Traumatic Arthrotomy

Aka: Traumatic Arthrotomy, 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 with risk of Septic Joint

III. Exam

  1. Observe Laceration while performing joint range of motion
    1. Observe for bubbles or viscous fluid exiting the wound during range of motion
  2. Evaluate for concurrent injury
    1. Open Fracture
    2. Open Dislocation

IV. Diagnostics

  1. Saline Load Test
    1. Perform Arthrocentesis and instill saline into joint
    2. Observe for saline leaking from Laceration (confirms Traumatic Arthrotomy)
    3. Amount of saline to instill into joint varies by 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]

V. Imaging

  1. XRay Joint
    1. Air within joint has high Test Specificity, but low Test Sensitivity
  2. CT Joint
    1. Offers better Test Sensitivity than XRay
    2. However, has not been compared with Saline Load Test for all joints
    3. Knee CT for intraarticular air performed better than saline load test
      1. Konda (2013) J Orthop Trauma 27(9):498-504 +PMID: 23287770 [PubMed]

VI. Precautions

  1. No test completely excludes Traumatic Arthrotomy

VII. 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

VIII. 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/

IX. References

  1. Raukar and Swaminathan in Herbert (2021) EM: Rap 21(7): 4-5
  2. Brubacher (2020) J Am Acad Orthop Surg 28(3):102-11 +PMID: 31977606 [PubMed]

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