Open Joint Injuries

1. Open Joint Injuries

2. Overview • Signs • Treatment • Joint Sepsis • Hip Wounds • Special Considerations for the Shoulder

3. Signs • Open joint injuries are usually no immediately life-threatening, but must be addressed within 6 hours to prevent development of potentially life threatening infection • Sigs of possible open joint injury include wound associated with: • Proximity to a joint • Periarticular fracture • Esposed joint • Effusion • Loss of range of motion • Intra-articular air or foreign body on X-ray • Abnormal joint aspiration indicating hemarthrosis • Extravasation from joint on diagnostic injection

4. Signs • How to perform a diagnostic joint injection or aspiration: • First, prep the joint in sterile fashion • Using an 18 gauge needle and 30 cc syringe, enter the joint (avoid neurovascular structures) • Attempt aspiration. If blood is aspirated, a hemarthrosis is present • If no hemarthrosis, inject with normal saline until joint is fully distended and check for extravasation

5. Signs • Approaches for aspiration:

6. Treatment • All open joint injuries require IV antibiotics ASAP and continued for 48 hours post-operatively • Control bleeding with tourniquet • Use standard arthrotomy incisions • Drape extremity freely to allow full range of motion • Remove all intra-articular foreign material, loose cartilage, blood clots, and bony fragments • Remove all damaged tissue • Irrigate the joint with normal saline

7. Treatment • Internal fixation is contraindicated unless there are large articular fragments that can be stabilized with Kirscher wire or Steinmann pins • Close synovium if possible without tension. The remainder of the wound should remain open • If synovium cannot be closed, dress the joint with moist fine mesh gauze • Re-explore the wound after 48-72 hours • Use splints or bi-valve cast to stabilize the joint • Delayed primary closure can be done after 4-7 days if there are no signs of infection • Gentle range of motion therapy can be started after delayed primary closure

8. Treatment • Surgical approaches

9. Joint Sepsis • If any suspicion of joint infection, the joint should be immediately explored • Signs of joint infection • Persistent swelling • Marked pain • Local warmth • Fever • Intense pain with restriction of range of motion

10. Hip Wounds • Hip injuries are problematic because • They are difficult to diagnose with aspiration or injection. Maintain a high index of suspicion and low threshold for joint exploration • Fractures may perforate hollow organs which may contaminate the joint • Presacral drainage is encouraged for rectal injury with joint extension

11. Hip wounds • Hip exploration technique • Semilateral or lateral position with abdomen, pelvis, and entire lower extremity prepped and draped free • Tibial traction pin to suspend the leg from the ceiling may be helpful • Complete fractures of the femoral neck/head must be resected due to high rate of sepsis and/or necrosis • The surgical incision is not closed except for the superior/posterior portion of anterior ileofemoral incision

12. Hip wounds • Anterior ileofemoral approach: allows extensive exposure of hip, acetabulum, and ilium

13. Hip wounds • Posterior (Kocher) approach: allows for posterior exposure and posterior drainage

14. Shoulder injuries • Technique for shoulder exploration: • Semilateral position allows for anterior and posterior aproaches • Anterior deltopectoral approach is preferred. Attempt to preserve supraspinitus attachment.

15. Shoulder injuries • Technique for shoulder exploration: • Loose fragments or devitalized humeral head are resected to prevent infection • Delayed primary closure is done 4-7 days later and infraspinatus and teres minor reattached at that time if previously detached