Take Home points:

Always suspect an open joint if there is a laceration, regardless of size, the lies over joint
CT scan of the affected joint is widely considered to be the standard approach to evaluation but the saline load test may be useful in certain circumstances.
Obtain emergency orthopedics consultation for all open joints and administer antibiotics and update tetanus in all patients

REBEL Core Cast 131.0 – Traumatic Arthrotomy

Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment

A laceration into the joint exposes the normally sterile intra-articular contents to external contamination
Inoculation of the joint often results in septic arthritis

Physical Exam:

Laceration over joint (can be variable in size)
Local wound exploration may be sufficient in identifying the open joint
Exam findings suspicious for joint capsule involvement:
- - Air bubbles
  - Extravasation of joint fluid – straw colored, viscous, sometimes oily in appearance

Diagnostic testing:

ED Management:

Reduce open fractures if present
Irrigate grossly contaminated wounds in the ED
Immobilize the joint to prevent further injury
Obtain early orthopedic evaluation for joint exploration, and washout to be performed within 6-24 hours
Tetanus prophylaxis
Prophylactic antibiotics (best if given within 6 hours)
- Staph/strep coverage: 1^st generation cephalosporin (i.e. cefazolin or cefuroxime)
- If risk factors for MRSA present, use agent with activity against MRSA (i.e. vancomycin)
- If significant soft tissue injury, add gram negative coverage like late generation cephalosporin, extended-spectrum penicillin, or aminoglycoside (i.e. gentamycin)
- If concern for fecal or clostridial infection, add high dose penicillin (i.e. zosyn)
- If seawater contamination and concern for vibrio vulnificus, add doxycycline

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

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