John D. Jennings, MD; Asif M. Ilyas, MD

Disclosures

J Am Acad Orthop Surg. 2018;26(4):109-115. 

In This Article

Abstract and Introduction

Abstract

Septic arthritis of the wrist is an uncommon condition, but one that can result in substantial morbidity. Timely identification and treatment is critical to patient care. No serum laboratory values have been shown to consistently confirm wrist joint infection. Thus, diagnosis is made based mainly on a thorough patient history, physical examination, and joint aspiration. When infection is suspected, aspiration of the wrist should be performed to confirm the diagnosis. Broad-spectrum antibiotics and joint aspiration or surgery are required to manage the infection and prevent sequelae.

Introduction

Septic arthritis of the wrist is a rare but serious clinical entity that is typically defined by an infection within the radiocarpal joint; however, it can also include infections in the midcarpal and distal radioulnar joints.[1] In patients with severe infection or delayed presentation, the infection may extend into the carpal tunnel or deep soft tissues after exiting the wrist joint[1,2] (Figure 1). Thus, symptoms may vary depending on the location and timing of presentation. Although this joint-threatening condition has been described for nearly a century, few prospective trials are available to guide diagnosis and treatment because of the relative rarity of true septic arthritis in the wrist.

Figure 1.

Clinical photograph demonstrating a case of a neglected septic arthritis of the wrist with extension of the infection out of the joint and into the snuffbox region of the wrist, resulting in a sinus that was initially assumed to be a superficial abscess.

Joint infection typically occurs because of direct inoculation by puncture or trauma, hematogenous spread from another site of infection, or contiguous spread from adjacent tissue.[3,4] After the organism is seeded, a reactive inflammatory process triggers the release of both cytokines and proteases, which ultimately cause cartilage destruction.[4]

For any infected joint left untreated, serious negative sequelae such as cartilage destruction and chondrolysis may begin as early as 8 hours after infection and can result in permanent joint dysfunction[5,6] (Figure 2). Further consequences, such as contiguous spread to the subchondral bone with resultant osteomyelitis, sinus formation, and even systemic sepsis, can result in cases of neglected septic arthritis.[7]

Figure 2.

AP (A) and lateral (B) radiographs of the wrist demonstrating substantial radiocarpal destruction and chondrolysis from prolonged joint space infection.

Septic arthritis of the wrist often presents with a warm, erythematous, painful wrist without antecedent trauma[3] (Figure 3). Other conditions that mimic this presentation in the differential diagnosis include crystalline arthropathy, tenosynovitis, subcutaneous abscess, osteoarthritis, and cellulitis. Septic arthritis of the wrist is the most serious joint-threatening condition in the differential diagnosis.[8,9]

Figure 3.

Clinical photograph demonstrating typical presentation of septic arthritis of the wrist, including a swollen, warm, erythematous, and painful wrist without antecedent trauma.

The true incidence of septic arthritis of the wrist is not well established.[9,10] In limited series, Mehta et al[10] reported that 23% of upper extremity joint infections occur in the wrist, although Skeete et al[9] reported only a 5% overall incidence. Similarly, a large study by Yap and Tay[11] confirmed only 40 cases of septic arthritis of the wrist over an 11-year period. Thus, although the incidence of septic arthritis of the wrist is not established, the diagnosis can be assumed to be uncommon. However, because of the high morbidity of permanent wrist dysfunction, vigilant diagnosis and treatment is indicated in patients with suspected wrist joint infection.

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