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SEPTIC ARTHRITIS

Introduction

Septic arthritis (SA) is an infection of the joint space and is considered to be a joint-threatening emergency owing to substantial morbidity and mortality.1 It can affect any joint and is relatively uncommon in the hand and wrist; however, there are unique aspects of these cases that distinguish them from cases involving other joints. Septic arthritis is most commonly caused by a penetrating trauma or spread of an infection from contiguous structures, and like other closed-space infections, bacterial toxins and the local inflammatory response result in damage to the affected joint.2 Because SA can rapidly lead to articular destruction and eventually osteomyelitis, it requires urgent treatment that includes intravenous (IV) antibiotics, immediate irrigation, and debridement, followed by early mobilization.1,3 

Pathophysiology

  • SA of the hand or wrist is typically caused by direct joint penetration (eg, human or animal bite) or the extension of an infection through contiguous or hematogenous spread;4 direct spread of an infection can also occur in phalangeal joints from a felon, paronychia, or pyogenic flexor tenosynovitis5
  • Spontaneous SA in is generally uncommon, but there have been occasional reports cases in the wrist without a definable etiology6
  • The most common organisms that cause SA are beta-hemolytic Staphylococcus aureus and Streptococcus organisms7
    • Eikenella corrodens: commonly found in SA of the metacarpophalangeal joints from a clenched-fist injury due to direct inoculation or from a human bite5
    • Neisseria gonorrhoeae: should be considered in sexually active patients or young adults with monarticular, nontraumatic SA8
    • Haemophilus influenza: should be considered in young, unvaccinated children2
    • Pasteurella multocida: may be responsible in patients that are bitten by a cat or dog9 
    • Pseudomonas aeruginosa: may be responsible in patients with a history of IV drug abuse10 
    • Hand and wrist joints are prone to local trauma that predispose them to unusual microbiologic infections (eg, anaerobic and mycobacterial infections) that require antimicrobial management substantially different from that for Staphylococcus aureus9
    • Like other close-space infections, cartilage destruction results from bacterial toxins, proteolytic enzymes, and other associated enzymes that are released during the joint infection; with time, direct damage to cartilage ensues, which can ultimately lead to osteomyelitis2,4
    • Predisposing factors for SA include infancy, immunosuppressive therapy, alcoholism, drug abuse, some immunoglobulin deficiencies, phagocytic cell dysfunction, chronic arthritis, previous joint damage, previous joint surgery, and a history of intra-articular glucocorticoid injections6

Related Anatomy

  • There are several unique aspects of SA of the hand and wrist that distinguish it from SA of other joints:
    • By virtue of the small joint size, the infectious burden in any single septic wrist or finger joint is much smaller than it is in larger septic joints
    • Although the hands typically have a very good blood supply, circulation may be compromised in some patients with comorbid medical problems
    • The small joint size limits serial aspiration as a practical option for drainage9
    • In severe infections, purulence can exit the wrist joint and extend into the carpal tunnel and subcutaneous tissues11

Incidence and Related Conditions

  • The incidence of SA is estimated to be 2–5/100,000/year in the general population, and rates depend on population variables and pre-existing structural joint abnormalities1,10
    • Incidence rates are higher, 28–38/100,000 individuals with rheumatoid arthritis (RA) and 40–68/100,000 individuals with a prosthetic joint1
    • The incidence of SA of the wrist is not known, but it occurs less frequently than in other large joints and is considered rare; ~25% of upper extremity cases affect the wrist1
      • In one of the largest series available, only 29 cases of SA of the wrist were identified over a 10-year period12

Differential Diagnosis

  • Septic bursitis
  • Cellulitis
  • Gout
  • Pseudogout
  • Transient synovitis
  • Osteomyelitis
  • Abscess
  • Rheumatoid arthritis

Laboratory Workup

  • Key diagnostic test is synovial fluid analysis
    • Gram stain, culture, white blood cell count and differential, and polarizing microscopy for crystals11
      • Unfortunately, bacterial Gram stain and culture—is not consistently positive in an acute septic joint, and the culture might become positive only after several days
      • Gonococcal SA is notorious for being culture negative in ~50% of cases11
    • Fluid findings characteristic of SA include:
      • A friable mucin clot
      • A white blood cell count >50,000 with greater than 75% are polymorphonuclear leukocytes
      • A glucose level 40mg less than the fasting blood glucose level2,8
ICD-10 Codes

