Dr. Ashley Jacobson is an emergency medicine resident physician in Rochester, MN.
Dr. Sara Hevesi is an emergency medicine consultant physician in Rochester, MN.
Dr. Neha Raukar is an emergency medicine consultant physician in Rochester, MN.
The third Mayo EM residency journal club of the year met on September 16, hosted by consultant physician, Dr. Neha Raukar. We reviewed the original saline load test article by Patzakis in 19751, Konda’s 2013 article on CT scan to diagnose traumatic arthrotomy2, and the ACEP Now article by Strong.3 Due to COVID-19, we again opted to have a small in-person group meeting with additional participants joining via Zoom. We were happy to have one of our rotating medical students join this month. We also had a guest participant to give some valuable insights – Dr. Raukar’s husband, Dr. George Raukar, who is an orthopedic surgeon!
Dr. Paige Cardin presented on the Patzakis article. The main focus of the original article by Patzakis was on an antibiotic and irrigation system for patients presenting with penetrating joint injuries. The only mention of using a saline load test was as one way to diagnose penetrating joint injury. It did not mention procedural method nor comment on volume of fluid instilled. Overall, we felt that this article, while considered the gold standard and referred to by subsequent studies, left much to be desired in terms of using the saline load test as a clinical procedure.
Dr. Ashley Jacobson presented on the Konda article. This novel retrospective study assessed the sensitivity and specificity of CT to diagnose intra-articular air on knee lacerations concerning for joint involvement. The study found 100% sensitivity and 100% specificity of CT to detect intra-articular air with resultant traumatic arthrotomy. However, this study used development of a septic joint as the gold standard for diagnosing traumatic arthrotomy, but was underpowered to reach a conclusion. Konda also found that the saline load test was 92% sensitive and 92% specific when using a mean saline volume of 74 mL, though according to Robert and Hedges’ Clinical Procedures the recommended fluid volume for knee joints is 100-200 mL saline for accurate diagnosis.4
Dr. Jacobson also presented on the ACEP Now article by Strong. This article was a case presentation and did a great job of reviewing the literature on saline load testing and the initial Konda study on CT scans. The ultimate conclusion from the article was to discuss with the institution and learn its guidelines, discuss with the patient, and assess your own risk tolerance. Overall, they concluded that CT scan may be a valid option for diagnosing traumatic arthrotomy.
Overall, the discussion centered around utility of using CT for sole diagnosis of a traumatic arthrotomy. Many of the participants have not had much experience performing a saline load test, and hence felt they may be more comfortable using CT as a diagnostic test. The saline load test is more cost effective and saves radiation exposure and CT usage, however, CT scan is a painless way to diagnose this condition.
Our guest participant, Dr. George Raukar, an orthopedic surgeon, reminded us that care should be individualized to the patient and mechanism of injury, which offers a pretest probability of capsule violation. Since the studies were not powered enough to eliminate saline load test and replace it with CT, his recommendation is that we should learn the skill and use when indicated. It is likely that our consulting teams will still prefer we do the saline load test but would accept a positive finding on CT. Consensus was to use a patient-centered approach, consider shared decision making, and use clinical reasoning based upon the joint in question.
This Wednesday evening journal club was complete with dinner from CRAVE and home made apple cider. The next journal club will be October 22nd at 10am and will be a joint meeting with Regions Emergency Medicine Residency! Topic TBD!