Review Question - QID 5039

Septic arthritis is an orthopedic emergency that requires prompt drainage followed by IV antibiotics.

This patient is presenting with exam and laboratory findings concerning for septic glenohumeral arthritis. Methods of joint drainage in children include aspiration; arthroscopic irrigation and debridement; and open irrigation and debridement with formal arthrotomy. The arthroscopic technique allows for inspection and thorough debridement without the morbidity of an open procedure. Importantly, septic arthritis may progress to osteomyelitis and bony destruction. Therefore, imaging should be carefully reviewed for evidence of bony lysis, osteonecrosis, sequestra (necrotic bone), and involucra (new bone formation around bony necrosis).

Losses et al. reviewed glenohumeral septic arthritis in their 1998 report of 11 cases, which included 5 children. The authors note children commonly present with swelling, shoulder pain, limited motion, and irritability. Advanced imaging was not available, but radiographs were normal in four cases with destructive joint changes identified in the fifth. Predisposing disease was present in three cases and included Group B Streptococcus sepsis, Salmonella sepsis, and Klebsiella pneumonia sepsis. The authors report poor clinical outcomes in pediatric patients who had undergone open surgical debridement and suggest closed aspiration when needed in this population. They conclude that patients can be expected to improve with no serious long-term effects if treated with prompt antibiotic therapy and drainage of the shoulder.

Smith et al. performed a prospective randomized study on aspiration versus arthrotomy and washout in 61 children with septic arthritis of the shoulder. They note the method of drainage is controversial in the pediatric population. The authors found no significant difference in outcomes between the two methods and conclude both aspiration and arthrotomy with washout are effective methods of drainage in children with septic arthritis of the shoulder.

Forward et al. described an arthroscopic technique for washout of the shoulder in infants with septic arthritis. The authors note aspiration may be inadequate for complete drainage and suggest the use of an arthroscopic technique, which avoids the morbidity of a formal arthrotomy. After initial aspiration, a 30° wrist arthroscope is inserted via a posterior portal and used to perform a washout under direct visualization. Complete clearance of pus allows for assessment of inflammation and articular surface damage. Full recovery was achieved after a single intervention in all three patients.

Figure A is an AP radiograph of a skeletally immature patient without evidence of acute osseous abnormality, physeal disruption, or bony erosion. Figures B and C are coronal and axial MRI images demonstrating an effusion of the glenohumeral joint with surrounding soft tissue edema and normal-appearing ossification centers without evidence of osteomyelitis. Illustration A shows purulence and synovitis during an arthroscopic washout of the same patient. Illustration B depicts a sequestrum (E) and an involucrum (C).

Incorrect Answers
Answers 1, 2 & 3: Septic arthritis treatment in children requires either drainage, arthroscopic I&D, or open I&D; in addition to admission, close observation, and close follow-up. In patients who are not systemically ill initiation of IV antibiotics should be delayed until cultures are obtained.
Answer 4: Open irrigation is an alternative to the arthroscopic technique, although variable outcomes have been reported in the pediatric population. Debridement of the epiphysis is not indicated in this patient.