Open Joint Injuries

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

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

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

Signs Approaches for aspiration:

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

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 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

Treatment Surgical approaches

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

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

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

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

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

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

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