1
|
Gheewala RA, Lakra A, Villacres Mori B, Carroll JD, Puleo JM, Smith MP, Mulligan MT. Computed Tomography Scan Versus Saline Load Test in the Detection of Traumatic Arthrotomies of the Ankle: A Cadaveric Study. J Orthop Trauma 2024; 38:196-199. [PMID: 38442239 DOI: 10.1097/bot.0000000000002747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/15/2023] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To evaluate the sensitivity and ability of computed tomography (CT) scan for diagnosing traumatic ankle arthrotomies compared with that of the saline load test (SLT). METHODS Eleven cadaveric ankles were included in this study. Before intervention, a CT scan was obtained to confirm the absence of intra-articular air. Arthrotomies were created at the anterolateral, posterolateral, anteromedial, and posteromedial aspects of the ankle under fluoroscopic visualization. A postarthrotomy and postrange of motion CT scan was obtained to evaluate for the presence of intra-articular air. Each ankle then underwent a SLT with 60 mL of saline, where volumes provoking extravasation were recorded. RESULTS Of the 11 included ankles, intra-articular air was detected in all 11 ankles by CT scan. All 11 ankles also demonstrated extravasation of saline through the arthrotomy site during SLT. Thus, the sensitivity for both CT scan and SLT for detecting ankle traumatic arthrotomy was 100%. The mean volume of saline needed for extravasation was 7.7 mL, with a range of 3-22 mL and a SD of 5.4. CONCLUSIONS Given that CT scan was equally as sensitive to the SLT, this study presents good evidence that CT scan may be used for the detection of ankle traumatic arthrotomies.
Collapse
Affiliation(s)
- Rohan A Gheewala
- Department of Orthopedic Surgery, Albany Medical Center, Albany, NY; and
| | - Akshay Lakra
- Department of Orthopedic Surgery, Albany Medical Center, Albany, NY; and
| | | | - Jeremy D Carroll
- Department of Orthopedic Surgery, Albany Medical Center, Albany, NY; and
| | - James M Puleo
- Department of Orthopedic Surgery, Albany Medical Center, Albany, NY; and
| | | | - Michael T Mulligan
- Department of Orthopedic Surgery, Albany Medical Center, Albany, NY; and
| |
Collapse
|
2
|
Kallevang JK, Berault TJ, Olsen AA, Zuppke JN, Clark JK, Douglas TJ, Smith CS. Detection of Traumatic Ankle Arthrotomies: Computed Tomography Scan Versus Saline Load Test. J Orthop Trauma 2024; 38:200. [PMID: 38289230 DOI: 10.1097/bot.0000000000002768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE Periarticular wounds present a common diagnostic dilemma for emergency providers and orthopedic surgeons because traumatic arthrotomies (TA) often necessitate different management from superficial soft tissue wounds. Historically, TA have been diagnosed with the saline load test (SLT). Computed tomography (CT) scan has been studied as an alternative to SLT in diagnosing TA in several joints, but there are limited data specifically pertaining to the ankle. This study aimed to compare the ability of a CT scan to identify an ankle TA versus a traditional SLT. The hypothesis was that there would be no significant difference between a CT scan and SLT in diagnosing ankle TA in a cadaveric model. METHODS This cadaveric study used 10 thawed fresh-frozen cadaveric ankles. A baseline CT scan was performed to ensure no intra-articular air existed before simulated TA. After the baseline CT, a 1 cm TA was created in the anterolateral arthroscopy portal site location. The ankles then underwent a postarthrotomy CT scan to evaluate for the presence of intra-articular air. After the CT scan, a 30 mL SLT was performed using the anteromedial portal site location. RESULTS After arthrotomy, intra-articular air was visualized in 7 of 10 cadavers in the postarthrotomy CT scan. All the ankles had fluid extravasation during the SLT with <10 mL of saline. The sensitivity of the SLT for TA was 100% versus 70% for the CT scan. CONCLUSIONS The SLT was more sensitive in diagnosing 1-cm ankle TA than a CT scan in a cadaveric model.
