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Hello, everyone. I'm going to talk how to take a referral for septic arthritis. So two of the most important things we need to ask is the X ray and the blood. This is not only restricted to septic arthritis, but for it is essential for any kind of orthopedic referral. So we'll start with a history. What the patient is going to present this with the joint per se. It's going to be pain, swelling. And main thing is the patient won't be able to wait at all on that limb. So especially if it's lower limb, the patient won't be able to wait at all. There will be a restriction of movements mainly because of the effusion. And one thing we usually forget to ask is if there was any systemic symptoms like fever or they were feeling unwell for the past 2 to 3 days. So that is an important question to ask. The next is if they had any previous history of surgery, for example, a replacement surgery or a fracture fixation involving a joint. Next would be if they had any previous history of injection or any kind of iatrogenic procedure done for a patient for example, patients with osteoarthritis come for regular steroid injections and we could have iatrogenically caused a septic joint. So another history which we need to ask if that is the only joint, which is involved, this will help in differentiating whether it is septic arthritis or any other kind of arthritis. Because usually septic arthritis is a monoarthritis, meaning it involves usually only one joint. Although in my own personal experience, I have seen a patient with two joint involvement. But anyway, this is very important to ask. Then we need to think about why this patient could have caught septic arthritis. So we need to go into past medical history if they have got any diabetes or any kind of immunocompromised state. If they are an IV drug abuser, if they have caught gout, rheumatoid arthritis, osteoarthritis in the past, because this could be a differential for septic arthritis. This next question would be any previous history of joint swellings, whether they have had any knee joint swellings in the past. So that can again, differentiate, it could not have been diagnosed as gout, but it could be gout. So which is a flaring up often. So next question we ask is any, if there's any previous history of infection in the past two weeks because it could be reactive arthritis. Next thing we ask is the nil by mouth status just in case if the patient's got a septic joint, then the treatment would be washing out the joint. So for that, essentially, we can ask them by mouth status, but it doesn't matter if it's a septic joint, we are going to as an emergency procedure going on to the examination joint per se, what we are going to go and examine. So if there's any tenderness along the joint line, there would be obvious swelling and it would be red and hot to touch, there would be severe pain while trying to move the joint. So patient wouldn't even let you move by 1020 degrees. Even that would cause severe pain by trying to move the joint. And obviously, the range of movements will be reduced. And this has to be recorded in terms of degrees of flexion or extension. So if it comes to any joint, so full extension will be zero degrees and any other, what what other uh joint movement they're going to do is flexion. So that has to be recorded in terms of degrees of you need to uh check whether there's cellulitis over the joint and it has to be mentioned and recorded. Next would be the neurovascular status that is extremely important for any orthopedic case. Ok. So if the patient is septic, we need, we might need to examine the chest abdomen and whatever part is necessary. And next we go on to the investigations. So what are the main investigations we need is the bloods, so full blood count CRP ESR. And next would be aspiration of the joint. So ideally, we use a white needle, which is usually there in the theaters, might not be there in the and it has to be done in a very sterile manner. And obviously, we can have separate teaching sessions as to how to aspirate each joint. Or else we can even watch uh videos on youtube as to how to aspirate the joint. And there's always a registrar who can help you aspirate if in case you can't do it. So what are the two conditions which we should not aspirate immediately is if there's, there's cellulitis over this joint or if that's a prosthetic joint. So the main reason is because when there is a cellulitis over the joint, what we're going to do is, for example, the patient might not be septic at all, but we are going to introduce a new infection. So the need is going to go to pass through the skin and that will carry the microorganisms which you are going to inject into the joint. So I we are causing a septic joint. So we should never ever aspirate a joint which has cellulitis on the top and prosthetic joint, ideally should not be aspirated in the ed because it's again not considered very sterile. So it has to go or be taken up for the to be aspirated with respect to exercise. So we majorly talked about x rays and bloods are the main investigations for septic arthritis So what are we going to have uh look in the X ray? So first of all, to check whether it is a prosthetic joint. So some patients might be