If the knee joint has clearly been violated due to penetrating injury, orthopedic consultation should be obtained for joint irrigation in the operating room. If penetration is suspected, but is in doubt, injection of the joint with sterile methylene blue can help to confirm the diagnosis. Extravasation of dye indicates penetration and the need for irrigation. Remember that the history obtained must recreate the position of the knee when the penetrating injury occurred. Many occupational injuries occur with the knee flexed, but the joint is examined with the knee resting in extension. Failure to anticipate the trajectory of injury with the knee flexed could lead to misdiagnosis and failure to anticipate joint penetration.
Radiopaque foreign bodies (i.e., metal, glass) will visualize on conventional radiographs. In general, foreign bodies in the knee joint need to be removed. A bullet in the joint can destroy the cartilage and lead poisoning can occur. 27 A bullet lodged in the bone only, however, does not necessitate removal. Antibiotics to cover streptococci and staphylococci are generally indicated for both penetrating knee wounds and foreign bodies. Tetanus prophylaxis should be administered if indicated.
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