II. Definitions
- Traumatic Arthrotomy
- Laceration extends into joint capsule, exposing intra-articular surface with risk of Septic Joint
III. Exam
- Evaluate skin overlying joint
- Lacerations
- Exposed bone or hardware
- Erythema
- Purulence
- Joint Exam
- Joint effusion
- Joint range of motion (active and passive)
- Observe Lacerations and wounds while performing joint range of motion
- Observe for bubbles or viscous fluid exiting the wound during range of motion
- Evaluate for concurrent injury
- Open Fracture
- Open Dislocation
- Other exam
- Neurovascular Exam
- Extremity compartments
IV. Labs
- Complete Blood Count with differential
- Inflammatory markers (CRP and ESR)
V. Diagnostics
- Saline Load Test
- Perform Arthrocentesis and instill saline into joint
- Observe for saline leaking from Laceration (confirms Traumatic Arthrotomy)
- Amount of saline to instill into joint varies by joint
- Instilling 194 ml into knee offers Test Sensitivity of 95%
- Keese (2007) J Orthop Trauma 21(7):442-3 +PMID: 17762473 [PubMed]
VI. Imaging
- XRay Joint
- Air within joint has high Test Specificity, but low Test Sensitivity
- CT Joint
- Offers better Test Sensitivity than XRay
- However, has not been compared with Saline Load Test for all joints
- Knee CT for intraarticular air with 100% Test Sensitivity
- Saline load test by comparison has a Test Sensitivity of 92%
- Konda (2013) J Orthop Trauma 27(9):498-504 +PMID: 23287770 [PubMed]
- However False Positive air also occurs with closed intraarticular tibial Fractures (knee)
VII. Precautions
- No test completely excludes Traumatic Arthrotomy
VIII. Management
- Emergently consult orthopedics
- Operative joint wash-out is indicated in confirmed or suspected Traumatic Arthrotomy
- Acute emergency department management
- Reduce open Fractures and open dislocations
- Copious Wound Irrigation
- Update Tetanus Vaccination
- Joint Immobilization
- Antibiotic prophylaxis
- Base Staphylococcus and Streptococcus coverage
- First Generation Cephalosporin (Cefazolin) OR
- Vancomycin if MRSA coverage indicated by patient history
- Extensive Soft Tissue Injury
- Add Gram Negative coverage (e.g. Third Generation Cephalosporin, Aminoglycoside)
- Wound contaminated with organic matter
- Add extended-spectrum Penicillin (e.g. Piperacillin-tazobactam)
- Seawater contamination (Vibrio vulnificus risk)
- Add Doxycycline
- Base Staphylococcus and Streptococcus coverage
IX. Resources
- Traumatic Arthrotomy (Emergency Physician Monthly)
- Traumatic Arthrotomy (Core EM)
X. References
- Augusta and Riveros (2024) Crit Dec Emerg Med 38(9): 20-1
- Raukar and Swaminathan in Herbert (2021) EM: Rap 21(7): 4-5
- Brubacher (2020) J Am Acad Orthop Surg 28(3):102-11 +PMID: 31977606 [PubMed]