having dementia and you never know whether the patient underwent any kind of intervention. So maybe a prior scar might be there, but still you don't know what is there in inside. So you need to see whether it is a prosthetic joint. So it it's a prosthetic joint. Again, you're not going to go and aspirate in the second would be what you can see in the X ray as such is joint, space widening. That is ba basically because of the effusion. Again, because of the effusion, there can be joint subluxation or dislocation. And fourth thing it can, there can be arthritic changes which we can attribute to why there could be a swelling in case it's not a septic arthritis. So, X rays are extremely important going on the aspiration. So the main role of aspiration is to get a grand stain ASAP. So we are going to go to the ed. We accept the referral. We go down to the ed, we ask all the symptoms and everything and we examine the joint. We think ok, something could be aspirated from this joint. So if it's going to be a dry tap, it naturally rules out septic arthritis. And if there is effusion, we are going to aspirate and get a gram stain as soon as possible that how it has to be done, it has to be sent to the micro biology lab in Basildon as soon as possible. So again, I have written over here, if it's from 8 a.m. to five pm, the sample goes every hour. So at eight o'clock, nine o'clock, 10 o'clock, so every one hour the sample goes to basil. But if it's in from five pm to 8 a.m. basically in out of hours. So the micro lab technician in Basildon has to be contacted first for approval and our pathology lab to be contacted telling that basin Microlab technician has accepted the sample. So we have to have to send the sample immediately and they will send it and we need to follow it up. I know it can be a little demanding at times because you're going to see other referrals in the meanwhile, but this is something very important. We need to get the ground stain as soon as possible. So when you aspirate, there are three things which can happen, you can either get a clear fluid or you can get a strong fluid or it could be pus fluid basically. So if it's going to be a clear fluid, it's very less likely to be septic arthritis if it's a strong color fluid, if and it looks serious as in very thin like water, again, less likely to be septic arthritis. It could be a different type of arthritis like gout or an acute flare up of osteoarthritis. But if it's stubborn, it could be high suspicion of septic arthritis. And if it's pus pus, it is septic arthritis. So, if you have a septic arthritis in the Ed, how are you going to manage? What's the next line of management? So, what we need to do is we give broad spectrum antibiotics after aspiration. So for example, if someone calls you from the Ed telling that this quiring septic arthritis, we need to first tell if we have accepted to tell them not to give any kind of antibiotic until the aspiration is done. All right, even if the patient is septic, we need to go immediately try and aspirate the joint and then try and give antibiotics. Most of the times antibiotics is already given. We can't do anything at that time. But again, most of uh it's better telling them not to give the antibiotic and after aspiration, obviously, broadspectrum antibiotics. Second would be a wash out of the joint. That would be the definitive management for aseptic arthritis. We'll have a detailed class about detailed teaching session about her septic arthritis. But this session is mainly to tell you how to accept the referral with respective arthritis. So what can be the causes for septic arthritis? In a, in a short, in short, I will just tell it could be a skin infection, it could be an lrti uti. So basically the main causative organism for septic arthritis is is staph aureus group, a streptococcus and gonorrhea. These are the usual organisms which cause septic arthritis. So these all could be a skin infection which will spread inside and then involve the joint. It could be LRTI or uti, then hematogenous spread, osteomyelitis from the bone. It can come onto the joint and sepsis, hematogenous spread or it could be an sti mainly in, in the form of gonorrhea. So again, a hematogenous spread. So what will happen if we leave septic arthritis? Just like that? It's important to know if the organism will eat up the cartilage and the joint will be destroyed, causing arthritis and severely damaged joint forever for the patient. So it it's a reversible thing. If we wash out the joint as soon as possible, it's mostly irreversible after 24 hours. That's why it's a an emergency. So just to recap from the top, we need to ask the history of whatever I've explained and examine the patient. Get the investigations, both x-rays and bloods mainly and then do an aspiration. If the aspiration is a right up, most likely it's not septic arthritis and the to blood. What will be elevated is the white cell counts will be high, the CRP will be high. Sometimes the white cell counts can be normal, but the CRP is high. Still, we need to suspect septic arthritis. So if the patient has gout, can the patient present with septic arthritis? Yes, they can still present with septic arthritis. So we need to be careful in rolling out septic arthritis. Thank you so much.