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Acute arthritis of the hip--case series describing emergency physician performed ultrasound guided hip arthrocentesis.

Introduction

Making the diagnosis of acute hip arthritis is critical as septic arthritis may lead to rapid, irreversible destruction of the joint and long-term morbidity. Arthrocentesis of the hip is traditionally performed in the fluoroscopy suite by interventional radiologist or in the operating room by orthopaedic surgeons. The capability to perform this procedure is often not readily accessible leading to delays in diagnosis and patient care. We describe two cases of acute hip arthritis where arthrocentesis was performed in the emergency department by the treating clinician. The use of ultrasound allowed the arthrocentesis to be performed safely and rapidly, at the bedside, expediting diagnosis and patient care.

Case Presentation

Case 1

An 18 year old female presented to the emergency department with five days of atraumatic right hip pain. She denied fevers or other symptoms and was 23 weeks pregnant (uncomplicated). Medical history was unremarkable. She denied IV drug use or recent invasive procedures.

On exam, she was afebrile with normal vital signs. She was well-appearing, in no distress with a gravid abdomen. The right hip and knee were held slightly flexed. Ranging the hip produced pain. Exam was otherwise negative. Lab studies revealed WBC 16, C-reactive protein 15.164, and ESR-47.

Bedside ultrasound of the right hip revealed a significant effusion. Arthrocentesis was performed under direct bedside ultrasound guidance. Approximately 20 cc of turbid, brown, and foul-smelling fluid was obtained and analysis revealed:

* Gram stain--rare WBCs, several PMNs, no organisms or crystals

* Cell count--RBC 19K, WBC 35.6K, 83% PMNs

* Glucose--<5

* Protein--6.3

Orthopaedic surgery was

consulted and the patient underwent operative washout where more grossly purulent fluid was encountered. The patient did well postoperatively and was placed on 6 weeks of IV antibiotics. Cultures remained negative. Her pregnancy proceeded without complication.

Case 2

A 15 year old male presented to the emergency department with right hip pain for 1 day. He initially denied injuries or fevers. Medical history was unremarkable. He denied IV drug use or recent invasive procedures. On exam, he was afebrile and vital signs were normal. He was in significant distress, holding the right hip and knee flexed with the hip slightly internally rotated. His right hip appeared frankly rigid and any range of motion produced severe pain. The remainder of his exam was unremarkable. X-rays were negative. Laboratory analysis revealed WBC -21, PMN-83%, Bands-1%. Bedside ultrasound of the right hip revealed a significant right hip effusion. Ultrasound guided arthrocentesis was performed at the bedside by the emergency physician using sterile technique. Approximately 20 cc of turbid, yellow fluid was obtained and sent for analysis revealing:

* Gram stain--rare WBCs, several PMNs, no organisms or crystals

* Cell count--RBC 29.5K, WBC 53.5K, 96% PMNs

* Glucose--20

* Protein--5.9

The patient later recalled a possible straining injury while skateboarding and an MRI was recommended by pediatric orthopaedics. The MRI revealed a small anterior labral tear and hip effusion. The patient was observed overnight and symptoms significantly improved, so a diagnosis of reactive arthritis was made. He was discharged in good condition, fully able to ambulate. All cultures remained negative.

Discussion

Arthrocentesis is a key diagnostic procedure in acute inflammatory arthritis. Hip arthrocentesis is usually performed by specialists in facilities that are not readily available. It is a procedure that often requires procedural sedation in children. The use of ultrasound to guide hip arthrocentesis was described in 1989 by Mayekawa and colleagues and has been performed by emergency physicians in mostly pediatric patients with good results. (4,5,6,7) Bedside ultrasound assists in the identification of hip effusions and allows arthrocentesis to be performed under direct guidance, making aspiration of this joint more feasible for clinicians who are experienced with bedside ultrasound and ultrasound guided needle placement. Ultrasound played a crucial role in both of these cases. In the first case, it allowed the differential diagnosis to be rapidly narrowed and definitive diagnosis to be made without exposing the fetus to potentially harmful ionizing radiation. In the second case, the necessary diagnostic procedure was able to be performed safely and rapidly in the emergency department.

Figure 1 from case 1 shows a sagittal-oblique view of the right hip with a significant effusion. Comparison is made to the left hip (Figure 2) with a minimal amount of synovial fluid present.

Figure 3 from case 2 again shows a sagittal-oblique view of the right hip with a significant effusion with a comparison view of the asymptomatic left hip (Figure 4) showing no significant effusion.

The use of ultrasound by clinicians to aid in diagnoses and assist procedures is growing rapidly. Ultrasound is a tool that is safe, portable and accessible. The skilled use of ultrasound has been shown to make procedures safer and more efficient. (8) Additionally, ultrasound use has been shown to improve diagnostic accuracy and efficiency at a relatively low cost without exposure to ionizing radiation. (9) Ultrasound is a tool that can help clinicians in many medical specialties provide better care to patients.

Conclusion

We report 2 patients with acute hip arthritis whose management was significantly aided by a clinician--performed ultrasound guided hip arthrocentesis--a procedure not commonly performed by emergency physicians. These cases are two examples illustrating how the skilled use of ultrasound by clinicians can improve patient care.

References

(1.) Goldenberg DL, Cohen AS. Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med. 1976;60:369-77.

(2.) Harcke HT. Hip in infants and children. Clin Diagn Ultrasound. 1995;30:179-99.

(3.) Herman MH, Pizzutillo PD, Geller E, et al. Ultrasound-guided aspiration of the hip in children: a new technique. Clin Orthop Relat Res. 2003;415:244-7.

(4.) Smith SW. Emergency physician-performed ultrasonography-guided hip arthrocentesis. Acad Emerg Med. 1999;6:84-6.

(5.) Freeman K, Dewitz A, Baker WE. Ultrasound-guided hip arthrocentesis in the ED. Am J Emerg Med. 2007;25:80-6.

(6.) Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J Emerg Med. 2008; 35:393-9.

(7.) Mayekawa DS, Ralls PW, Kerr RM, et al. Sonographically guided arthrocentesis of the hip. J Ultrasound Med. 1989;8:665-7.

(8.) Abboud PA, Kendall JL. Ultrasound guidance for vascular access. Emerg Med Clin North Am. 2004 Aug;22(3):749-73.

(9.) Testa A, Lauritano EC, Giannuzzi R, Pignataro G, Casagranda I, Gentiloni Silveri N. The role of emergency ultrasound in the diagnosis of acute non-traumatic epigastric pain.Intern Emerg Med. 2010 Oct;5(5):401-9. Epub 2010 May 18.

Joseph Minardi, MD

Nick Denne, MD

Miryam Miller, MD

Hollynn Larrabee, MD

Owen Lander, MD

West Virginia University, Department of Emergency Medicine, Morgantown, WV
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Article Details
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Title Annotation:Scientific Article
Author:Minardi, Joseph; Denne, Nick; Miller, Miryam; Larrabee, Hollynn; Lander, Owen
Publication:West Virginia Medical Journal
Article Type:Case study
Geographic Code:1U5WV
Date:Sep 1, 2013
Words:1105
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