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Suspected septic arthritis following intra-articular corticosteroid injection — MSRA MCQ

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HardShoulder InjuriesSuspected septic arthritis following intra-articular corticosteroid injectionMSRA

A 63-year-old woman presents to your GP surgery 4 days after an ultrasound-guided intra-articular glenohumeral injection of methylprednisolone for symptomatic shoulder osteoarthritis. She has type 2 diabetes treated with metformin. The injection initially reduced her pain for about 18 hours, but she has since developed rapidly worsening deep shoulder pain, feels shivery and is unable to dress independently. Her temperature is 38.2°C and pulse is 104 beats/minute. The shoulder is diffusely warm with mild erythema. Active elevation is 15 degrees and passive abduction is limited to 30 degrees by severe pain. There is no recent trauma, deformity or focal neurological deficit. Distal perfusion and sensation are normal. What is the most appropriate management now?

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Correct answer: B — Arrange same-day emergency-department assessment for suspected septic arthritis

This presentation should be managed as suspected septic arthritis. The decisive features are rapid deterioration after an intra-articular corticosteroid injection, systemic features (fever, shivering and tachycardia), local inflammation, and profound restriction of passive as well as active movement. Passive restriction makes isolated rotator-cuff pathology or pain-limited weakness less likely. The Depo-Medrone SmPC specifically identifies marked pain escalation with swelling, further movement restriction, fever and malaise after intra-articular injection as suggestive of septic arthritis. This requires urgent hospital assessment, where joint aspiration/drainage and intravenous antimicrobial treatment can be arranged. A post-injection flare may cause transient pain but does not satisfactorily account for fever, systemic upset and progressive passive restriction. Oral flucloxacillin with community follow-up risks delaying diagnostic aspiration and definitive treatment. Ultrasound may identify an effusion but must not delay emergency assessment. Blood tests and blood cultures may contribute to hospital assessment, but normal inflammatory markers early in infection would not safely exclude septic arthritis and should not determine whether referral occurs.

Reference: Depo-Medrone 40mg/ml Suspension for Injection - Summary of Product Characteristics (Last updated 16 March 2026) — https://www.medicines.org.uk/emc/product/8957/smpc Septic arthritis (Last reviewed 23 March 2023) — https://www.nhs.uk/conditions/septic-arthritis/ Shoulder - DGRefHelp (Accessed 15 August 2026) — https://www.rightdecisions.scot.nhs.uk/dgrefhelp-nhs-dumfries-galloway/musculoskeletal-system/shoulder/