Working Diagnosis:
Septic Arthritis of the Shoulder

Treatment:
An urgent incision and drainage (I&D) of the shoulder joint with Orthopedic Surgery was performed on the same day of the joint aspiration. Infectious Disease was consulted and recommended IV Daptomycin for 4 weeks. He was able to start physical therapy one week post op. Follow up shoulder x-rays showed some bony erosion of his humeral head Case Photo #4 when compared to his initial x-ray Case Photo #1 . As the patient is clinically back to normal and participating in full baseball practice with no issues, we plan to continue to follow clinically and obtain an MRI if any concerns arise.

Outcome:
The patient is back to full function and participation in sports.

Author's Comments:
Septic arthritis is a limb and life threatening issue. If not treated emergently it can cause long term effects. Septic arthritis most commonly occurs in lower extremities, but the shoulder is involved in about 5-12% of all cases with 3-5% of cases involving pediatrics. Joint infections can stem from bacteremia, direct inoculation, or contiguous spread. An untreated hemarthrosis can lead to infection as blood creates a good medium for bacterial growth. This is what we think happened with our patient and we suspect the abrasion on the elbow was the entry point for bacteria. Diagnosis requires aspiration of joint fluid with WBC over 50,000 and obtaining a culture, with the most common pathogen grown being staph aureus. Treatment is with emergent surgical I&D with directed IV antibiotics for 3-6 weeks, with transition to oral antibiotics as indicated. Delayed treatment can lead to osteomyelitis, damaged cartilage and in the pediatric population, physeal arrest and subluxation of the shoulder.

Editor's Comments:
Septic arthritis of the shoulder can cause damage to the glenohumeral joint resulting in pain, instability, and reduced level of function. Clinicians should have a high index of suspicion in a patient with fever and an effusion as delayed diagnosis can have devastating consequences.

References:
1. Scarfone R, Steele R. Pediatric Septic Arthritis: Practice Essentials, Etiology, Epidemiology. eMedicine. Published online August 1, 2023. Accessed April 13, 2024. https://emedicine.medscape.com/article/970365-overview?form=fpf#a6
2. Azhar AA, Jamil K, Rasid AFA, Azhar AA, Jamil K, Rasid AFA. Shoulder Septic Arthritis in a Child: A Diagnostic Dilemma. Cureus. 2023;15(8). doi:https://doi.org/10.7759/cureus.42986
3. Walker JW, Hennrikus WL. Septic Arthritis of the Pediatric Shoulder: From Infancy to Adolescence. International Journal of Pediatrics. 2016;2016:1-4. doi:https://doi.org/10.1155/2016/3086019
4. Sheth U, Moore D. Septic Arthritis - Adult - Trauma - Orthobullets. www.orthobullets.com. Published November 29, 2022. https://www.orthobullets.com/trauma/1058/septic-arthritis--adult
5. Bois AJ, Gabig AM, Griffin LP, Rockwood CA, Brady CI, Dutta AK. The evaluation, classification, and management of septic arthritis of the shoulder: the comprehensive shoulder sepsis system. Journal of shoulder and elbow surgery. 2023;32(12):2453-2466. doi:https://doi.org/10.1016/j.jse.2023.05.019
6. Salazar LM, Gutierrez-Naranjo JM, Meza C, et al. Joint aspiration and serum markers - do they matter in the diagnosis of native shoulder sepsis? A systematic review. BMC Musculoskeletal Disorders. 2022;23(1). doi:https://doi.org/10.1186/s12891-022-05385-8
7. Maguire KJ, Otsuka NY. Septic shoulder presenting as a shoulder dislocation in the pediatric patient: a case report. Journal of Pediatric Orthopaedics B. 2017;26(3):270-273. doi:https://doi.org/10.1097/bpb.0000000000000383

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