  • SEPTIC ARTHRITIS

    Diagnostic Guide Name

    SEPTIC ARTHRITIS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    SEPTIC ARTHRITIS    
    - STAPHYLOCOCCAL    
     - ELBOW M00.022M00.021 
     - WRIST M00.032M00.031 
     - HAND M00.042M00.041 
    - PNEUMOCOCCAL    
     - ELBOW M00.122M00.121 
     - WRIST M00.132M00.131 
     - HAND M00.142M00.141 
    - STREPTOCOCCAL    
     - ELBOW M00.222M00.221 
     - WRIST M00.232M00.231 
     - HAND M00.242M00.241 
    - SEPTIC ARTHRITIS DUE TO OTHER BACTERIA    
     - ELBOW M00.822M00.821 
     - WRIST M00.832M00.831 
     - HAND M00.842M00.841 
    - PYOGENIC ARTHRITIS, UNSPECIFIED (INFECTIVE ARTHRITIS, NOS)M00.9   

    Instructions (ICD 10 CM 2020, U.S. Version)

    USE ADD'L CODE (B95.0-B95.2, B95.4-B95.5) TO IDENTIFY BACTERIAL AGENT

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Joint pain with motion and axial loading
Swelling, erythema, warmth and tenderness over joint
Joint immobility
Fever/chills/rigors
Typical History

The typical patient is a 63-year-old, right- or left-handed man with poorly controlled diabetes who is also immunocompromised from taking prednisone regularly. He was checking the mail when he cut his right hand on the sharp edge of the mailbox, which resulted in a deep laceration. After sustaining the injury, he bandaged his hand but failed to clean the wound thoroughly or seek out medical help. Within two days, the area surrounding the laceration swelled and became red and warm. He began experiencing severe pain when he moved his injured hand. Based on his increasing pain levels and other symptoms, he went directly to the emergency department. 1,3,11

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • The choice of antibiotic treatment depends on the type and severity of infection, host factors, clinical presentation and regional infectious epidemiology.
  • Consultation with infectious disease team can help and is encouraged, especially in patients with antimicrobial allergies, immunocompromised states, unusual presentations or atypical organisms.
  • Antibiotic treatment should be broad-spectrum coverage of gram positive and gram negative organisms before identification of the offending bacteria, after which treatment can be tailored accordingly.11
  • SA of the hand or wrist typically requires surgical intervention combined with a course of antibiotic treatment11
  • Antibiotic management commonly consists of 2–4 weeks of parenteral treatment after initial debridement, often followed by a course of oral antimicrobial therapy.
  • Needle aspiration is usually considered for definitive treatment only in the idiopathic cases (resulting from hematogenous spread, for example), which must be differentiated from the treatment of postoperative infections, post-traumatic infections, or infections involving prosthetic or hardware devices, in which case, surgical treatment is empirically considered preferable.
Operative
  • Standard of care: open irrigation and debridement
    • Open drainage of the wrist is through a longitudinal incision between the third and fourth dorsal compartments
    • Metacarpophalangeal joints should be entered through a longitudinal, dorsal incision, with at least partial preservation of the sagittal bands to avoid postoperative extensor tendon subluxation.
    • Interphalangeal joints should be approached through a midaxial incision between the volar plate and the accessory collateral ligament, or between the lateral slip of the extensor mechanism and cordlike portion of the collateral ligament, to avoid postoperative finger deformities.
  • Arthroscopic irrigation and debridement
  • The wound can be left open to heal by secondary intention, closed over an intermittent or continuous irrigation catheter, or treated with delayed primary closure4
  • Postoperatively, the hand is splinted in a functional position and maintained in strict elevation for 48–72 hours before starting active and passive motion exercises
  • Parenteral antibiotics should be continued until local and systemic signs have resolved8
Complications
  • Articular damage
  • Osteomyelitis
  • Systemic infection spread
  • Arthrodesis
  • Amputation
  • Stiffness
Outcomes
  • Outcomes for SA of the hand and wrist are closely related to the duration of the infection before adequate treatment begins8
  • Good overall results with minimal disability in the medium term can be expected if appropriate surgical drainage and debridement of the joints is carried out within 7 days, and both antibiotic treatment and hand therapy are started early
  • Arthroscopic irrigation and debridement can result in smaller incisions, less pain, superior visualization of the articular surfaces, and no open wound requiring dressing changes; it results in fewer operations and shorter hospital stays for patients with isolated SA of the wrist1
  • Poorer outcomes are associated with the presence of S aureus organisms, Gram-negative rods, or anaerobes, polymicrobial infections, positive blood cultures, and associated osteomyelitis8
  • Current mortality rates range from 10–20%, depending on the presence of comorbid conditions (eg, older age, renal/cardiac disease, immunosuppression)10
Key Educational Points
  • Diagnosis of SA in the hand or wrist should include a patient history, physical examination, and an analysis of synovial fluid8,11
  • Physical examination may show pain with active or passive motion and axial loading, swelling, fusiform joint erythema
    • A puncture wound may or may not be identified
    • Determine if the site of inflammation is intra-articular or periarticular10
    • Hematogenous spread should be suspected in patients with systemic symptoms8
  • Noninfectious conditions like crystalline arthropathies (ie, gout and pseudogout) may present similarly to SA and should be ruled out; the presence of crystals does not preclude a diagnosis of SA8,10
  • Most common predisposing risk factors include age over 60, recent bacteremia and medical conditions such a degenerative joint disease, rheumatoid arthritis, corticosteroid therapy, diabetes, cancer, renal disease and patients having cytotoxic chemotherapy.
  • There is inadequate evidence to determine the relative effectiveness of joint aspiration alone, arthroscopic debridement, and open debridement
    • Evidence is also lacking regarding the best antimicrobial route, as well as the use or duration of oral versus parenteral antibiotics8.11
References

