Pseudo paralysis of the shoulder and increased C-reactive protein are predictive factors for septic shoulder in children superior to other clinical symptoms: A retrospective case series of 25 patients

Abstract

Purpose The aim of the study was to evaluate predictable parameters with the highest sensitivity used in the diagnosis of children septic shoulder arthritis. Methods All children treated in our paediatric orthopaedic hospital between 2000 and 2017 with intraoperative verified septic arthritis of the shoulder were included in this retrospective study. Diagnostic procedures e.g. ultrasound, MRI, radiograph or blood samples as well as typical clinical symptoms were evaluated as predictable parameters for septic shoulder arthritis in paediatric patients. Descriptive statistics as well as sensitivity analysis were performed. Results In all, 25 children, 20 boys and five girls, aged from eight days to 15 years, were included for further statistical analysis. All parameters included were tested for sensitivity with binomial confidence intervals (Cis) of 95%. Predictive parameters with highest sensitivity were pseudo paralysis (100%, CI 0.86 to 1.00) and C-reactive protein (CRP) (96%, CI 0.79 to 0.99) superior to temperature (52%, CI 0.3 to 0.73), white blood count (11%, CI 0.01 to 0.34), radiograph (21%, CI 0.04 to 0.50), ultrasound (71%, CI 0.47 to 0.88) or MRI (100%, CI 0.78 to 1.00). Conclusion The diagnosis of a septic arthritis of the shoulder in children can be challenging for the clinician and especially for the resident doctor. Clinical symptoms such as pseudo paralysis and increased CRP level must be considered as predictive markers not to delay further diagnostics and treatment. Level of Evidence IV

Descriptive Epidemiology of Upper Extremity Septic Arthritis in Children—Review of a Retrospective Multicenter Database

“…Schmidt et al 14 described septic arthritis of the shoulder as a “disease of infancy,” as 8 of the 9 patients in their series were under 18 months of age. Similarly, Danilov et al 6 evaluated 25 patients with septic arthritis of the shoulder and half of their cohort was between 4 weeks and 3 years of age, which is consistent with our findings. It is unclear why infants and very young children are more susceptible to septic arthritis of the shoulder.…”

“…It is unclear why infants and very young children are more susceptible to septic arthritis of the shoulder. Interestingly, two-thirds of the intraoperative cultures in Danilov et al ’s6 series were negative. Of the patients who had positive cultures, Staphylococcus aureus and group B Beta-hemolytic Streptococcus were the most common.…”

“…While there are numerous studies investigating pediatric septic hip and knee arthritis, only a few small single-center case series and case reports have been conducted on pediatric UESA. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] As UESA is much less common than septic hip and knee arthritis, it is important for treating clinicians to maintain a high index of suspicion and include septic arthritis in the differential when patients present with joint symptoms, such as pain with motion, decreased range of motion, swelling, and erythema. UESA can also occur in newborns and infants, who are unable to provide a history and are less capable of active participation in the physical exam.…”

“…Upper extremity septic arthritis (UESA) is uncommon in children, and there is a lack of published data on the characteristics, diagnostic findings, and management. While there are numerous studies investigating pediatric septic hip and knee arthritis, only a few small single-center case series and case reports have been conducted on pediatric UESA 1–14. As UESA is much less common than septic hip and knee arthritis, it is important for treating clinicians to maintain a high index of suspicion and include septic arthritis in the differential when patients present with joint symptoms, such as pain with motion, decreased range of motion, swelling, and erythema.…”

Atypical Salmonella Septic Arthritis of the Shoulder in a Youth Athlete

“…This initiated further evaluation with serologic studies which revealed elevated inflammatory markers leading to prompt advanced imaging and surgical intervention. A recent retrospective case series by Danilov et al ( 9) examined predictive factors for the diagnosis of septic arthritis in pediatric patients and found the two most reliable factors to be pseudo paralysis and elevated CRP, both of which were present in our patient and support this algorithm of evaluation (9). Other studies found similar findings with patients often having joint pain, fever, and elevated inflammatory markers (10,11).…”