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septic arthritis of the pediatric shoulder is a rare condition , with most reports citing a prevalence of 35% of all septic joints . as such
, there is a lack of data available regarding its clinical presentation , clinical course , and treatment .
additionally , septic arthritis of the shoulder is often stated to be a disease of infancy and is commonly associated with osteomyelitis of the adjacent bone [ 13 ] .
the anatomy of the shoulder joint likely contributes to the association with osteomyelitis , as the capsule of the shoulder envelopes the metaphysis , facilitating hematogenous spread between the bone and joint space .
treatment recommendations vary ; however , surgical opening and exploration of the glenohumeral capsule and biceps tendon sheath are recommended for thorough cleansing of the joint . in this review ,
42 children with septic joints were identified , of whom 4 , or 9.5% , were found to have septic arthritis of the shoulder .
following medical school institutional review board ( irb ) approval , review of all records , from 2008 to 2015 , for pediatric patients ( < 18  yo ) with septic shoulders treated with irrigation and debridement was completed .
forty - two patients with septic arthritis were identified , of whom 5 had an infected shoulder .
one of the five was a 17-year - old female who acquired a shoulder infection as a postoperative complication and was excluded from the current study ( n = 4 ) .
special attention was paid to the time required for diagnosis , laboratory data , treatment strategies , and long - term complications .
the average age was 5 years with a range of 1 month to 15 years .
the average time until diagnosis was 7 days , with a range of 4 to 10 days .
all four patients presented with decreased use of the affected shoulder , and 1 of the 4 had an antecedent trauma ( case 2 ) .
this patient fell onto the affected shoulder during a basketball game  a few weeks  prior to presentation .
two patients were born prematurely at 27 weeks ( case 3 ) and 32 weeks ( case 4 ) .
three of 4 patients had elevated c - reactive protein ( crp ) levels on laboratory data with an average of 11.17  g / dl ( 0.814.3  g / dl ) .
the erythrocyte sedimentation rate ( esr ) was reported in 3 of the 4 patients , with an average of 66  mm / hr ( 20125  mm / hr ) .
the white blood cell count ( wbc ) had an average of 20.19  10/mcl ( 17,00023,800 ) .
these consisted of methicillin - resistant staphylococcus aureus ( two ) , methicillin - sensitive staphylococcus aureus , candida albicans , and pseudomonas aeruginosa .
one patient was treated with an aspiration followed by arthrotomy and antibiotics , while the other three were treated with arthrotomy and antibiotics . in all surgeries ,
patients were treated with antibiotics for an average of 43 days , with a range of 32 to 48 days . in 3 of 4 cases ,
both parenteral and oral antibiotics were used . empirical treatment with vancomycin was initiated in all four cases until culture returned and a more narrow - spectrum antibiotic could be chosen .
the average follow - up of these patients was 8 months , with a range of 2 months to 12 months .
of these patients , one reported decreased range of motion at 2 months of follow - up ( case 1 ) .
septic arthritis of the glenohumeral joint is considered by many to be a disease of infancy [ 1 , 2 , 5 , 6 ] . however , in this study , only 2 patients were infants ( mage = 5 years ) .
each patient presented to the emergency department , three as transfers from an outside institution and one from home . in each case , the patient 's chief complaint included pain with motion in the glenohumeral joint . in case 3 ,
the patient also presented with decreased movement of the right lower extremity secondary to a concomitant knee infection .
literature regarding the initial evaluation of children with joint pain or concern for septic arthritis recommends obtaining a full blood count with differential , esr , crp , synovial fluid analysis , and synovial fluid culture [ 69 ] . of the laboratory studies done in this study , the most consistently elevated marker was total white blood cell count ( > 12,000 ) , which was present in 100% of the cases . the esr and crp were elevated ( > 2  g / dl and > 40  mm / hr , resp . ) in 75% of the cases .
however , the esr was not requested in one of the cases , likely due to the patient 's age ( 3 months ) .
the elevated crp in 75% of the cases supports recent literature recommending the inclusion of crp in the diagnostic criteria for septic arthritis .
cultures obtained from these cases were positive for mrsa ( 2 ) , mssa ( 1 ) , pseudomonas aeruginosa ( 1 ) , and candida albicans ( 1 ) .
the fungemia patient , 4-month - old born at 27-week gestation , had multifocal septic arthritis , with positive cultures for candida albicans and mssa found in both the glenohumeral and acetabulofemoral joints .
the severity of this presentation and pathogen involved can be explained partly by the increased susceptibility of infant 's joints to hematogenous spread of infection , as well as the immature immune system associated with infants of preterm birth [ 5 , 10 , 11 ] .
fifty percent of cases in this review presented with concomitant osteomyelitis and septic arthritis of the shoulder .
these data are similar to the reported rate of 75% by montgomery et al . , 67% by belthur et al . , and 56% by schmidt et al .
