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especially in the setting of gonococcal disease. Gram stain

is positive in approximately 60-80% of cases on

nongonococcal septic arthritis. Synovial crystals s uggest a

Table 94-1. Synovial fluid findings based on condition.

Normal Inflammatory Septic

Synovial <25,000 >1 100/j.!l if

WBC prosthetic

>25,000/j.!l;

LR 3.2

>50,000/j.!l;

LR 4.7

>100,000/j.!l;

LR 1 3.2

Synovial <5.6 mmoi/L <5.6 mmoljl >5.6 mmoljl

lactate

Synovial LDH <250 U/l <250 U/l >250 U/l

Culture Negative Negative >50% Positive

LDH, lactate dehydrogenase; LR, likeli hood ratio.

Adapted from Genes N, Chisolm-Stra ker M. Monoarticu lar arthritis

u pdate: current evidence for diag nosis and treatment in the

emergency department. Emerg Med Proct. 201 2 May; 1 4(5):1-1 9.

crystal-induced arthritis; however, a septic joint can be

present in a patient with gout or pseudogout.

� Imaging

Radiographs have a limited role in the diagnosis of septic

arthritis and are typically performed to exclude other

disease processes.

PROCEDURES

� Arthrocentesis

Once the area is cleansed with Betadine or chlorhexidine

and anesthetized via local infiltration, an 18-gauge needle

(for large joints) or 20- to 25-gauge needle (for smaller

joints) is used to puncture and then aspirate the joint

space. General principles to performing successful

arthrocentesis include always inserting the needle over the

extensor surface, applying approximately 20 degrees of

joint flexion, and using slight distraction of the joint.

Prosthetic joints benefit from orthopedic consultation

before arthrocentesis. Hip arthrocentesis is associated with

a high rate of complication and ultrasound or fluoroscopic

guidance is useful. Overlying cellulitis and coagulopathy

are relative contraindications to performing arthrocentesis.

MEDICAL DECISION MAKING

Table 94-2 includes a differential for the presentation of

patients with joint pain. If a clinician suspects a septic

joint, then an arthrocentesis should be performed with labs

sent for synovial WBCs, LDH, lactate, crystals, Gram stain,

and culture. Based on the results of these fmdings,

appropriate disposition can be determined (Figure 94-1).

CHAPTER 94

Table 94-2. Differentia l diag nosis for acute joint pain

and swel ling.

Number of joints

Monarticular

Polyarticular

Differential Diagnosis

Septic arthritis

Crystal induced (gout, pseudogout)

Osteoarthritis

Lyme disease

Avascular necrosis

Tumor

Lyme disease

Reactive arthritis

Gonococcal septic arthritis

Rheumatic fever

Rheumatoid arthritis

Systemic lupus erythematosus

Osteoarthritis

Ankylosing spondylitis

Ada pted from B u rton JH. Chap. 281 . Acute Disorders of the

joi nts and Bursae. In: Tintina lli JE, Sta pczynski J S, Ma OJ, Cline

OM, Cyd ulka RK, Meckler GO. Tintina/lis Emergency Medicine:

A Comprehensive Study Guide . 7th ed. New York: McGraw-Hill,

201 1.

TREATMENT

Emergency physicians must combine the clinical presentation

with the synovial fluid results to determine whether the

patient should be treated for a septic arthritis. Treatment

includes administering intravenous antibiotics and providing adequate analgesia. There are no randomized controlled

trials for antibiotic selection; therefore, choice of antibiotic is

based on the suspected pathogen. Vancomycin should be

given if Staphylococcus is suspected, especially with the r ising

prevalence of methicillin-resistant S. aureus. Additional

treatment with ceftriaxone is suggested, especially in the setting of presumed gonococcal arthritis. Consultation with an

orthopedic surgeon should also be obtained for consideration of open irrigation in the operating room.

DISPOSITION

� Admission

Patients who are presumed to have a septic joint based on

presentation and laboratory evaluation should be admitted

to the hospital for intravenous antibiotics and possible open

irrigation. For patients with an undetermined cause and

continued pain, consider possible admission or orthopedic

consultation to monitor the cultures and symptoms.

Acute onset of joint pain and swelling

Figure 94-1. Septic arthritis diag nostic algorithm.

SEPTIC ARTHRITIS

� Discharge

Patients who are felt not to be suffering from septic

arthritis can be treated with pain control and follow-up

with an orthopedist, rheumatologist, or their primary

care provider based on the suspected etiology of the joint

pain.

SUGGESTED READING

Burton JH. Acute disorders of the joints and bursae. In: Tintinalli

JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20 11, pp. 1926-1933.

Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence

based diagnostics: Adult septic arthritis. Acad Emerg Med.

20 1 1; 1 8:782-796.

Coakley G, et al. BSR & BHPR, BOA, RCPG and BSAC guide ­

lines for the management of the hot swollen joint in adults.

Rheumatology. 2006;45:1039-1041.

Genes N, Chisolm-Straker M. Monoarticular arthritis update:

current evidence for diagnosis and treatment in the emergency department. Emerg Med Pract. 20 12;14: 1-19.

Splinting

Scott C. Sherman, MD

Key Points

• Splinting a fracture is useful to permit heal ing, relieve

pain, and stabil ize bony fragments.

• In acute i njuries, splints are preferable to circumferential casts to limit the potential for iatrogenic compartment syndrome.

