hx of gout, red swollen ankle--when do u tap?

[Painter1]

considering a septic joint is an orthopedic emergency i reckon we need to have a low treshold; but in a patient with a hx of gout and a new painful swollen joint, when do u tap to look for a co-morbid infection?

50-something-year-old in signficant pain over right ankle, tender and swollen. can u range the joint? in my limited experience, in patients who ended up just having gout, there joints were equally painful to range compared to septic ones. anyway, hard to range his ankle from pain. no fever, no chills. mild white out 12,000 with shift. esr 30.

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[Hercules]

considering a septic joint is an orthopedic emergency i reckon we need to have a low treshold; but in a patient with a hx of gout and a new painful swollen joint, when do u tap to look for a co-morbid infection?

50-something-year-old in signficant pain over right ankle, tender and swollen. can u range the joint? in my limited experience, in patients who ended up just having gout, there joints were equally painful to range compared to septic ones. anyway, hard to range his ankle from pain. no fever, no chills. mild white out 12,000 with shift. esr 30.

Sometimes it's gut. I would assume that if you got an ESR and white count there was something else bothering you, as I wouldn't draw labs on what I thought was just gout.

 

[DrQuinn]

Eh, history of gout, wouldn't worry too much unless fever or other cause for concern for septic arthritis (RA, indwelling catheter, PICC line, whatever other source for hematogenous spread). Unsure if I would go by ESR, wouldn't gout bring that up?

Hard party is little old ladies with no history of gout, red hot wrist, but no risk factors for septic arthritis....
Q

 

[GiJoe]

if febrile, i tx as septic joint. when in doubt, tap. your ortho colleges will appreciate you did. if neg, or equivocal result, d/w ortho either way because many septic joints will have a near normal tap. I have sent some home with close ortho fu the next day after a dose of abx in the ED.

 

[DrQuinn]

THanks for your input, Tired. Much appreciated.

I had an old lady, warm left wrist, on coumadin (though this is not a reason NOT to tap, per R&H), no hx of gout. I XR'd her (to buy some time), gave her some perkies, and some nsaids, and talked to two other ER docs in the other side.... neither would have tapped. I tried tapping a wrist once in an old lady, similar situation, a few months ago, couldnt' get the tap. Landmarks were hard to appreciate from the swelling. Anyways, I DC'd her, f/u with ortho in AM, and they tapped her, was gout (In an old lady with no hx of gout), but still made me nervous. I was just surprised that the two other ER docs wouldn't have even tried to tap her wrist. Ankles, sure. Elbows, maybe, knees, no problem. Wrists I think are one of those that we just don't do.

And our ortho guys only want to be called if they're going to the OR witha broken hip.

Q

 

[txterp98]

Tired, to echo Quinn's comments, thanks for the input....good stuff and well-appreciated. Also appreciated the understanding of the ER's limitations on not having a microscope and slide readily available. You're dead on the money....the lab won't do anything with the couple of drops in the needle (which sucks for us, ortho consultants, and the patient).

Back in residency, with ortho residents around 24/7, these people did get a consult and waited until the resident became available for consultation. In private practice, though, it really is highly dependent. Banker's hours of 9-5 might get the ortho consultant to the ER to do the tap themselves or they still may have us do it and we'll call them back. Later in the night, though, I won't call until having done (or at least attempted) the tap. In addition, I'll have the WBC count and ESR result to discuss. I know they're of limited usefulness of distinguishing a septic vs crystal arthropathy, but it's always appreciated from the ortho consultant on the other end of the phone. From there, if there's anything equivocal, if my clinical suspicion is high, we'll admit the patient to their service for consult in the morning. If my clinical suspicion is low, I'll DC them from the ER for follow-up in the office the next morning/afternoon.

Is it right? Well, I'm unfortunately not saying it is. But, in my experience, academics and private medicine don't always match up. And as for how I risk stratify low vs. high suspicion....well, I can't say I have a good decision making tree. Pretty much history, risk factors, physical exam, and gestalt.

Life in the fishbowl is what it is.

Thanks again for your posts.

 

[sanchito45]

(removed at authors request)

 

[DrQuinn]

Aren't you supposed to avoid tapping when the overlying skin is erythematous due to the risk of introducing sepsis? That's always confused me. If you're worried about a septic joint you should tap, but the overlying skin will probably be erythematous, in which case you shouldn't tap...

I think its less erythema but more concern for cellulitis. You're correct, most septic joints are red and warm, but there's a difference I think clinically. That being said I've only seen a handful of septic joints (thought eh last one I saw, last week, was an infected DIP of a finger).
Q

 

[Painter1]

so in general, with no hx of gout, after doing some reading it seems that esr is not sufficient to r/o septic joint but time and time again ortho wants the esr and make decisions on whether to tap based on it. where are they getting there data to justify this? also, i couldn't find any research backing up that "if you can range the joint, then there is no septic joint". frustating.