Orthopedic Logbook re-examines patient when he is in doubt!

in Education/Medicine/Training by

“I think it’s Septic Arthritis.”

Twenty six years old male farmer with a history of fall from level ground, landing on his buttocks, able to stand up and walk immediately after without pain. The next day he felt excruciating pain in his swollen left hip, was unable to move his L thigh nor ambulate. He was brought to a bone setter who “massage” his L thigh but patient wasn’t relieved of the pain at all. In severe pain and febrile the next day, he was brought to the hospital immediately.

“It looks like septic arthritis to me.”

He was referred to a surgeon instead, who took x-rays and showed a less than 5% compression deformity of L5 . His differential count showed leucocytosis with lymphocytic predominance. He was started on Cefuroxime IV and pain meds. Four days after patient still has fever spikes and increasing trend of leucocytosis with lymphocytic predominance. Unable to move his swollen L hip and thigh he was referred to me.

“I’m leaning towards reactive synovitis or septic hip here, bacterial or otherwise”.

Short of doing formal arthrocentesis, I asked for an ultrasound of the hip-looking for water filled masses or pus filled joint. There was none according to radiologist. The white cell count is still increasing with lymphocytic predominance. I started the patient on Metronidazole and re -examined the patient carefully. He was afebrile for 2 days and noted an improvement in L hip range of motion. But there was still L hip pain and is unable to walk. The white cell count is still increasing. Lymphocytosis?Mature lymphocytes? Let’s call in an internist (we don’t have infectious disease specialist here nor a hema-oncologist)! See if it’s a possible lymphoproliferative thing!

“I still think its septic arthritis, but I have no hard evidence yet”

Instead, the IM gave more pain relievers and suggested patient be seen by a neurologist for a radiculopathy 2 herniated disc. The neurologist agrees triumphantly and advised more pain meds and bed rest. Sighed. Febrile, 26/male with L hip pain and elevated white cell count? Radiculopathy? I re-examined the patient. I courteously asked the patient if they can afford a CT scan of the hip and then asked the Radiologist to make the cuts up to the lumbar area and “peek” at possible herniated disc.

“I’m still convinced this is septic arthritis L hip”.

“No lumbar disc herniation nor radiculopathy. The L hip and anterior musculature is enlarged and fluid filled much more than the right. No fractures. Septic Arthritis highly considered”. Double sighed. Tomorrow I have to open up this patient’s hip joint, drain it’s pus, wash it carefully and apply traction. I gave enough time for guess making here.

So when In doubt, go back and re-examine your patient!

Dr. Remo-tito Aguilar co-founded #HealthXPh. A board certified orthopedic surgeon, he is Chief of Clinics at General Santos Medical Center and Medical Specialist II Orthopedics at the Southern Philippines Medical Center in Davao City. Dr. Aguilar is a healthcare social media evangelist and writes his medical musings at The Cast & Curious (www.remomd.com).