Failure to Diagnose by ER Doctor Leads to Septic Shock

This case involves a forty-two-year-old female patient who presented to the emergency room with extreme knee pain. The patient described that he was an avid runner who ran about three miles per day. He explained that the pain started after a long jog through the park in which he sustained a trip and fall. The patient denied any puncture wounds to the knee joint and only took ibuprofen for the pain. The emergency room physician assured the patient that the injury was likely musculo-skeletal in origin and that ice and anti-inflammatory therapy as needed would suffice. Three weeks later, the patient was rushed back to the hospital in a severely toxic state. It was determined that the patient had septic arthritis of the knee joint that evolved to full blown septic shock. He required immediate intubation for ventilatory support and long term care in the ICU unit to fight the systemic infection.

Question(s) For Expert Witness

1. What other tests or diagnostic studies could have prevented this situation?

Expert Witness Response

Plain radiography is of limited value in evaluating a joint for infection, and periarticular soft-tissue swelling is the most common finding. This imaging modality is most useful in ruling out underlying osteomyelitis or periarticular osteomyelitis caused by the joint infection itself. An approach to rapid evaluation of an acutely inflamed joint is to screen the synovial fluid for crystals via polarizing microscopy and for organisms via Gram stain (63-96% sensitive). If crystals are present and the Gram stain findings are negative, treatment for crystal-associated arthritis should be initiated. However, an exception to this would be the presence of significant risk factors for infection (eg, the focus of infection lies somewhere that could lead to bacteremia, such as pneumonia or pyelonephritis). Therapeutic decisions cannot be delayed until results of the synovial fluid culture are available. If the patient's condition does not improve significantly after five days, the joint must be reaspirated and examined.