Saline Load Test for Detecting Traumatic Arthrotomy in the Wrist

Goyal, Nitin; Bohl, Daniel D.; Frank, Rachel M.; Slikker, William; Fernandez, John J.; Cohen, Mark S.; Wysocki, Robert

doi:10.1055/s-0039-1683365

Cited by 6 publications

(17 citation statements)

References 10 publications

(31 reference statements)

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“…Therefore, any laceration around the elbow needs to be evaluated for a traumatic arthrotomy. A diligent physical examination of the injured extremity is required yet may not be enough to identify disruption of the joint capsule, i.e., traumatic arthrotomy [ 2 , 6 , 7 , 8 , 12 , 14 ]. An open arthrotomy can seed bacteria from the skin or environment into the joint and develop into septic arthritis [ 1 , 5 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

Traumatic Elbow Arthrotomy Pediatric Case Report: The Saline Load Test is a Reliable Method of Detection

Kupchick¹,

Wall²

2021

JOCR

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Introduction: Lacerations and open elbow injuries are common emergency department visits which necessitate an orthopedic surgery evaluation for a traumatic elbow arthrotomy (TEA). A delay in this diagnosis can lead to septic arthritis, requiring more invasive surgical procedures, prolonged antibiotics, and possible long-term sequelae. To date, there is scarce literature on TEA. The purpose of this case report is to better educate the orthopedic community on a reliable method of detection for a TEA, including pediatric patients. Case Report: Case 1 – Twelve-year-old boy sustained a traumatic dog bite to the right elbow by a large stray dog. Evaluation in the emergency department revealed five 1 centimeter or smaller lacerations over the lateral elbow and another 1 cm laceration to the volar and proximal forearm. A saline load test (SLT) was performed from a posterior approach and was positive after 20cc of normal saline was injected into the joint. An arthroscopic irrigation and debridement were performed as definitive treatment. He was discharged with Augmentin BID for 7 days. Follow-up appointments at 1 and 4 weeks post-operatively revealed no signs of infection. Case 2 – Seven-year-old boy who was in a bicycle accident and sustained a large laceration over the posterior elbow. Evaluation in the emergency department revealed an approximately 15 by 4 cm laceration over the posterior elbow. A SLT was positive after 30cc’s was injected from the anterolateral approach. He underwent arthroscopic irrigation and debridement as definitive treatment and was discharged home with Cephalexin BID for 7 days. Follow-up appointments at 1 and 4 weeks post-operatively showed no signs of infection. Conclusion: Performing a SLT is a reliable method of detection to evaluate for a TEA. Our case report demonstrated confirmation of TEA in two pediatric patients based on positive SLT. We were able to treat these injuries appropriately with early surgical intervention and prophylactic anti

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Section: Introductionmentioning

confidence: 99%

Traumatic Elbow Arthrotomy Pediatric Case Report: The Saline Load Test is a Reliable Method of Detection

Kupchick¹,

Wall²

2021

JOCR

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“…6 Goyal et al studied the SLT of the wrist in patients undergoing elective wrist arthroscopic procedures and displayed a 99% sensitivity using 2.5 mL. 5 The same study showed a statistically significant increase in volume required for males and increasing height. Our study demonstrated a mean volume of extravasation at 3.7 mL (SD ¼ 2.6).…”

Section: Discussionmentioning

confidence: 98%

CT Scan versus Saline Load Test for Detection of Traumatic Wrist Arthrotomy

et al. 2021

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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.

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“…Therefore, in addition to being universally available, the SLT adds value compared to advanced imaging alternatives, which demonstrate lower sensitivities yet greater costs, thereby proving crucial [8]. SLT consists of an injection of a certain volume of sterile saline into a given joint separate from the site of injury, whereby extravasation of saline from the injury site is a positive result that indicates a capsular breach [6,7]. Identifying the sensitivity of detecting arthrotomy through extravasation per injected saline volume is critical since underloading the joint may potentially lead to missed capsular violations.…”

Section: Introductionmentioning

confidence: 99%

“…Notably, such aggressive interventions would not be warranted in the absence of joint arthrotomy. As such, accurate detection of joint capsule penetration on presentation is crucial to facilitate appropriate and timely downstream management [ 6 , 7 ]. Published investigations have demonstrated poor accuracy of computerized tomography (CT) scans in diagnosing traumatic elbow arthrotomy.…”

Section: Introductionmentioning

confidence: 99%

“…Kupchick et al [ 8 ] recently reported that zero out of ten iatrogenically arthrotomized cadaveric elbows demonstrated evidence of intra-articular air on CT, despite repetitive ranging of the joint. In the setting of possible traumatic arthrotomy, the saline load test (SLT) is the most common and accepted diagnostic modality [ 6 ]. Therefore, in addition to being universally available, the SLT adds value compared to advanced imaging alternatives, which demonstrate lower sensitivities yet greater costs, thereby proving crucial [ 8 ].…”

Section: Introductionmentioning

confidence: 99%

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The Effectiveness of Saline Load Test in Detecting Simulated Traumatic Elbow Arthrotomies: A Cadaveric Investigation

Ferré¹,

Maurant²,

Steckler³

et al. 2021

Cureus

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BackgroundThe saline load test has not been well explored in the elbow. We aimed to determine 1) the saline infusion volume needed for 90%, 95%, and 99% sensitivity in detecting elbow arthrotomy; and 2) factors associated with higher volume at detection using sixteen forequarter upper extremity amputation cadavers. MethodsSixteen fresh-frozen forequarter upper extremity amputations were procured, and demographic data, including age, body mass index (BMI), and laterality, were recorded. The olecranon process, radial head, and the lateral epicondyle were palpated, and elbow arthrotomy was consistently performed at the direct lateral arthroscopic portal site. The elbow joint was loaded with saline mixed with methylene blue (concentration: 2 mg/300 mL) using an 18-gauge needle inserted just medial to the triceps tendon 2 cm superior to the olecranon. ResultsMean volume for extravasation was 12.2 mL ±6.26. Volume needed for 90%, 95%, and 99% sensitivities were 21 mL, 23 mL, and 25.4 mL. Linear regression demonstrated that increasing age was associated with lower volume to extravasation (OR: 0.67; 95% CI: 0.48-0.932; p=0.037), while BMI (p=0.571) and extremity laterality (p=0.747) did not affect the volume. ConclusionsThe saline load test can be effective in diagnosing the violation of the elbow joint in traumatic injuries. This test should be used in conjunction with the clinical examination and radiographs before operative decisions are made. We recommend using ≥26 mL to rule out traumatic elbow arthrotomy.

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Saline Load Test for Detecting Traumatic Arthrotomy in the Wrist

Cited by 6 publications

References 10 publications

Traumatic Elbow Arthrotomy Pediatric Case Report: The Saline Load Test is a Reliable Method of Detection

Traumatic Elbow Arthrotomy Pediatric Case Report: The Saline Load Test is a Reliable Method of Detection

CT Scan versus Saline Load Test for Detection of Traumatic Wrist Arthrotomy

The Effectiveness of Saline Load Test in Detecting Simulated Traumatic Elbow Arthrotomies: A Cadaveric Investigation

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