Septic Joint

What It Is

• Bacterial infection of a synovial joint

Why It’s an Emergency

• The combination of the bacteria and inflammatory response (“pus under pressure”)
can cause rapid erosion of the cartilage with irreversible joint destruction.
• Occasionally, an infected joint can be a bacterial source in a septic patient, and
treatment of the sepsis requires timely source control.

How “Emergent” Is It?

• Usually emergent—The longer diagnosis and treatment are delayed, the more
damage to the joint occurs, sometimes on the order of hours.

When to Be Suspicious

• Classic presentation is a painful effusion or a new effusion in a patient who has

known bacteremia.

© Springer International Publishing Switzerland 2017 21

M.C. Makhni et al. (eds.), Orthopedic Emergencies,
DOI 10.1007/978-3-319-31524-9_6
22 J. Shillingford

How to Diagnose

• Initial diagnosis is from clinical exam, which usually includes an effusion and
pain with joint passive micromotion, although these are not always present.
• Serum inflammatory markers (CBC with differential, ESR, CRP) should also be
part of initial work-up - unreliable in immunosuppressed patients.
• In the pediatric population, the “Kocher Criteria” determine the risk of hip infec-
tion. If >3 of these are present, 90 % chance of septic joint.

° Inability to bear weight

° Temperature >101.3 °F
° WBC >12 k
° ESR >40 mm/h
° CRP >2.0 mg/dL
• Definitive diagnosis is from arthrocentesis (see joint aspiration techniques in
“Appendix B”).

° Stat WBC count + PMN % should be available within hours. Under 30 k makes
septic joint very unlikely. Over 50 k makes it more likely
⁃ Fluid should also be sent for crystal examination to eval for crystalline
arthropathy as well, although he presence of crystals doesn’t definitively
rule out infection
• Culture from aspirate usually not back within 2 days, so less important for
immediate emergent decision making

How to Treat

• Treatment of septic joint is surgical irrigation and debridement (either open or

arthroscopic) + broad-spectrum IV antibiotics until cultures and sensitivities back.

References

Kocher MS, Mandiga R, Murphy JM, Goldmann D, Harper M, Sundel R, et al. A clinical practice
guideline for treatment of septic arthritis in children: efficacy in improving process of care and
effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am. 2003;85-A(6):994–9.
Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA.
2007;297(13):1478–88.
Shah K, Spear J, Nathanson LA, McCauley J, Edlow JA. Does the presence of crystal arthritis rule
out septic arthritis? J Emerg Med. 2007;32(1):23–6.