( n = 6 ) with osteomyelitis of the proximal humerus had septic arthritis of the shoulder . in all cases of osteomyelitis in the current study ,
the metaphysis was drilled in order to decompress the bone , in keeping with previous recommendations .
in addition to laboratory evaluation , imaging modalities are recommended in the evaluation of septic arthritis [ 1 , 2 , 4 ] . in all 4 cases ,
imaging modalities were used to assist in the diagnosis of septic arthritis , with mri being the modality of choice .
initial plain radiographs were obtained in all four cases and failed to note abnormalities in 75% of the patients .
in addition , plain radiograph had a false - negative rate of 50% for changes consistent with osteomyelitis .
technetium - pyrophosphate bone scans have been reported as useful in the literature , as they assist in the diagnosis of skip lesions in osteomyelitis , which are often missed when localized mris are used .
repeat aspiration and irrigation and debridement are reported modalities of drainage for septic arthritis of the shoulder .
however , one author recommends dividing and exploring the biceps tendon sheath to ensure full debridement of infected tissue . in the current study ,
the surgical exploration and treatment left the biceps tendon intact , with a thorough irrigation of the joint noted in each procedure . on follow - up , the patients ' outcomes were generally good .
the patient in case 2 was noted to have sclerotic changes to the proximal humerus on radiograph , without clinical manifestations of these changes .
previous studies demonstrated a delay in treatment for shoulder infection as compared to hip infections and postulated that the lack of an evidence - based clinical algorithm may contribute .
the kocher criteria were developed as a joint - specific algorithm for the diagnosis of septic arthritis of the pediatric hip and have facilitated in the diagnosis of septic hips .
joint insensitive clinical algorithms do exist for the diagnosis of septic arthritis [ 16 , 17 ] .
( 2015 )   recommend that patients with an acute joint in the outpatient setting receive routine lab work involving serum wbc , esr , and crp .
mathews and coakley ( 2008 ) stated that though serum wbc , esr , crp , and temperature were all useful in the evaluation of an acute joint , they were not diagnostic .
synovial white cell count is cited as being the only predictive laboratory value , with values 17,500 having sensitivity and specificity of 83% and 67% , respectively , and is considered not better than the  gold standard ,  which is clinical suspicion by an expert physician with experience in musculoskeletal disease [ 16 , 18 ] .
therefore , a more specific set of diagnostic criteria for septic shoulders and increased clinical suspicion would facilitate the clinician in making a prompt diagnosis and thus improve clinical outcomes [ 2 , 3 , 9 , 10 ] .
additionally , it is important to note that the age of the patients within this study is markedly advanced in comparison to previous literature , and therefore clinicians should have appropriate suspicion for septic arthritis of the shoulder , even in the older child .
although generally associated with infants , septic arthritis of the shoulder must be considered when evaluating any patient with shoulder pain and systemic signs of inflammation .
septic arthritis of the shoulder may put patients at risk for long - term changes of the articular surface of the joint , and prompt diagnosis and management must be undertaken to reduce the severity of these complications .
development of diagnostic criteria specific to the shoulder would be facilitated in this endeavor and should be addressed in future literature .
background . 
 septic arthritis of the glenohumeral joint in the pediatric population ( < 18  yo ) is not commonly described in the literature . 
 there is a corresponding paucity of information regarding its presentation and treatment 
 . methods . an irb approved review of patients treated with irrigation and debridement by the orthopaedic department was completed . 
 this retrospective study includes four patients , presenting from 2005 to 2015 , with septic arthritis of the shoulder . results . the mean age ( mage ) at presentation was 5 years , with a range of 1 month to 15 years . 
 patients presented on average after 7 days with pain and a mean temperature of 39c , erythrocyte sedimentation rate of 66  
 mm / hr , a c - reactive protein level of 11.17  g / dl , and a white blood cell count of 20.2  103/mcl . 
 staphylococcus aureus , candida albicans , and pseudomonas aeruginosa were cultured from the wounds . 
 all cases were treated operatively with irrigation and debridement and with antimicrobial therapy . 
 patients received antibiotics for an average of 6 weeks . 
 conclusion . septic arthritis of the shoulder occurs in all pediatric ages . 
 successful treatment of septic arthritis of the shoulder was accomplished in four cases without division of the biceps sheath , with an average follow - up of 8 months .