Ver el código de «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 DDX}}

==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.<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). 
***>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 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>
**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>

==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]]
===[[Antibiotics (Main)|Prophylactic Antibiotics]]===
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)
*If more contaminated – add [[anaerobic]] coverage ([[gentamicin]] 300mg IV)
*Very contaminated/farm contamination – concern for [[clostridial]] infection ([[piperacillin/tazobactam]] 4.5 g q8 hrs)
*Seawater contamination – concern for [[vibrio vulnificus]] ([[doxycycline]])

==Disposition==
Admit to trauma or orthopedic surgery

==See Also==
*[[Open fracture]]
*[[Fracture (Main)]]

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

==References==
<references/>

[[Category:Orthopedics]]