Traumatic Arthrotomy

Aka: Traumatic Arthrotomy, Open Joint Injury, Penetrating Joint Injury, Laceration with Joint Injury, Laceration Exposing Joint

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II. Definitions

  1. Traumatic Arthrotomy
    1. Laceration extends into joint capsule, exposing intra-articular surface
    2. High risk for Septic Joint

III. Exam

  1. Evaluate skin overlying joint
    1. Lacerations
    2. Exposed bone or hardware
    3. Erythema
    4. Purulence
  2. Joint Exam
    1. Joint effusion
    2. Joint range of motion (active and passive)
      1. Observe Lacerations and wounds while performing joint range of motion
      2. Observe for bubbles or viscous fluid exiting the wound during range of motion
  3. Evaluate for concurrent injury
    1. Open Fracture
    2. Open Dislocation
  4. Other exam
    1. Neurovascular Exam
    2. Extremity compartments

IV. Labs

  1. Complete Blood Count with differential
  2. Inflammatory markers (CRP and ESR)

V. Diagnostics

  1. Saline Load Test
    1. Perform Arthrocentesis and instill saline into joint
    2. Passively range the joint to promote fluid escape and increase Test Sensitivity
    3. Observe for saline leaking from Laceration (confirms Traumatic Arthrotomy)
    4. Addition to saline of methylene blue (was historically used) does not increase Test Sensitivity
      1. Metzger (2012) J Orthop Trauma 26(6): 347-9 [PubMed]
    5. Amount of saline to instill into joint varies by joint, and limited by patient tolerance
      1. Knee: Instill at least 60 ml into Knee Joint
        1. Instilling 194 ml into knee offers Test Sensitivity of 95%
        2. Keese (2007) J Orthop Trauma 21(7):442-3 +PMID: 17762473 [PubMed]

VI. Imaging

  1. XRay Joint
    1. Air within joint has high Test Specificity, but low Test Sensitivity
  2. Non-Contrast CT Joint
    1. Contrast dye is indicated if evaluating for vascular injury
      1. Free air density is very low (-1000 HU) and provides adequate radiographic contrast
      2. Air is easily distinguished from all soft tissue (>-100 HU), esp. on bone or lung CT windows
    2. CT Offers better Test Sensitivity than XRay, and in many cases appears to be more sensitive than saline load
    3. However, has not been compared with Saline Load Test for all joints
    4. Knee CT for intraarticular air with 100% Test Sensitivity
      1. Saline load test by comparison has a Test Sensitivity of 92%
      2. Konda (2013) J Orthop Trauma 27(9):498-504 +PMID: 23287770 [PubMed]
    5. However False Positive air also occurs with closed intraarticular tibial Fractures (knee)
      1. Noble (2017) J Orthop Trauma 31(11): e381-4 [PubMed]

VII. Precautions

  1. No test completely excludes Traumatic Arthrotomy

VIII. Management

  1. Emergently consult orthopedics
    1. Operative joint wash-out is indicated in confirmed or suspected Traumatic Arthrotomy
  2. Acute emergency department management
    1. Reduce open Fractures and open dislocations
    2. Copious Wound Irrigation
    3. Update Tetanus Vaccination
    4. Joint Immobilization
    5. Antibiotic prophylaxis
      1. Base Staphylococcus and Streptococcus coverage
        1. First Generation Cephalosporin (Cefazolin) OR
        2. Vancomycin if MRSA coverage indicated by patient history
      2. Extensive Soft Tissue Injury
        1. Add Gram Negative coverage (e.g. Third Generation Cephalosporin, Aminoglycoside)
      3. Wound contaminated with organic matter
        1. Add extended-spectrum Penicillin (e.g. Piperacillin-tazobactam)
      4. Seawater contamination (Vibrio vulnificus risk)
        1. Add Doxycycline

IX. Resources

  1. Traumatic Arthrotomy (Emergency Physician Monthly)
    1. https://epmonthly.com/article/confidently-rule-traumatic-arthrotomy-knee/
  2. Traumatic Arthrotomy (Core EM)
    1. https://coreem.net/core/traumatic-arthrotomy/

X. References

  1. Augusta and Riveros (2024) Crit Dec Emerg Med 38(9): 20-1
  2. Broder (2024) Crit Dec Emerg Med 38(10): 24-6
  3. Raukar and Swaminathan in Herbert (2021) EM: Rap 21(7): 4-5
  4. Brubacher (2020) J Am Acad Orthop Surg 28(3):102-11 +PMID: 31977606 [PubMed]

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