Collapse
Affiliation(s)
- Jonathan K Kallevang
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; and
| | - Thomas J Berault
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; and
| | - Aaron A Olsen
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; and
| | - Julia N Zuppke
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; and
| | - James K Clark
- Department of Radiology, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Thomas J Douglas
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; and
| | - Christopher S Smith
- Department of Orthopedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA; and
| |
Collapse
|
3
|
Koskiniotis AE, Stefanou N, Metaxiotis N, Amprazis V, Varitimidis S. Pediatric Knee Injury: A Unique Case of Intra-articular Osteochondral Fracture Following Penetrating Trauma. Cureus 2024; 16:e53236. [PMID: 38425623 PMCID: PMC10903575 DOI: 10.7759/cureus.53236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Penetrating injuries to the musculoskeletal system pose common challenges for orthopedic surgeons in emergency departments (EDs). The complexity escalates when a joint is affected, increasing the risk of severe complications such as infection and post-traumatic arthritis. Given the potential importance of these injuries, early diagnosis and a meticulous treatment plan are crucial. In this paper, we present a unique case of penetrating trauma, resulting in an intra-articular defect on the lateral femoral condyle of an adolescent girl. This case underscores the importance of tailored interventions in managing complex musculoskeletal injuries.
Collapse
Affiliation(s)
- Alexandros E Koskiniotis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Nikolaos Stefanou
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Nikolaos Metaxiotis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Vasileios Amprazis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Sokratis Varitimidis
- Department of Orthopaedic Surgery and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| |
Collapse
|
4
|
Berger GK, Schwartz AK, Kent WT. Safe and Effective Aspirations and Nerve Blocks for the On-Call Orthopaedic Surgeon. J Am Acad Orthop Surg 2023; 31:957-967. [PMID: 37276580 DOI: 10.5435/jaaos-d-23-00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/17/2023] [Indexed: 06/07/2023] Open
Abstract
The on-call orthopaedic surgeon is faced with a wide array of orthopaedic pathology for which intra-articular aspiration, injection, and/or nerve/hematoma block may be used. Efficient use of these diagnostic and therapeutic modalities affords better patient care and a more effective on-call period. Often, these interventions are the rate limiting factor in a reduction or diagnosis. In this review, we describe joint aspirations, saline load tests, hematoma blocks, and nerve blocks in detail to include their indications, techniques, related pharmacology, pearls, and pitfalls.
Collapse
Affiliation(s)
- Garrett K Berger
- From the Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
| | | | | |
Collapse
|
5
|
Villacres Mori B, Lakra A, Gheewala RA, Carroll JD, Bibicheff D, Smith MP, Mulligan MT. Computed Tomography Scan Versus Saline Load Test for Detection of Traumatic Shoulder Arthrotomy: A Cadaveric Study. J Orthop Trauma 2023; 37:e349-e354. [PMID: 37127902 DOI: 10.1097/bot.0000000000002622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Traumatic shoulder arthrotomy (TSA) is a rare injury that is commonly detected through saline load test (SLT). There are no studies that have studied the ability of computed tomography (CT) scan to detect a TSA. The purpose of this study is to determine the ability of CT scan to detect a TSA and compare it with the SLT. METHODS Twelve cadaveric shoulders were included in the study. Before intervention, a CT scan was conducted to determine presence of intra-articular air. After confirmation that no air was present, an arthrotomy was made at the anterior or posterior portal site. A CT was obtained postarthrotomy to evaluate for intra-articular air. Each shoulder then underwent an SLT to assess the sensitivity of SLT and the volume needed for extravasation. RESULTS Twelve shoulders were included after a pre-intervention CT scan. Six shoulders received an arthrotomy through the anterior portal and six shoulders received an arthrotomy through the posterior portal. After the arthrotomy, air was visualized on CT scan in 11 of the 12 shoulders (92%). All 12 shoulders demonstrated extravasation during SLT. The mean volume of saline needed for extravasation was 29 mL with an SD of 10 and range of 18-50 mL. CONCLUSIONS CT scan is a sensitive modality (sensitivity of 92%) for detection of TSA. In comparison, SLT is more sensitive (sensitivity of 100%) and outperforms CT scan for the diagnosis of TSA in a cadaveric model. Further research is needed to solidify the role that CT imaging has in the diagnosis of TSAs.
