Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIX: Wounds and Injuries of Bones and Joints

Joint Injuries

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

A penetrating wound of a joint has a high potential for infection which can often be avoided or at least minimized by appropriate surgery. In addition to the previously described techniques of wound surgery, the following specific principles are applicable to open joint injuries:

1. For all penetrating injuries of a joint, a formal arthrotomy is required. While this sometimes can be accomplished through the actual wound itself by extending it as necessary, a separate standard arthrotomy incision may be required. The extremity should be draped in a manner that allows movement of the joint as necessary to facilitate exposure. Arthrotomy should be done as soon as possible after injury in an operating room. If applicable, the use of a tourniquet is recommended.
2. All loose bony fragments, detached or badly damaged cartilage, foreign bodies, dots, and devitalized tissue should be removed. Biplanar radiographs are desirable.
3. The joint should be thoroughly explored utilizing appropriate retractors.
4. The joint should be copiously irrigated with an antibioticcontaining solution, utilizing pulsatile lavage when possible.
5. The wound should be left open. The same principles apply to joint injuries as to open fractures with respect to wound closure Depending on the degree of contamination, it may be possible to close the synovium leaving the capsule or soft tissue open. However, closure of the synovium is not absolutely necessary provided an occlusive dressing is applied.
6. If the synovium or capsule cannot or should not be closed because of joint contamination, the open joint should be dressed carefully with a single layer of fine-mesh gauze and followed by fluffed gauze and a wrap. Depending on the degree of damage of the articular surface, appropriate immobilization may be instituted. Early motion should be considered in those injuries where the joint surfaces are not significantly involved.
7. Penetrating wounds of the lower abdomen and pelvic area should be evaluated carefully for involvement of the hip joint. Any evidence that the hip has been penetrated requires arthrotomy, exploration, irrigation, and drainage Frequently these procedures coincident with the abdominal operation. Posterior arthrotomy may be necessary to adequately accomplish the surgical goals; care should be taken with respect to the posterior blood supply of the femoral head.
8. Joint injuries thus treated should be dressed and immobilized as previously delineated for fractures.

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