November 13, 2024

REBEL Core Cast 131.0 – Traumatic Arthrotomy

6 minutes

Take Home points:

Always suspect an open joint if there is a laceration, regardless of size, the lies over joint

CT scan of the affected joint is widely considered to be the standard approach to evaluation but the saline load test may be useful in certain circumstances.

Obtain emergency orthopedics consultation for all open joints and administer antibiotics and update tetanus in all patients

REBEL Core Cast 131.0 – Traumatic Arthrotomy

Click here for Direct Download of the Podcast.

Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment

A laceration into the joint exposes the normally sterile intra-articular contents to external contamination

Inoculation of the joint often results in septic arthritis

Physical Exam:

Laceration over joint (can be variable in size)

Local wound exploration may be sufficient in identifying the open joint

Exam findings suspicious for joint capsule involvement:

Air bubbles

Extravasation of joint fluid – straw colored, viscous, sometimes oily in appearance

Diagnostic testing:

Imaging:

X-ray

Limited ability to see air in joints but a reasonable first test

CT scan

Intra-articular air visualized on CT (Konda 2013)

May be up to 100% sensitive for joint violation

Study limited by small numbers, inclusion bias + inadequate gold standard

May be considered the standard evaluation modality in many settings.

Saline load test

Has mainly been supplanted by CT scan due to ease in obtaining, reported performance characteristics, consultant recommendation and difficulty in interpreting test.

Useful if physical examination equivocal or plain radiographs non-diagnostic

Technique (Video)

Perform arthrocentesis of the joint with a large bore needle (18-20 gauge)

Sterile saline is injected into the joint while passive movement is applied to the joint

The laceration site is watched for saline extravasation indicating communication between the joint and external environment

Sensitivity ranges from 34%-99% depending on the study, joint, and the amount of saline used to load the joint (Browning 2016)

Methylene blue

Aids in distinguishing a true positive from additional bleeding from the wound

Recent studies suggest that the addition of methylene blue does not increase sensitivity if a sufficient amount of saline is used (Metzger 2012)

Volume of fluid injected

Varies depending on the joint in which you are injecting

Higher volumes increase sensitivity but also increase pain for the patient

Knee Joint (Keese 2007)

50 ml: Sensitivity of about 46%

194 ml: sensitivity of 95%

Elbow Joint (Feathers 2011)

20 ml: Sensitivity of 86%

40 ml: Sensitivity of 95%

Ankle Joint (Bariteau 2013)

7 ml: Sensitivity of 50%

30 ml: Sensitivity of 95%

ED Management:

Reduce open fractures if present

Irrigate grossly contaminated wounds in the ED

Immobilize the joint to prevent further injury

Obtain early orthopedic evaluation for joint exploration, and washout to be performed within 6-24 hours

Tetanus prophylaxis

Prophylactic antibiotics (best if given within 6 hours)

Staph/strep coverage: 1st generation cephalosporin (i.e. cefazolin or cefuroxime)

If risk factors for MRSA present, use agent with activity against MRSA (i.e. vancomycin)

If significant soft tissue injury, add gram negative coverage like late generation cephalosporin, extended-spectrum penicillin, or aminoglycoside (i.e. gentamycin)

If concern for fecal or clostridial infection, add high dose penicillin (i.e. zosyn)

If seawater contamination and concern for vibrio vulnificus, add doxycycline

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

The post REBEL Core Cast 131.0 – Traumatic Arthrotomy appeared first on REBEL EM - Emergency Medicine Blog.

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By Salim R. Rezaie, MD

4.8

158158 ratings

November 13, 2024

REBEL Core Cast 131.0 – Traumatic Arthrotomy

6 minutes

Take Home points:

Always suspect an open joint if there is a laceration, regardless of size, the lies over joint

CT scan of the affected joint is widely considered to be the standard approach to evaluation but the saline load test may be useful in certain circumstances.

Obtain emergency orthopedics consultation for all open joints and administer antibiotics and update tetanus in all patients

REBEL Core Cast 131.0 – Traumatic Arthrotomy

Click here for Direct Download of the Podcast.

Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment

A laceration into the joint exposes the normally sterile intra-articular contents to external contamination

Inoculation of the joint often results in septic arthritis

Physical Exam:

Laceration over joint (can be variable in size)

Local wound exploration may be sufficient in identifying the open joint

Exam findings suspicious for joint capsule involvement:

Air bubbles

Extravasation of joint fluid – straw colored, viscous, sometimes oily in appearance

Diagnostic testing:

Imaging:

X-ray

Limited ability to see air in joints but a reasonable first test

CT scan

Intra-articular air visualized on CT (Konda 2013)

May be up to 100% sensitive for joint violation

Study limited by small numbers, inclusion bias + inadequate gold standard

May be considered the standard evaluation modality in many settings.

Saline load test

Has mainly been supplanted by CT scan due to ease in obtaining, reported performance characteristics, consultant recommendation and difficulty in interpreting test.

Useful if physical examination equivocal or plain radiographs non-diagnostic

Technique (Video)

Perform arthrocentesis of the joint with a large bore needle (18-20 gauge)

Sterile saline is injected into the joint while passive movement is applied to the joint

The laceration site is watched for saline extravasation indicating communication between the joint and external environment

Sensitivity ranges from 34%-99% depending on the study, joint, and the amount of saline used to load the joint (Browning 2016)

Methylene blue

Aids in distinguishing a true positive from additional bleeding from the wound

Recent studies suggest that the addition of methylene blue does not increase sensitivity if a sufficient amount of saline is used (Metzger 2012)

Volume of fluid injected

Varies depending on the joint in which you are injecting

Higher volumes increase sensitivity but also increase pain for the patient

Knee Joint (Keese 2007)

50 ml: Sensitivity of about 46%

194 ml: sensitivity of 95%

Elbow Joint (Feathers 2011)

20 ml: Sensitivity of 86%

40 ml: Sensitivity of 95%

Ankle Joint (Bariteau 2013)

7 ml: Sensitivity of 50%

30 ml: Sensitivity of 95%

ED Management:

Reduce open fractures if present

Irrigate grossly contaminated wounds in the ED

Immobilize the joint to prevent further injury

Obtain early orthopedic evaluation for joint exploration, and washout to be performed within 6-24 hours

Tetanus prophylaxis

Prophylactic antibiotics (best if given within 6 hours)

Staph/strep coverage: 1st generation cephalosporin (i.e. cefazolin or cefuroxime)

If risk factors for MRSA present, use agent with activity against MRSA (i.e. vancomycin)

If significant soft tissue injury, add gram negative coverage like late generation cephalosporin, extended-spectrum penicillin, or aminoglycoside (i.e. gentamycin)

If concern for fecal or clostridial infection, add high dose penicillin (i.e. zosyn)

If seawater contamination and concern for vibrio vulnificus, add doxycycline

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

The post REBEL Core Cast 131.0 – Traumatic Arthrotomy appeared first on REBEL EM - Emergency Medicine Blog.

...more