Collapse
Affiliation(s)
| | - Akshay Lakra
- Albany Medical Center, Department of Orthopedic Surgery, Albany, NY; and
| | - Rohan A Gheewala
- Albany Medical Center, Department of Orthopedic Surgery, Albany, NY; and
| | - Jeremy D Carroll
- Albany Medical Center, Department of Orthopedic Surgery, Albany, NY; and
| | | | | | - Michael T Mulligan
- Albany Medical Center, Department of Orthopedic Surgery, Albany, NY; and
| |
Collapse
|
6
|
Somma MG, Ahern BJ. A man with a traumatic knee injury. J Am Coll Emerg Physicians Open 2022; 3:e12733. [PMID: 35591940 PMCID: PMC9092484 DOI: 10.1002/emp2.12733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Matthew G. Somma
- Department of Emergency Medicine William Beaumont Army Medical Center Fort Bliss Texas USA
| | - Brian J. Ahern
- Department of Emergency Medicine William Beaumont Army Medical Center Fort Bliss Texas USA
| |
Collapse
|
7
|
Perloff E, Posner A, Murtaza H, Vig K, Smith M, Mulligan MT. CT Scan versus Saline Load Test for Detection of Traumatic Wrist Arthrotomy. J Wrist Surg 2022; 11:154-160. [PMID: 35478947 PMCID: PMC9038302 DOI: 10.1055/s-0041-1735888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
Background Traumatic arthrotomy of the wrist is most commonly detected using the saline load test (SLT); however, little data exists on the effectiveness of the SLT to this specific joint. The use of computed tomography (CT) scan has been validated as an alternative method to detect traumatic arthrotomy of the knee, as the presence of intra-articular air can be seen when there is violation of the joint capsule. Question/Purpose The purpose of this study was to determine the ability of CT scan to identify arthrotomy of the wrist capsule and compare the diagnostic performance of CT versus traditional SLT. Materials and Methods Ten fresh frozen cadavers which had undergone transhumeral amputation were initially used in this study. A baseline CT scan was performed to ensure no intra-articular air existed prior to intervention. After baseline CT, an arthrotomy was created at the 6R radiocarpal portal site. The wrists then underwent a postarthrotomy CT to identify the presence or absence of intra-articular air. Following CT, the wrists were subjected to the SLT to detect the presence of extravasation from the arthrotomy. Results Nine cadavers were included following baseline CT scan. Following arthrotomy, intra-articular air was visualized in eight of the nine cadavers in the postarthrotomy CT scan. Air was seen in the radiocarpal joint in eight of the nine wrists; midcarpal joint in seven of the nine wrists; and distal radioulnar joint in six of the nine wrists. All wrists (nine of the nine) demonstrated extravasation during the SLT. The mean volume of extravasation occurred at 3.7 mL (standard deviation = 2.6 mL), with a range of 1 to 7 mL. Conclusion CT scan correctly identified eight of the nine simulated traumatic arthrotomies. Injection of 7 mL during the SLT was necessary to identify 100% of the arthrotomies. Clinical Relevance CT scan is a sensitive modality for detection of traumatic arthrotomy of the wrist in a cadaveric model.
