24.1

Open-Joint Injuries

Chapter 24

Open-Joint Injuries

Introduction

Open injuries to the joints are rarely immediately life

threatening. They are frequently quite dramatic in appearance

and draw the inexperienced caregiver’s attention away from

the truly life threatening, associated injuries. Neurovascular

structures are in close proximity to the major joints, and may

require vascular management and repair. Open joints have

long-term morbidity and some secondary mortality from

infection due to missed injury or inadequate treatment.

All open-joint injuries must be explored and treated

within 6 hours to prevent infection and joint destruction.

With rare exceptions, closed-joint injuries should be treated

nonoperatively in the combat zone. Definitive intervention and

rehabilitation usually require months before complete recovery.

Thus, patients with closed injuries to major joints should be

evacuated from the theater for definitive surgical intervention

and rehabilitation.

The key to treating open-joint injures is recognition.

Once identified, goals are prevention of infection and

preservation/restoration of normal joint function.

 Signs of possible open-joint injury are a wound associated

with the following:

ο Proximity to a joint.

ο Periarticular fracture.

ο Exposed joint.

ο Effusion.
24.2

Emergency War Surgery

ο Loss of joint motion.

ο Intra-articular air or foreign body on biplanar radiographs.

ο Abnormal joint aspiration demonstrating hemarthrosis.

ο Extravasation from joint on diagnostic injection.

Open-joint injuries always require surgery. Joint

aspiration/injection may be performed to confirm a

suspected open joint. If in doubt, treat as an open-joint

injury to prevent missed injury sequelae.

 The technique for aspiration/injection involves:

ο Sterile prep.

ο 18-gauge needle, 30-cc syringe.

ο Enter suspected joint, avoiding neurovascular structures.

ο Attempt aspiration — if blood is aspirated a hemarthrosis

is present.

ο If no hemarthrosis, inject with normal saline (methylene

blue if available) until joint is fully distended — the joint

is damaged if extravasation is detected.

ο If there is no extravasation, open joint injury may still be

present.

 Approaches for aspiration are shown for the shoulder, elbow

(Lateral), knee (Medial parapatellar), and ankle (Anterolateral) (Fig. 24-1a,b,c,d).

Treatment of All Open-Joint Injury

 IV antibiotics should be started ASAP after wounding, and

continued postop for 48 hours.

 Tourniquet control of operative bleeding is essential.

 Standard arthrotomy incisions are utilized (Fig. 24-2a,b,c).

(Wound margins are incorporated if possible, provided they

do not compromise exposure or create non-viable flaps).

 The extremity must be draped free to allow full range of

motion during surgery.

 All intra-articular foreign material, loose cartilage (including

flaps), blood clots, and detached bony fragments without

major articular surface must be removed.
24.3

Open-Joint Injuries

 All recesses must be explored and all damaged tissue must

be removed.

 The joint must be thoroughly irrigated with normal saline

(pulse lavage and 6 to 9 L is recommended).

 Internal fixation is contraindicated with the exception of

large articular fragments that may be stabilized with Kirscher

wire (K-wire) or Steinmann pins.

b

d

a

Shoulder

Knee

Ankle

Elbow

c

Fig. 24-1a,b,c,d. Aspiration/injection approaches to the shoulder,

elbow, knee, and ankle.
24.4

Emergency War Surgery

 Close synovium if possible without tension and without

surgical tissue advancement. The remainder of the wound

should never be closed at the initial surgical exploration.

 If synovial closure is not possible, the joint should be dressed

open with moist fine mesh gauze occlusive dressing.

 The wound should be reexplored in 48–72 hours.

 A bivalved cast or splints can be used to stabilize the joint.

b

c

a

Ankle Elbow

Knee

Fig. 24-2a,b,c. Surgical approaches to the ankle, elbow, and knee.
24.5

Open-Joint Injuries

 If there are delays in evacuation or inability to move the

patient, the following steps can be taken:

ο Delayed primary closure (DPC) can be undertaken in 4–7

days if there are no signs of infection.

ο If there is extensive soft-tissue loss, split-thickness skin

grafts may be applied to granulating synovium.

 After DPC, gentle range-of-motion therapy is begun, based

on consideration of any associated fractures or neurovascular

injuries.

Any time joint infection is suspected, the joint should

be immediately explored/re-explored.

