrasound.. Ultrasound-guided hip arthrocentesis in the ED.. Note how the echogenicity of the extensor tendon of the finger decreases near the leading edge (green arrows) as the angle between the probe and the tendon deviates from 90 degrees.
An overview of septic arthritis including aetiology, clinical features, key investigations, management and prognosis.
The most common cause of infection is Staphylococcus aureus , which enters the joint through direct inoculation or haematogenous spread from a different site, commonly a soft tissue infection.. However, most cases are caused by bacterial infection .. Risk factors for septic arthritis can be categorised as those predisposing an individual to infection, those providing opportunity for the pathological agent to gain access to the joint, and a past medical history of joint disease or inflammation which facilitates bacterial invasion through neovascularisation , increased expression of adhesion factors and an impaired synovial immune response.. Table 1 lists alternative diagnoses for a hot, swollen, tender joint .. Antibiotic therapy in septic arthritis.. Immediate investigations include prompt joint arthrocentesis and synovial fluid analysis (crystal microscopy, gram staining, culture, and sensitivity testing), which will require orthopaedic referral.. Does this adult patient have septic arthritis?. Septic arthritis .
Pediatric Gonococcal Hip Arthritis Diagnosed by Emergency Point-of-Care Ultrasound-Guided Arthrocentesis (2022) ›
Point-of-care ultrasound-guided arthrocentesis performed in the emergency department can expedite the diagnosis and treatment of septic arthritis, potentially averting the need for surgery.Source control via aspiration of purulent synovial fluid, when accompanied by intravenous (IV) antibiotics, may...
We report a case of pediatric gonococcal monoarthritis of the hip, for which initial diagnosis and treatment were directed by emergency medicine (EM)-performed POCUS-guided arthrocentesis.. Introduction Acute septic hip arthritis is a pediatric emergency.. (Video) Benifit of POCUS in Pediatric Emergency Medicine for Hip Joint Aspiration. POCUS examination of bilateral hips revealed a 10 mm fluid collection anterior to the left femoral neck consistent with a hip effusion.. 7-10 In a prospective multicenter treatment study of pediatric osteoarticular infections, however, 50 of 62 children with septic arthritis of the hip were treated successfully with aspiration and antibiotics alone.. Emergency department point-of-care hip ultrasound and its role in the diagnosis of septic hip a Pediatr Emerg Care .
Septic arthritis of the pediatric hip: update on diagnosis and treatment (2019) | James F. Mooney | 6 Citations ›
Purpose of reviewTo review the clinical diagnosis, management and natural history of septic arthritis of the hip (SAH) in the pediatric patient, and to highlight new information that may improve the management of these patients.Recent findingsThe basics of management of possible pediatric SAH have r
TL;DR: This study retrospectively reviewed the cases of children who were evaluated at a major tertiary-care children's hospital between 1979 and 1996 and constructed a set of independent multivariate predictors that had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation.. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested.. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.. Authors of recent retrospective studies have used presenting factors to establish algorithms for predicting septic arthritis of the hip in children.. This study differs from previous work in three ways: data were collected prospectively, C-reactive protein levels were recorded, and the focus was on children in whom the findings were so suspicious for septic arthritis that hip aspiration was performed.. Results: Univariate analysis showed that fever, the C-reactive protein level, and the erythrocyte sedimentation rate were strongly associated with the final diagnosis (p < 0.05).. On multivariate analysis, the C-reactive protein level and erythrocyte sedimentation rate were found to be significant predictors.. Abstract: Background:The differentiation between septic arthritis and transient synovitis of the hip in children can be difficult.. TL;DR: How rapidly cartilage loses glycosaminoglycan when it is involved by arthritis caused by staphylococci and how early treatment of the infection reduces the loss of collagen are shown.. We measured the extent to which early antibiotic therapy with ceforanide altered the degradation of the cartilage after arthritis due to Staphylococcus aureus had been produced in the knee joint in rabbits.. Three weeks after the infection was produced, the cartilage had lost more than half of its glycosaminoglycan whether the antibiotic therapy had been started at one, two, or seven days after infection.. Clinical relevance: The findings reported here show how rapidly cartilage loses glycosaminoglycan when it is involved by arthritis caused by staphylococci and how early treatment of the infection reduces the loss of collagen.
ScienceDirectCorporate sign inSign in / registerViewPDFAccess throughyour institutionThe Journal of Emergency MedicineVolume 60, Issue 5, May 2021, Pages 633-636https://doi.org/10.1016/j.jemermed.2020.12.019Get rights and contentAbstractBackgroundJoint arthrocentesis is a commonly performed procedur...
Joint arthrocentesis is a commonly performed procedure by the emergency physician (EP).. POCUS was performed to evaluate for an ankle joint effusion, which was not present.. We present a case of an isolated talonavicular joint effusion that was identified and aspirated by the EP using point of care ultrasound (POCUS) at the bedside.. POCUS has shown effectiveness in the management of atraumatic joint pain among patients in the ED.. Tuberculosis infection of the talonavicular joint (Video) Common Foot And Ankle Injections - Everything You Need To Know - Dr. Nabil Ebraheim. Our objective was to compare the performance of MASCC score with PCT in predicting adverse outcomes in patients with FN.. PCT is a useful marker with better prognostic efficacy than MASCC score in patients with FN and can be used as an adjunct to the score in risk-stratifying patients with FN.. (Video) Ultrasound-guided ankle joint aspiration in a patient with reactive arthritis. The objective of this study was to compare the test characteristics of point-of-care lung ultrasound (LUS) with chest x-ray study (CXR) at radiographically detecting COVID-19 pneumonia.. LUS was more sensitive than CXR at radiographically identifying COVID-19 pneumonia.
Ultrasound-Guided Hip Arthrocentesis in a Child with Hip Pain and Fever - The Western Journal of Emergency Medicine ›
Children presenting to the emergency department with hip pain and fever are at risk for significant morbidity due to septic arthritis. Distinguishing between septic arthritis and other causes of hip pain may be challenging. Sonographic visualization of the hip with real-time ultrasound-guided arthrocentesis may allow faster differentiation between etiologies, hastening definitive therapy and improving analgesia. This report describes the use of hip sonography in a case of Lyme arthritis. The authors review the medical literature in support of bedside hip sonography and discuss how to perform ultrasound-guided hip arthrocentesis. Clinical findings in septic and Lyme arthritis are also described.
The authors review the medical literature in support of bedside hip sonography and discuss how to perform ultrasound-guided hip arthrocentesis.. Clinical findings in septic and Lyme arthritis are also described.. Normal appearance of the left hip with no fluid in the anterior synovial space.. When examined by the orthopedist approximately an hour after arthrocentesis, the patient had significant improvement in his pain and was able to bear weight on the affected leg.. Finally, Tsung and Blaivas 13 performed bedside ultrasound-guided arthrocentesis in 2 pediatric patients, of whom 1 was diagnosed with transient synovitis and 1 with septic arthritis.. Thus, the 93-month-old child in this case could have a fluid collection up to 7.7 mm wide in the anterior synovial recess in the absence of pathology.. Tien et al 1 additionally reported that an effusion 1.46 mm wider than on the contralateral side is also abnormal.. Ultrasound-guided hip arthrocentesis in the ED.. Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound.. Bedside ultrasonography to identify hip effusions in pediatric patients.. Does this adult patient have septic arthritis?