Cited

  1. Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am 2009;91(6):1387-93. PMID: 19487516
  2. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am 2014;39(8):1628-35. PMID: 25070032
  3. Sinha M, Jain S, Woods DA. Septic arthritis of the small joints of the hand. J Hand Surg Br 2006;31(6):665-72. PMID: 17046120
  4. McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am 2011;36(8):1403-12. PMID: 21816297
  5. Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics 2014;34(7):1968-86. PMID: 25384296
  6. Chin KR, Spak JI, Jupiter JB. Septic arthritis and osteomyelitis of the wrist: reconstruction with a vascularized fibular graft. J Hand Surg Am 1999;24(2):243-8. PMID: 10194006
  7. Hausman MR, Lisser SP: Hand infections. Orthop Clin North Am 1992;23:171- 185.
  8. Abrams RA, Botte MJ. Hand Infections: Treatment Recommendations for Specific Types. J Am Acad Orthop Surg 1996;4(4):219-230. PMID: 10795057
  9. Kowalski TJ, Thompson LA, Gundrum JD. Antimicrobial management of septic arthritis of the hand and wrist. Infection 2014;42(2):379-84. PMID: 24307329
  10. Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML. Approach to septic arthritis. Am Fam Physician 2011;84(6):653-60. PMID: 21916390
  11. Birman MV, Strauch RJ. Management of the septic wrist. J Hand Surg Am 2011;36(2):324-6. PMID: 21276897
  12. Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg 1983;65A:824–828. PMID: 6863365

New Articles

  1. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am 2014;39(8):1628-35. PMID: 25070032
  2. Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics 2014;34(7):1968-86. PMID: 25384296
  3. Kowalski TJ, Thompson LA, Gundrum JD. Antimicrobial management of SA of the hand and wrist. Infection 2014;42(2):379-84. PMID: 24307329

Reviews

  1. Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML. Approach to septic arthritis. Am Fam Physician 2011;84(6):653-60. PMID: 21916390
  2. Birman MV, Strauch RJ. Management of the septic wrist. J Hand Surg Am 2011;36(2):324-6. PMID: 21276897

Classics

  1. Robins RH. Infections of the hand. J Bone Joint Surg Br 1952 Nov;34-B(4):567-80. PMID: 12999946
  2. Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg 1983;65A:824–828. PMID: 6863365
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