October 31, 2016

Septic Arthritis of the Untouched Shoulder

What we typically see in these atypical cases

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By Sumit Kanwar, MD, Manisha R. Chand, MD, and Gregory Gilot, MD

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The medical literature contains no mention of septic arthritis of the untouched shoulder, yet we’ve seen several cases in our practice and believe it’s frequently missed.

Overall, the literature on septic shoulder arthritis is mostly limited to case reports or small series, and no reports have specifically focused on cases developing without any manipulation, injury, injections, arthroscopy or surgical procedures within the prior year.

Regardless of etiology, early identification of glenohumeral septic arthritis is vital to preventing morbidity and improving functional outcomes.

A typical atypical case

While the presenting symptoms of “virgin” shoulder infections may be vague and variable, in our experience a typical case is a middle-aged (average 57-61 years) male, presenting with either acute or vague anterior or posterior shoulder pain and limited range of motion, typically in the dominant arm. Elevated erythrocyte sedimentation rate (ESR) and inflammatory markers, low-grade fever and x-ray displaying degenerative joint disease are also common.

For all such cases, we recommend further workup with advanced imaging, such as ultrasound, CT or MRI. If there is anterior space joint effusion with soft tissue involvement, septic arthritis of the glenohumeral joint should be suspected.

Septic arthritis management traditionally has involved incision and drainage or needle aspiration of synovial fluid, supplemented with three to six weeks of intravenous antibiotics. However, arthroscopy may be preferred for infections in the shoulder, due to better irrigation and joint visualization. If these methods fail, open surgical drainage is necessary.

Case 1: 59-year-old male

One of our recent cases was a 59-year old disabled male who presented with a chief complaint of left shoulder pain of two weeks’ duration in the anterior, posterior and superior aspects. Although he had not had any shoulder interventions within the previous year, his past history was notable for rotator cuff repair of his other (right) shoulder.

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MRI of the right shoulder. Anterior space effusion is visible.

On examination, he had swelling, global tenderness and painful range of motion. Laboratory findings included elevated ESR and C-reactive protein levels. His MRI was highly suspicious for abscesses and osteomyelitis of the humeral head.

After we diagnosed him with septic arthritis, we performed a left incision and drainage of the abscess with an arthrotomy of the glenohumeral joint with exploration and drainage. Culture was positive for Staphylococcus aureus, which was resistant to penicillin G.

We inserted a central catheter for long-term antibiotic (ciprofloxacin and gentamicin) treatment, and he completely recovered in six weeks.

Case 2: 55-year-old male

Another case, a 55-year-old male, presented with intense, sharp, right shoulder pain of about two months’ duration, swelling and limited ROM. He reported that he felt a “pop” in his shoulder two months’ prior, following a motor vehicle accident. He had a past medical history of morbid obesity and peripheral vascular disease, and had previously undergone bilateral knee arthroscopy.

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Ultrasound of the right shoulder. Anterior space effusion is visible.

On examination, his right upper extremity had pitting edema down to the fingers.

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His preoperative laboratory results included elevated white blood cell count, ESR and CRP, and postoperative culture detected E. coli. He was treated with surgical arthrotomy and extended spectrum beta lactam antibiotics and has been stable to date.

These and other cases continue to remind us to keep an open mind for the possibility of infection in the glenohumeral joint, even when it seems to have arisen de novo.

Drs. Kanwar and Chand are research fellows in the Department of Orthopaedic Surgery at Cleveland Clinic Florida.

Dr. Gilot is Chair of the Department of Orthopaedic Surgery at Cleveland Clinic Florida.

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