Evidence-based medicineManagement of the Septic Wrist
Section snippets
The Patient
A 62-year-old woman presents to the emergency department with 2 days of increasing right wrist pain and swelling. She denies any preceding trauma. Range of motion of the right wrist is limited to a 30° arc, with pain at the extremes; the wrist is warm, swollen, and tender. Radiographs of the right wrist demonstrate no notable arthritic changes or fracture. Aspiration of the radiocarpal joint performed dorsally between the third and fourth extensor compartments with an 18-gauge needle yields 2.5
The Questions
What tests are most helpful in diagnosing a septic wrist? In the setting of a likely or confirmed septic wrist, what is the best treatment strategy?
Current Opinion
Diagnosis of a septic wrist relies heavily on the examiner's experience and level of clinical suspicion; analysis of synovial fluid is the most useful diagnostic test in arriving at the correct diagnosis. In combination with parenteral antibiotics, the treatment options for a septic wrist include one or more needle aspirations, open irrigation and debridement, and arthroscopic irrigation and debridement. Persistent infection in the joint can lead to substantial articular damage, osteomyelitis,
Diagnosis
Serum studies are considered helpful for diagnosing a septic joint, but none are definitive. A systematic review examined some of these factors and found that an abnormal serum white blood cell count, erythrocyte sedimentation rate, or C-reactive protein did little to change the pretest probability of a septic joint.1
Synovial fluid analysis is the key diagnostic test for septic arthritis. Unfortunately, the most definitive test of the joint fluid—bacterial gram stain and culture—is not
Shortcomings of the Evidence
To date, the diagnosis of the septic wrist relies on clinical acumen. Synovial fluid analysis for gram stain, culture, and crystals is the most helpful diagnostic test; the synovial WBC can provide some guidance, but the current literature suggests that it is unreliable in establishing or excluding the diagnosis.
There is inadequate evidence to determine the relative effectiveness of aspiration alone, arthroscopic debridement, and open debridement. Evidence is lacking regarding the use or
Directions for Future Research
Larger, prospective studies are needed to evaluate the role of laboratory tests in diagnosis. It is increasingly recognized that rather than all or none certainties, diagnoses such as septic wrist are inevitably probabilities. A multicenter prospective study of clinical and laboratory parameters could help develop a clinical decision rule to establish the probability of wrist sepsis in an inflamed wrist. Given the possibility that a substantial percentage of cultures might be negative in true
Our Current Concepts for This Patient
For postoperative infection, or in cases in which patients present late and the purulence has erupted through the wrist joint, we favor open surgical drainage of the clinically involved joints. Otherwise, we have been satisfied with the results of needle aspiration combined with empiric parenteral antibiotics. Needle aspiration can be performed once or as often as twice daily, as required, until joint effusion and symptoms improve. We elect surgical intervention when signs and symptoms fail to
References (13)
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How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis?
Am J Emerg Med
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Synovial fluid analysis
Best Pract Res Clin Rheumatol
(2005) Septic arthritis of the hand and wrist
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Does this adult patient have septic arthritis?
JAMA
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Acute septic arthritis: remember gonorrhea
Rheumatol Int
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Another look at synovial fluid leukocytosis and infection
J Clin Rheumatol
(2002)
Cited by (14)
Evaluation of predictive factors of septic wrist to avoid overdiagnosis
2024, Journal of Plastic, Reconstructive and Aesthetic SurgeryContribution of arthroscopy in case of septic appearance arthritis of the wrist: A nine cases series
2013, Chirurgie de la MainCitation Excerpt :In clinical practice, it is not such an easy matter to correctly diagnose a septic arthritis in an emergency situation, since many acute arthritides of chronic inflammatory or degenerative rheumatisms mimic septic arthritis: gout, chondrocalcinosis or osteoarthritis. As joint puncture is mostly non-contributive [21] and arthrotomy often leaves after-effects, surgical indication is difficult to establish. Furthermore, it is difficult to justify an arthrotomy for suspected septic arthritis without any bacteriological evidence.
Arthroscopic Treatment for Septic Arthritis
2012, Operative Techniques: Hand and Wrist Surgery, Second EditionSeptic arthritis of the wrist: a retrospective review of 39 cases
2022, Journal of Hand Surgery: European VolumeReconstruction of Carpal Bone Loss of Septic Wrist Arthritis Using Induced Membrane Technique
2020, Journal of Hand and Microsurgery
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