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Septic arthritis resident survival guide:

Complete diagnostic approach:

Common Presentation Symptoms in newborns or infants: Cries when infected joint is moved (e.g. diaper change causes crying if hip joint is infected) Fever Inability to move the limb with the infected joint (pseudoparalysis) Irritability Symptoms in children and adults: Inability to move the limb with the infected joint (pseudoparalysis) Intense joint pain Joint swelling Joint redness Low fever The tenosynovitis is characterized by pain, swelling, and erythema around the tendon Less common Presentation Chills
Focused History Intravenous drug use Sexual activity Terminal complement deficiency Dog or cat bite Ingestion of unpasteurized dairy products Nail through shoe Soil exposure/gardening Soil or dust exposure containing decomposed wood (north-central and southern United States) Southwestern United States, Central and South America (primary respiratory illness) Cleaning fish tank
Physical Examination Appearance of the Patient Patient with septic arthritis usually appears toxic and with joint pain children usually appear irritable Vital Signs Low grade fever. Chills and spiking fever are very rare. Hyperthermia over the joint involved Tachycardia Tachypnea Skin Warmth over the joint Erythema over the around the joint that involved Disseminated gonococcal infection often present with skin lesions, typically multiple, painless macules and papules, most often found on the arms or legs or on the trunk. Extremities Most commonly involves knee > hip > shoulder > ankle. Other joints such as sacroiliac joint (~10%), sternoclavicular or costoclavicular joints may be involved in patient with history of intravenous drug abuse (IVDA), penetrating trauma, animal or human bites and local steroid injections. Swelling of the joint that involved Decreased range of motion such as pseudo paralysis Patient hold the hip in flexed and externally rotated position if SA involving hip. If child, unwillingness to bear weight on the affected joint (antalgic gait)
Laboratory Workup CBC with DC SMA-7 Creatine kinase Urinalysis with microscopic examination Erythrocyte sedimentation rate C-reactive protein Synovial fluid analysis Synovial WBC count with differential Crystal analysis Gram stain Culture and sensitivity
Imaging Study Plain radiographs of swollen joints Erosions Ultrasonography of painful joints Detect synovitis and tenosynovitis in the hands and wrists in patients with SLE Renal ultrasonography To assess kidney size To rule out urinary tract obstruction Chest radiography For suspected pleural effusion, interstitial lung disease, cardiomegaly Echocardiography For suspected pericardial involvement, to assess for a source of emboli, or noninvasive estimation of pulmonary artery pressure; and for evaluation of suspected valvular lesions, such as verrucae Computed tomography (CT) For abdominal pain, suspected pancreatitis, interstitial lung disease Magnetic resonance imaging (MRI) For focal neurologic deficits or cognitive dysfunction
Other Investigation Bronchoscopy Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial lung biopsies: To substantiate the diagnosis of alveolar hemorrhage Barium swallow or esophagography Esophageal stricture Peptic strictures that appear as smooth, tapered narrowing in the distal esophagus Esophageal dilatation Biopsy Renal biopsies: Determining the degree of renal involvement Delineating treatment decisions and prognosis in certain clinical scenarios Assess activity and damage (i.e., chronicity) Helping with classification Endomyocardial biopsy: May be helpful in guiding treatment towards the use of corticosteroids Paracentesis Paracentesis in the presence of the following conditions either for symptomatic relief (therapeutic) or fluid evaluation (diagnostic): Ascites Massive pleural effusion Massive pericardial effusion and tamponade Arthrocentesis In the presence of joint effusion to differentiate between different causes of arthritis