INDICATIONS

Fracture immobilization is extremely important to ensure

proper healing, relieve pain, and stabilize bony fragments. Most

acute injuries in the emergency department (ED) are immobiIized with the use of splints (instead of casts) to prevent the

consequent swelling from inducing a significant increase in

tissue pressures. Of note, not all fractures require splinting, and

in some situations, prolonged immobilization can lead to contracture formation and the long-term loss of function. In most

cases, the extremity is placed in the position of function before

immobilization (Table 95-1). The joints immediately distal

Table 95-1. Proper joint position for immobil ization

after most injuries.

Hand DIP and PIP 5-1 oo flexion

MCP 6G-90° flexion

Wrist 2G-30° extension

Elbow 90° flexion

Shoulder Adducted and internally rotated

Knee 20-30° flexion

Ankle Neutral position (90°)

DIP, distal interpha langeal; MCP, metacarpophala ngeal; PIP, proximal

interphalangeal.

• The position of immobil ization is important to facil itate

proper healing and limit secondary joint stiffness.

• Always maintain a low threshold for splint appl ication in

situations with strong clinical concern but normal radiographs, as some fractures may be occult on initial imaging.

and proximal to the fracture should be included in the splint

to ensure proper stabilization of the injury.

Splints are indicated for the majority of extremity fractures

and certain soft tissue injuries such as reduced joint dislocations (Table 95-2). Splint placement is also warranted when

Table 95-2. Recommended method of immobil ization

for com mon fractures seen in the ED.

Phalanges

Metacarpals

Injury

Scaphoid (confirmed or

suspected)

Distal radius fracture

Method of Immobilization

Finger or thumb splint

Gutter or dorsal "clam digger" splint

Thumb spica splint

Sugar-tong splint

Elbow fractures Long arm posterior splint

Humeral shaft fracture Coaptation splint

Proximal humerus fractures Sling

Clavicle fracture Sling

Patella and tibial plateau Long leg splint or knee immobilizer

fractures

Tibia shaft fracture Long leg splint

Ankle and foot fractures Short leg splint

41 4

there is clinical evidence for a fracture despite equivocal or

negative plain radiographs. In some cases, fractures that are

not visible on the initial radiographs may become visible on

repeat imaging performed several days to weeks later.

� Splints

Posterior Leg Splint

This splint extends along the posterior aspect of the leg

from the toes to just below the knee (short leg) or to the

middle of the thigh (long leg) (Figure 95- 1). Fractures at

the knee (ie, tibial plateau) require the placement of a long

leg splint, whereas fractures of the ankle require only a

short leg splint. Apply an additional U-shaped splint ("stirrup") for particularly unstable ankle fractures ( eg, bimalleolar fracture). It should extend from the area just below

the knee on the medial aspect of the leg, around the heel,

to the same position on the lateral aspect of the leg.

Coaptation Splint

The coaptation splint is the preferred splint for fractures of

the humeral shaft. This splint extends from above the

A B

Figure 95-1 . Lower extremity splints. A. Short leg

posterior splint with U-shaped splint for additional support. B. Long leg splint. Reprinted with permission

from Simon RR, Sherman SC. Splints, Casts, and Other

Techniq ues. In: Simon RR, Sherman SC, eds. Emergency

Orthopedics. 6th ed. New York: McGraw-Hill, 201 1.

SPLINTING

shoulder joint down the lateral aspect of the arm, around

the elbow, and then up the medial aspect of the arm to the

axilla (Figure 95-2A). The weight of the splint applies

gentle continuous traction to the fractured humerus to aid

proper reduction and healing.

Sugar-Tong Splint

This splint is so named because it resembles the shape of

the tongs used to grab a cube of sugar for coffee or tea.

With the elbow positioned at 90 degrees of flexion, this

splint extends from the dorsal aspect of the hand at the

metacarpophalangeal (MCP) joints, around the elbow, to

the flexor crease of the palm (Figure 95-2B). The sugartong splint is useful for both distal radius fractures and

fractures of the radial and ulnar shafts.

Long Arm Posterior Splint

The long arm posterior splint extends along the ulnar

aspect of the forearm from the palmar crease to the middle

portion of the upper arm and functions to immobilize the

wrist and elbow (Figure 95-2C). It is used for both forearm

fractures and injuries to the elbow.

Gutter Splint (Radial And Ulnar)

These splints are positioned on either the radial or ulnar portion of the hand and forearm and extend two thirds of the way

up the forearm (Figure 95-2D). Both splints include the fingers (fourth and fifth digits for an ulnar gutter, second and

third digits for a radial gutter). For the radial gutter splint, a

hole is cut out for the thumb. These splints are useful for fractures of the metacarpals and phalanges of digits 2 through 5.

Dorsai "Ciam Digger" Splint

This splint is applied to the dorsal aspect of the hand and

forearm and extends the length of the digits (Figure

95-2E). The hand is cupped in such a way that when the

splint is applied, patients appear like they could go "digging

for clams on the beach." The hand is kept in the "wine glass

position;' with care to ensure that the MCP joints are

immobilized between 60 and 90 degrees of flexion. This

splint is useful in cases of multiple hand bone fractures

that a gutter splint cannot properly immobilize.

Thumb And Thumb Spica Splints

A thumb splint extends from the distal aspect of the first

digit to two thirds of the way up the forearm and is used to

immobilize the thumb. This splint is useful for thumb

fractures and injuries to the ulnar collateral ligament of the

first MCP (gamekeeper's thumb). A thumb spica splint is

similar but includes the addition of a volar splint that

extends from the palmar crease to two thirds of the way up

the forearm. Further extending this volar splint beyond the

elbow to the mid-upper arm ensures full immobilization

of the thumb, wrist, and elbow. This splint is used to

immobilize fractures of the scaphoid as it prevents both

pronation and supination of the forearm (Figure 95-2F).

CHAPTER 95