Open joint injury: Difference between revisions

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== Background==
==Background==
[[File:Gray299.png|thumb|Generic diagram of a joint.]]
*Also known as "traumatic arthrotomy"
*Also known as "traumatic arthrotomy"
*Soft tissue injury that penetrates the joint space and exposes the joint space to the environment.  
*Soft tissue injury that penetrates the joint space and exposes the joint space to the environment.  
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**Septic arthritis is a potentially very morbid sequela of untreated open joints.
**Septic arthritis is a potentially very morbid sequela of untreated open joints.


== Clinical Features==
==Clinical Features==
*Concern for joint space involvement with soft tissue injury:
*Concern for joint space involvement with soft tissue injury:
**Proximity of soft tissue injury to joint
**Proximity of soft tissue injury to joint
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**Obvious joint involvement of fracture with an open fracture on X-ray
**Obvious joint involvement of fracture with an open fracture on X-ray


== Differential Diagnosis==
==Differential Diagnosis==
{{Extremity trauma DDX}}
{{Extremity trauma DDX}}


== Diagnosis==
===Intra-articular gas===
*[[Open joint injury]]
*Surgical intra-articular intervention
*[[Septic arthritis]]
*Normal variation (i.e., intra-articular vacuum phenomena)
 
==Evaluation==
[[File:Radiopedia knee.png|thumb|Knee CT showing pneumoarthrosis consistent with open joint injury.]]
 
===Workup===
''All lacerations should have basic exploration; for those near a joint, depending on ''
*[[ATLS]]
*[[ATLS]]
*X-ray
**Trauma labs PRN
*CT – look for air in joint
*Consider X-ray
*Trauma labs PRN
*Consider CT
*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.  
===Diagnosis===
**However, negative joint loading test was associated with 0% infection rate in one study with non-operative management.<ref>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).</ref>
====CT Scan====
*First-line diagnostic test
*~100% specific and sensitive for a clinically significant open joint injuries<ref>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).</ref>
 
====Saline Loading Test====
*Second-line diagnostic test
**For those in which joint penetration is unclear  
**Involves injection into the joint (see [[arthrocentesis]] for procedural landmarks and technique) of saline or methylene blue to look for extravasation from wound.
**Sensitivity increases with increased fluid injected, but so does pain.
**Negative joint loading test associated with 0% infection rate in one study with non-operative management.<ref>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).</ref>
**For knees, 50 mL is standard (sensitivity 46%, increased with ROM).  
**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.<ref>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).</ref>
***>195 mL loading (very painful) needed for 95% sensitivity in small lacerations near the knee.<ref>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).</ref>
**For elbows, 20 mL w/ range of motion gave 86% sensitivity, 40 mL gave 95%.<ref>Feathers, T. et al. Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies. J. Trauma 71, E110–113 (2011).</ref>
**For elbows, 20 mL with range of motion gave 86% sensitivity, 40 mL gave 95%.<ref>Feathers, T. et al. Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies. J. Trauma 71, E110–113 (2011).</ref>
**For ankle, 10 mL is average needed, 23 mL and 30 mL for 90% and 95% sensitivity.<ref>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).</ref>
**For ankle, 10 mL is average needed, 23 mL and 30 mL for 90% and 95% sensitivity.<ref>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).</ref>
**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)<ref>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).</ref>


== Treatment==
==Management==
=== Pain control===
===Pain control===
[[Opioid]] of choice
*[[Opioid]] of choice (e.g. [[fentanyl]] 50 mcg IV)
=== Wound management===
 
===Wound management===
*Initial immobilization as needed
*Initial immobilization as needed
*Orthopedic "Golden 6 hours" – applies similarly to open fractures. Treat <6 hours with surgical debridement and washout
*Orthopedic "Golden 6 hours" – applies similarly to open fractures. Treat <6 hours with surgical debridement and washout
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Depends on concern for infection (similar to [[open fractures]])<ref>Gosselin, R. A., Roberts, I. & Gillespie, W. J. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst. Rev. CD003764 (2004).</ref>
Depends on concern for infection (similar to [[open fractures]])<ref>Gosselin, R. A., Roberts, I. & Gillespie, W. J. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst. Rev. CD003764 (2004).</ref>
*[[Staph]]/[[strep]] coverage – 1st generation [[cephalosporin]] ([[cefazolin]] 2g IV TID)
*[[Staph]]/[[strep]] coverage – 1st generation [[cephalosporin]] ([[cefazolin]] 2g IV TID)
*If more contaminated – add [[anaerobic]] coverage ([[gentamicin]] 300 mg IV)
*If more contaminated – add [[anaerobic]] coverage ([[gentamicin]] 300mg IV)
*Very contaminated/farm contamination – concern for [[clostridial]] infection ([[piperacillin/tazobactam]] 4.5 g q8 hrs)
*Very contaminated/farm contamination – concern for [[clostridial]] infection ([[piperacillin/tazobactam]] 4.5 g q8 hrs)
*Seawater contamination – concern for [[vibrio vulnificus]] ([[doxycycline]])
*Seawater contamination – concern for [[vibrio vulnificus]] ([[doxycycline]])


== Disposition==
==Disposition==
Admit to trauma or orthopedic surgery
*Admit to trauma or orthopedic surgery


==See Also==
==See Also==
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==External Links==
==External Links==
[http://emedicine.medscape.com/article/114453-overview#a7 General overview of joint loading test with methylene blue]
*[http://emedicine.medscape.com/article/114453-overview#a7 General overview of joint loading test with methylene blue]


==References==
==References==

Latest revision as of 20:19, 19 March 2025

Background

Generic diagram of a joint.
  • 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

Intra-articular gas

Evaluation

Knee CT showing pneumoarthrosis consistent with open joint injury.

Workup

All lacerations should have basic exploration; for those near a joint, depending on

  • ATLS
    • Trauma labs PRN
  • Consider X-ray
  • Consider CT

Diagnosis

CT Scan

  • First-line diagnostic test
  • ~100% specific and sensitive for a clinically significant open joint injuries[1]

Saline Loading Test

  • Second-line diagnostic test
    • For those in which joint penetration is unclear
    • Involves injection into the joint (see arthrocentesis for procedural landmarks and technique) of saline or methylene blue to look for extravasation from wound.
    • Sensitivity increases with increased fluid injected, but so does pain.
    • Negative joint loading test associated with 0% infection rate in one study with non-operative management.[2]
    • 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.[3]
    • For elbows, 20 mL with range of motion gave 86% sensitivity, 40 mL gave 95%.[4]
    • For ankle, 10 mL is average needed, 23 mL and 30 mL for 90% and 95% sensitivity.[5]

Management

Pain control

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]

Disposition

  • Admit to trauma or orthopedic surgery

See Also

External Links

References

  1. ↑ 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).
  2. ↑ 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).
  3. ↑ 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).
  4. ↑ Feathers, T. et al. Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies. J. Trauma 71, E110–113 (2011).
  5. ↑ 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).
  6. ↑ Gosselin, R. A., Roberts, I. & Gillespie, W. J. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst. Rev. CD003764 (2004).
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