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Suspected septic arthritis of the shoulder — MSRA MCQ

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HardShoulder InjuriesSuspected septic arthritis of the shoulderMSRA

A 54-year-old man attends your GP surgery with worsening left shoulder pain. Twelve days ago, he fell onto the shoulder while gardening. Emergency-department radiographs showed no fracture or dislocation, and his pain initially improved with ibuprofen. For the past 48 hours, however, he has developed rapidly escalating pain at rest, marked restriction of both active and passive movement, and feels feverish. He has rheumatoid arthritis treated with adalimumab and methotrexate. Temperature is 37.9°C. The shoulder is diffusely swollen, warm and erythematous. There is no focal acromioclavicular-joint tenderness, no glenohumeral deformity, and distal pulses, power and sensation are normal. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Refer to the emergency department the same day for suspected septic arthritis

Explanation lettering: B = shown as A · D = shown as B · E = shown as D · A = shown as E

This presentation requires same-day emergency assessment for suspected septic arthritis. Although there was preceding trauma and initially normal radiographs, the important change is rapidly progressive pain at rest with a hot, swollen, erythematous joint and marked limitation of passive as well as active movement. His treatment with adalimumab and methotrexate further increases concern for serious infection and may blunt the febrile response. The absence of deformity and a normal distal neurovascular examination make unreduced dislocation and acute vascular injury less likely. A is inappropriate because imaging must not delay urgent assessment for a possible joint infection; definitive investigation may include aspiration in secondary care. B is insufficient: suspected septic arthritis requires hospital assessment, with treatment commonly involving intravenous antibiotics and drainage after appropriate diagnostic sampling. C is contraindicated because corticosteroid injection could worsen an unrecognised joint infection. E would be reasonable for uncomplicated soft-tissue injury but not for a red, hot shoulder with systemic symptoms and severe passive restriction.

Reference: Shoulder | DGRefHelp, NHS Dumfries and Galloway (Published 2024) — https://www.rightdecisions.scot.nhs.uk/dg-refhelp/musculoskeletal-system/shoulder/ Septic arthritis | NHS (Page last reviewed 2023) — https://www.nhs.uk/conditions/septic-arthritis/