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Open joint injury
From WikEM
Contents
Background
- Also known as "traumatic arthrotomy"
- Soft tissue injury that penetrates the joint space and exposes the joint space to the environment.
- Increases the risk of joint infection and is cause for emergent orthopedic evaluation and treatment for joint exploration and washout.
- Rarely life threatening:
- Evaluate other injuries that may cause immediate loss of life/limb first.
- Evaluate nearby neurovascular structures.
- Maintain high suspicion for periarticular penetrating injuries to involve the joint:
- Septic arthritis is a potentially very morbid sequela of untreated open joints.
Clinical Features
- Concern for joint space involvement with soft tissue injury:
- Proximity of soft tissue injury to joint
- Visible joint capsule surface
- Periarticular fracture
- In these situations joint involvement is obvious and orthopedic surgery/washout is necessary without further testing:
- Foreign body in joint on X-ray
- Intra-articular air on X-ray or CT
- Obvious joint involvement of fracture with an open fracture on X-ray
Differential Diagnosis
Extremity trauma
- Peripheral nerve injury
- Vascular injury
- Tendon injury
- Laceration
- Fracture
- Open joint injury
- Crush syndrome
- Compartment syndrome
- Rhabdomyolysis
- Contusion
- Myositis ossificans
Evaluation
- ATLS
- X-ray
- CT – look for air in joint
- Trauma labs PRN
- Those in which joint penetration is unclear can have joint loaded with either saline or methylene blue to look for extravasation from wound.
- Debate on sensitivity and specificity – some say sensitivity is far too low.
- However, negative joint loading test was associated with 0% infection rate in one study with non-operative management.[1]
- For knees, 50 mL is standard (sensitivity 46%, increased with ROM).
- >195 mL loading (very painful) needed for 95% sensitivity in small lacerations near the knee.[2]
- For elbows, 20 mL with range of motion gave 86% sensitivity, 40 mL gave 95%.[3]
- For ankle, 10 mL is average needed, 23 mL and 30 mL for 90% and 95% sensitivity.[4]
- Another recent study suggests air in joint on CT of periarticular joint fracture is 95% sensitive for open joint and could potentially be used instead of joint loading(level III)[5]
Management
Pain control
Opioid of choice
Wound management
- Initial immobilization as needed
- Orthopedic "Golden 6 hours" – applies similarly to open fractures. Treat <6 hours with surgical debridement and washout
- Can irrigate grossly contaminated wounds in ED
- Tetanus prophylaxis
Prophylactic Antibiotics
Depends on concern for infection (similar to open fractures)[6]
- Staph/strep coverage – 1st generation cephalosporin (cefazolin 2g IV TID)
- If more contaminated – add anaerobic coverage (gentamicin 300mg IV)
- Very contaminated/farm contamination – concern for clostridial infection (piperacillin/tazobactam 4.5 g q8 hrs)
- Seawater contamination – concern for vibrio vulnificus (doxycycline)
Disposition
Admit to trauma or orthopedic surgery
See Also
External Links
General overview of joint loading test with methylene blue
References
- ↑ Konda, S. R., Howard, D., Davidovitch, R. I. & Egol, K. A. The saline load test of theknee redefined: a test to detect traumatic arthrotomies and rule out periarticular wounds not requiring surgical intervention. J. Orthop. Trauma 27, 491–497 (2013).
- ↑ Keese, G. R., Boody, A. R., Wongworawat, M. D. & Jobe, C. M. The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. J. Orthop. Trauma 21, 442–443 (2007).
- ↑ Feathers, T. et al. Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies. J. Trauma 71, E110–113 (2011).
- ↑ Bariteau, J. T., Blankenhorn, B. D. & Digiovanni, C. W. Evaluation of saline load test for simulated traumatic arthrotomies of the ankle. Injury 44, 1498–1501 (2013).
- ↑ Konda, S. R., Davidovitch, R. I. & Egol, K. A. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. J. Orthop. Trauma 27, 498–504 (2013).
- ↑ Gosselin, R. A., Roberts, I. & Gillespie, W. J. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst. Rev. CD003764 (2004).