Signs of Joint Sepsis

 Persistent swelling.

 Marked pain.

 Local warmth.

 Fever.

 Intense pain with restriction of the range of motion.

Special Considerations for Hip Wounds

 Open injuries of the hip joint are problematic for several

reasons.

ο Difficulty in diagnosis.

ο Highly virulent organisms leading to mortality or longterm morbidity.

 Violations of the hollow viscus organs associated with

fractures that extend into the acetabulum or femoral neck

uniformly contaminate the joint.

ο Ruling out joint involvement is difficult in the field

environment due to poor radiographic support and

difficulty in reliable joint aspiration/injection. Therefore,

a high index of suspicion with a low threshold for joint

exploration is essential for preventing devastating

complications.

 Presacral drainage is highly encouraged in rectal injury with

joint extension.
24.6

Emergency War Surgery

Hip Exploration Technique

 Semilateral or lateral decubitus position, with the abdomen,

pelvis, and full lower extremity prepped and draped free.

 A tibial traction pin to suspend the leg from the ceiling is

advantageous.

 Anterior iliofemoral (Fig. 24-3a,b,c) approach gives the most

extensive exposure to the hip, acetabulum, and ilium. (If the

incision was extended superior and posterior, closure of the

a

b

c

Iliofemoral Tract

Joint Capsule

Rectus Femoris

Fig. 24-3a,b,c. Anterior iliofemoral approach to the hip.
24.7

Open-Joint Injuries

a

b

Quadratus Femoris

Obdurator Internus

Sciatic Nerve

Gluteus Maximus

Piriformus

Sup & Inf

Gemelius

Fig. 24-4a,b. Posterior approach to the hip.

superior/posterior aspect of the incision only over the iliac

crest is necessary at the initial surgery to prevent muscle

retraction and subsequent inability to close the wound.)

 A posterior or Kocher approach (Fig. 24-4a,b) allows for

posterior exposure and allows for posterior drainage. It may

be used in conjunction with the iliofemoral approach or in

select cases alone for debridement. In an echeloned care/

delayed evacuation scenario, dependent posterior drainage

may be more critical than currently practiced in the civilian

environment.
24.8

Emergency War Surgery

 Complete fractures of the femoral neck/head should be

resected due to nearly uniform complications of sepsis and

avascular necrosis.

 Except as described above, the surgical incision is not closed.

Dressing of the wound is as previously described. The patient

may be placed in a spanning external fixator from the iliac

crest to the distal femur, or placed in a one and one-half hip

spica cast. (See Chapter 23, Extremity Fractures, for diagram.)

Special Considerations for the Shoulder

 Often associated with life-threatening thoracic or vascular

injuries. See Chapter 27, Vascular Injuries, for approaches to

the axillary and subclavian arteries.

 Technique for shoulder exploration:

ο Semilateral position will allow both anterior and posterior

approaches to the glenohumeral joint.

ο Anterior deltopectoral approach is recommended (Fig. 24-

5a,b,c,d). (Detachment of the short biceps, coracobrachialis,

and pectoralis minor off the coracoid may be needed for

adequate exposure.) The subscapularis is detached and the

joint capsule is trimmed of devitalized tissue. All attempts

are made to preserve the supraspinatus attachment.

ο Loose fragments or a completely devitalized humeral head

are resected to prevent infection. In an echeloned care/

delayed evacuation scenario, dependent posterior

shoulder drainage may be more critical than currently

practiced in the civilian environment.

ο At the time of the DPC, 4–7 days later, the infraspinatus

and teres minor are reattached if previously detached.

ο A Velpeau dressing is utilized for the wounds.

ο For transport, the shoulder can be wrapped in plaster,

suspending the cast from the opposite shoulder for

comfort. If this is not feasible, a sling and swath,

immobilizing the arm against the chest wall, may be used.

These patients will require litter transport.
24.9

Open-Joint Injuries

a b

c d

Subscapular

Pectoralis Major

Latissimus Dorsi

Joint Capsule Shattered Humoral Head

Fig. 24-5a,b,c,d. Anterior deltopectoral approach to the shoulder.

The key to success in dealing with open joints is a high

index of suspicion. If the joint is open, then aggressive

surgical management is imperative.
24.10

Emergency War Surgery