This article is more than 5 years old. Information may no longer be current.
Fever, elevated serum white blood cell count associated with septic wrist
Click Here to Manage Email Alerts
Recently published results showed fever and an elevated serum white blood cell count were associated with the diagnosis of septic arthritis of the wrist.
John D. Jennings, MD, and colleagues retrospectively reviewed 892 patients who presented with a swollen, painful wrist without trauma during a 10-year period. Researchers examined patient records for their history, as well as demographic and laboratory data for those who had a joint fluid analysis that included cell count, gram stain and cultures.
Results showed septic arthritis of the wrist in 1.5% of patients and 18% of wrists with a joint fluid analysis. Researchers found a serum white blood cell count greater than 11,000/μL, fever within 24 hours of aspiration, history of intravenous drug abuse and smoking positively predicted a diagnosis of septic arthritis. While no joint cell count analysis predicted septic arthritis, researchers noted an elevated joint white blood cell count of more than 97,000/μL was found in patients with septic wrist.
According to results, methicillin-resistant Staphylococcus aureus was the most frequently cultured organism among patients with septic arthritis. Among patients with negative cultures or clinical examination, researchers noted 23.6% had crystalline arthropathy; 18% had cellulitis; 18% had arthralgia; 12.5% had subcutaneous abscess; and 9.7% had flexor and extensor tenosynovitis. – by Casey Tingle
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to Top
David C. Ring, MD, PhD
Recent studies confirm that a spontaneous septic wrist is uncommon — about one patient a year in a busy urban referral hospital’s emergency department. This too few patients to learn much from. The thing I found most interesting about this cohort is the high rate of methicillin-resistant Staphylococcus aureus (MRSA) in cultures.
It is difficult to learn much about diagnosis from this cohort. The reference standard (positive culture or gram stain) is subject to both false positives and false negatives. The prevalence of a diagnosis of infection among suspected infections is extremely low (1.5%), which accentuates the shortcomings of diagnostic tests (read about Bayes’ adjusted positive and negative predictive values if you are interested).
This creates a difficult situation and raises more questions than answers. For one painful “hot” wrist we need to think about infection, but infection is uncommon and a positive test will have a low positive predictive value (relatively strong influence of false positives). Because septic wrist is uncommon, it is difficult to get enough patients to develop a probability calculator (clinical prediction rule). The possibility of using a large database occurs to me, but these are usually claims databases that would not have adequate clinical information to develop a probability calculator.
Keeping in mind that there is reasonable evidence for serial aspiration and antibiotics as an alternative to surgery, suspected infections could be aspirated, cultured and treated with antibiotics, saving surgery for those who clearly do not respond. Weighting toward nonoperative treatment would limit unnecessary surgery. Since most people with a potentially infected wrist do not have an infection, a shared decision might be made between initial close observation off antibiotics vs. aspiration and empirical treatment when the situation is unclear.
Read more about
Click Here to Manage Email Alerts