Open joint injury

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

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]

Disposition

Admit to trauma or orthopedic surgery

See Also

External Links

General overview of joint loading test with methylene blue

References

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