REBEL EM – Emergency Medicine Blog

REBEL Core Cast 131.0 – Traumatic Arthrotomy

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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

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    REBEL Core Cast 131.0 – Traumatic Arthrotomy

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    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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                                              REBEL EM – Emergency Medicine BlogBy Salim R. Rezaie, MD