Traumatic Arthrotomy

What is it? It’s a deep laceration that extends into the normally sterile intra-articular joint space and places the joint at risk of septic arthritis. The knee is the most commonly involved joint. Young adult males most at risk for traumatic arthrotomies. Think about high energy injuries like MVAs and falls from a significant height, and penetrating trauma (GSW, knives, sharp metal).

Why does it matter? Risk of significant functional impairment. Primary wound closure vs. operating room for emergent washout.

Usually local wound exploration is sufficient for diagnosing it or if it’s just obvious like in the picture above with the bone and/or tendon sticking out. Other times, you might look for air bubbles or extravasation of joint fluid which is apparently straw colored.

Where it gets interesting is if you are clinically unsure if the laceration violates the joint space. There’s been some limited data on x-rays and CT looking for intra-articular air as a sign of joint violation but the studies are small and it’s not the gold standard.

The standard tool for assessing traumatic arthrotomies, and what we do here, is the saline or methylene blue load test. These are the steps:

-          Arthrocentesis of the joint

-          Inject sterile saline or methylene blue while passive movement is applied to the joint

-          Observe the laceration site for extravasation

-          Sensitivity increases with more volume injected but so does the pain

Arthrocentesis of knee: You can enter from almost any direction, with the medial/lateral approach being the most common while the knee is fully extended.

Start at about the 1:58 mark https://www.youtube.com/watch?v=V8idT6fwU0Q&feature=emb_title

Remember, give antibiotics early, update tetanus, get orthopedics consult early on especially if there is uncertainty.

 Sources

https://coreem.net/core/traumatic-arthrotomy/

https://wikem.org/wiki/Arthrocentesis:_knee

FOOSH Injuries

Let’s talk about FOOSH (say that 3 times fast) injuries. That’s falling on an outstretched hand, you know so you don’t eat dirt. Falling this way can result in a number of upper extremity injuries and we will highlight some of the common fracture patterns.

Distal radius fractures

Colles fractures – think old lady with osteoporosis or high impact trauma.

There’s a classification called the Frykman classification system. It’s really just 4 main types in the left column and the right column adds on an ulnar styloid fracture

Most treated with closed reduction and short arm cast.

Smith fractures – it’s much less common, think of it as a reverse Colles fracture. You get it by falling onto a flexed wrist or a blow to the back of the wrist. So you’re going to have volar angulation. Compare that to the Colles.

Most are also treated with closed reduction and short arm cast.

Forearm fractures

Galeazzi fractures – children usually, especially ages 9-12. FOOSH with elbow in flexion. It is a radial shaft fracture + dislocation of the distal radioulnar joint.

Usually unstable and needs OR.

Monteggia fractures – Children usually as well especially age 4-10. Ulnar shaft fracture + dislocation of radial head. Cast or ORIF depending on the type.

A common mnemonic is MUGR (or GRUM)

Monteggia involves fracture of the ulna with proximal radial dislocation

Galeazzi involves fracture of the radius with distal radioulnar dislocation

Carpal bone fractures

Scaphoid fractures – most common, pain in the anatomical snuffbox. Risk of avascular necrosis. Thumb spica splint + ortho f/u if there is pain even without obvious fracture on x-ray. If there is an apparent fracture on imaging, get an ortho consult because there is a risk of non-union or malunion and they may offer surgery.

https://radiopaedia.org/articles/fall-onto-an-outstretched-hand?lang=us

https://www.physio-pedia.com/Colles_Fracture

Hyperthemia and Rapid Cooling

There are a number of causes for hyperthermia that isn’t just fever and r/o sepsis. There is certainly environmental hyperthermia – particularly the elderly in poorly or non- air-conditioned buildings, the runner training for a marathon, and the lost hiker.

Today though, I want to focus on sympathomimetics and psychostimulants. In these settings, rapid cooling is often needed as there is high mortality if not cooled promptly. 

Sympathomimetic/psychostimulant highlights:

• hyperthermia, mydriasis, tachycardia, diaphoresis, hypertension, agitation, psychosis

• cocaine, PCP, amphetamines, MDMA, LSD, bath salts, etc.

• can get the phenomenon of “excited delirium” where there is excess catecholamines and/or overstimulation of dopamine and NMDA receptors

In clinical practice…

-Get a rectal temp to asses someone’s core temperature!

-High body temperatures can cause protein unraveling, severe rhabdo -> AKI ->hyperkalemia

-When agitated and hyperthemic, consider benzodiazepines or dissociating with ketamine as we are trying to stop hypermetabolism and muscle contractions that generate further heat.

-If intubation is needed, rocuronium > succylcholine to avoid hyperkalemia.

-Ways to rapidly cool somebody: remove clothing, cold IV fluids, ice packs, ice baths, and even bladder irrigation.

-With an ice or cold water bath, you can cool somebody and drop their temperature about 3°F for every 5 min in the bath.

How might we set up an ice bath here at Maimonides? Get a body bag from the charge nurse, place the patient in it, grab ice from the ice machine if it’s working (inevitably 2 out of 3 machines in the department aren’t) or go to 3-in-1 and borrow their ice (order an iced coffee with just ice, no coffee). Place the ice in the body bag with the patient, or perhaps in large biohazard bags filled with ice around the patient.

Lastly, the evidence for dantrolene when rapid cooling is needed is very limited/non-existent. It’s expensive. It’s efficacy is mostly anecdotal. That being said, some of our event medicine teams have used it in the past at music festivals for excited delirium patients.