Treating the Chainsaw Laceration. Did This EP Do Enough?
Click here to read the original case
Click here to read Dr. William Sullivan’s response: The Chainsaw Verdict
Evaluation for a laceration to the extremity should include examination for multiple potential complications: neurologic, vascular including compartment syndrome, tendon, and infection (open fracture or open joint). A good mnemonic, which I developed for this article, for this evaluation is “INTACT”: Infection, Nerves, Tendons, Arteries, Compartments, Tendons.
Evaluation of quadriceps tendon function would involve documenting full strength with knee extension. Wound exploration should document whether any underlying tendon is involved by inspection. A partial tendon laceration may allow preserved function, but usually with significant pain with range of motion, especially against resistance, and may only be discovered during wound exploration. If a tendon is involved, prophylactic oral antibiotics are usually indicated. Evaluation for an open joint is important if the laceration is in close proximity to a joint.
For the knee in particular, it is important to know that the joint capsule extends well above the patella—far more proximally than one might intuit. If a large joint is violated, then consultation with an orthopedist is required and admission for IV antibiotics and formal wash-out will likely be recommended.
Testing for an open joint is not always straight forward, but it usually involves imaging, joint injection or both. Joint injection or a “saline load” test checks for joint integrity by the performance of the initial part of an arthrocentesis followed by injection of saline until resistance is met. If saline is observed to leak out the joint, that joint is open. The sensitivity of the saline load test may be improved by adding methylene blue to the saline. After the procedure, excess fluid should be removed. Another way to test for an open joint is with imaging to check for intra-articular air. Plain films may be adequate if positive and are a good initial test, but CT is better and has been shown to be superior to saline load testing, at least in the case of knees (100% vs. 92% sensitive in 32 open knees) .
In the case at hand, the patient developed a septic joint two months after his initial injury. Unfortunately from the limited information available for this case, it is unclear if saline load testing or any type of imaging was done in order to evaluate for an open joint. If either was performed and was negative, then my opinion is that the standard of care was met and this is reasonable care with respect to the open joint. If neither evaluation was done, then my opinion is that this was not reasonable care. With respect to the partial tendon injury, these do not usually require repair and if that was the case here, there were likely no damages caused by the delayed diagnosis. Finally, with respect to the staple remover, the facts of the case are unclear as there is conflicting testimony. Nevertheless, the lesson here is that it may be unwise to send a patient home with a staple remover unless the care plan for staple removal is both clearly delineated and documented. Remember, sometimes the road to hell actually is paved with good intentions.