Collapse
Affiliation(s)
- Eric Perloff
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | - Andrew Posner
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | - Hamza Murtaza
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | - Khushdeep Vig
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, New York
| | - Michael Smith
- Department of Anatomy, Anatomical Gift Program, Albany Medical College, Albany, New York
| | | |
Collapse
|
8
|
Chughtai M, Scollan JP, Emara AK, Brej B, Steckler A, Churchill JL, Ferre A, Saluan P, Styron JF. The "Fight Bite" Saline Joint Loading Test: Effectiveness in Detecting Simulated Traumatic Metacarpophalangeal Arthrotomies. Hand (N Y) 2022:15589447211068184. [PMID: 34991409 DOI: 10.1177/15589447211068184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The saline load test is routinely used to recognize other joints' traumatic arthrotomies; however, there are currently no studies evaluating the novelty of this test for metacarpophalangeal joints (MCPJs). This study aimed to investigate the effectiveness and sensitivity of saline load testing in identifying the traumatic arthrotomies of the MCPJs using human cadavers. Methods: This was a cadaveric study of 16 hands (79 MCPJs). Traumatic arthrotomies were created using 11-blade stab-incisions, followed by blunt probing into the joint on the radial or ulnar side of the flexed MCPJs. A 3-mL syringe was used to inject intra-articular methylene-blue-dyed saline from the contralateral side. The volume at saline extravasation was recorded. Test sensitivity and factors influencing extravasation volume were assessed. Results: The mean (range) volume injected to identify arthrotomy of all MCPJs was 0.18 mL (0.1-0.4 mL). The mean volume to identify MCPJ arthrotomy of the thumb, index, long, ring, and small fingers was 0.16 mL (0.1-0.3 mL), 0.19 mL (0.1-0.3 mL), 0.21 mL (0.1-0.4 mL), 0.17 mL (0.1-0.3 mL), and 0.16 mL (0.1-0.3 mL), respectively. Cadaver age, laterality, and joint range of motion were not significantly associated with the injected volume at extravasation(P > .05, each). Injection volumes of 0.3 and 0.32 mL were required to detect arthrotomies at 95% and 99% sensitivities across all MCPJs. None of the MCPJs required > 0.4 mL to detect arthrotomy. Conclusions: Saline joint loading volumes to detect traumatic arthrotomy were similar for all MCPJs. Injection volumes of 0.32 mL is suggested for 99% sensitivity. Our findings provide the first report, to our knowledge, on intra-articular injection volumes expected to detect an arthrotomy of MCPJ. This is critical for further validation using in vivo clinical studies.
Collapse
Affiliation(s)
| | | | | | - Ben Brej
- Cleveland Clinic Foundation, OH, USA
| | | | | | | | | | | |
Collapse
|
9
|
High risk and low prevalence diseases: Traumatic arthrotomy. Am J Emerg Med 2022; 54:41-45. [DOI: 10.1016/j.ajem.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/08/2022] [Accepted: 01/09/2022] [Indexed: 11/23/2022] Open
|
10
|
Use of Magnetic Resonance Imaging for Orthopedic Trauma and Infection in the Emergency Department. Top Magn Reson Imaging 2020; 29:331-346. [PMID: 33264273 DOI: 10.1097/rmr.0000000000000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Conditions affecting the musculoskeletal system constitute a significant portion of medical emergencies in the United States, with traumatic injury and infection being two of the most common etiologies. Although physical examination and plain radiographs are often sufficient to guide diagnosis and treatment, there are myriad traumatic and infectious pathologies that are commonly missed or simply not detectable on plain radiographs. Advanced imaging is subsequently warranted for additional workup.Magnetic resonance imaging (MRI) has become an increasingly used imaging modality for musculoskeletal complaints in the emergency department due to its superior visualization of soft tissues, focal edematous changes, and occult osseous insults often not visible on plain radiographs. Although multiple studies have evaluated its utility in the workup of emergency musculoskeletal complaints, there remains a dearth of literature examining the use of MRI for certain occult diagnoses.Radiologists, emergency clinicians, and orthopedic surgeons must be knowledgeable of the indications for MRI in the emergency setting, as delayed diagnosis may contribute to increased morbidity and possibly mortality. This review summarizes the use of MRI in diagnoses relating to trauma or infection among patients presenting to the emergency department with a musculoskeletal complaint.
Collapse
|