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Intra-articular Methylene Blue Injection

  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Jul 13, 2015
 

Overview

Background

Open joint injuries are skin and soft-tissue injuries that penetrate the joint space. Like open fractures, open joint injuries require timely diagnosis, exploration, and irrigation to minimize long-term morbidity and mortality. The procedure of intra-articular injection of methylene blue is an easy and safe way to identify disruption of the joint capsule and may facilitate early intervention.

Intra-articular injection of methylene blue that demonstrates extravasation of dye from the wound site is highly suggestive for open joint injury. In the absence of dye extravasation, open joint injury may still be present; therefore, an orthopedic consultation is recommended for all patients with a suspected open joint injury.[1]

The literature is inconclusive in regard to the sensitivity of this procedure for detection of joint capsule injuries, with reported sensitivities ranging from 31% to 99%. Some authors suggest that the diagnostic accuracy of the saline-load test is unacceptably low; others suggest that the test is still clinically relevant, in that patients with a negative test result and no clinical or imaging evidence of an arthrotomy appear to have an infection rate of 0% with nonoperative management.[2, 3, 4]

For more information on aspiration techniques, see Aspiration Techniques and Indications for Surgery, Septic Arthritis.

Indications

Indications for methylene blue injection include soft-tissue injury associated with at least one of the following:

  • Periarticular fracture
  • Visible joint capsule
  • Proximity to a joint

Contraindications

No absolute contraindications exist for intra-articular joint injection, though the following situations are strongly suggestive of open joint injury and therefore require joint exploration and irrigation regardless of the results of intra-articular joint injection:

  • Open fracture with obvious joint involvement on plain radiographs
  • Intra-articular air or foreign bodies on plain radiographs

The US Food and Drug Administration (FDA) warns against the concurrent use of methylene blue with serotonergic psychiatric drugs, unless it is indicated for life-threatening or urgent conditions. Methylene blue may increase serotonin levels in the central nervous system (CNS) as a result of monoamine oxidase A (MAO-A) inhibition, increasing the risk of serotonin syndrome.[5]

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Periprocedural Care

Equipment

Equipment used for intra-articular injection of methylene blue includes the following:

  • Sterile preparation solution and surgical scrubs
  • Sterile drapes
  • Sterile gloves
  • Sterile bowl
  • Normal saline bottle (approximately 500 mL)
  • Sterile methylene blue or fluorescein dye
  • Syringes, 12-mL and 20- or 30-mL
  • Needles, 18- and 21-gauge
  • Local anesthetic solution
  • Sterile 4 X 4 gauze pads

Patient preparation

For anesthesia, inject a local anesthetic agent such as 1% lidocaine subcutaneously until a skin wheal appears before entering the joint space. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Positioning varies according to the joint that is to undergo injection.  ↵

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Technique

Approach considerations

Intra-articular injection of dye requires the ability to create enough dye pressure to distend the joint capsule and maximize the chances to visualize dye extravasation from the wound. An 18-gauge needle is the recommended gauge for injection or aspiration of most adult joints.

This is a painful procedure that involves distention of the joint capsule (similar to arthroscopy); therefore, both parenteral analgesia and local anesthesia are indicated.[8, 9]

Select a joint injection approach that is as far as possible from the skin wound. Make sure to avoid any neurovascular structures. Aspirate back as much fluid as possible before withdrawing the needle.

Intra-articular injection of methylene blue that demonstrates extravasation of dye from the wound site is highly suggestive of open joint injury. In the absence of dye extravasation, open joint injury may still be present; therefore, an orthopedic consultation is recommended for all patients with a suspected open joint injury. Extravasation of contrast from an open joint injury necessitates immediate administration of intravenous (IV) antibiotics[10] and emergency (≤6 hours) orthopedic evaluation for exploration and irrigation of the joint.

An alternative technique that can be used in patients who are allergic to methylene blue is injection of sterile fluorescein in normal saline solution into the joint space.[6, 7] The authors recommend that the fluorescein solution and normal saline solution be tested for fluorescence with a Wood lamp before injection into the joint.

Injection of methylene blue into joint

Obtain informed consent from the patient.

On a sterile drape, open the sterile bowl, syringes, and needles. Pour the sterile normal saline solution into the sterile bowl, and add 1-2 mL of methylene blue to create a dark solution (see the image below). Fill at least one 20- or 30-mL syringe with the dark solution.

Adding methylene blue to normal saline solution. Adding methylene blue to normal saline solution.

After providing appropriate parenteral analgesia, cleanse a wide field by scrubbing the affected joint with a sterile preparation or a surgical scrub in circular motions, starting from within the wound and working outward (see the image below). Repeat the scrubbing process at least two more times. Cover the joint with sterile drapes to create a sterile field.

Skin preparation. Skin preparation.

Select a joint injection approach that is as far as possible from the skin wound (see the image below). Make sure to avoid any neurovascular structures.

Identify the injection site. Identify the injection site.

Elevate a skin wheal of local anesthetic using a 25-gauge needle (see the image below).

Skin wheal elevation. Skin wheal elevation.

Switch to a 21- or 18-gauge needle, and continue to inject lidocaine into the subcutaneous and deeper soft tissues until the joint space is entered (see the image below). Entry into the joint space can be confirmed by increased ease of injection and by aspiration of joint fluid (which is likely to appear bloody rather than its normal straw color).

Local anesthetic infiltration and entry into the j Local anesthetic infiltration and entry into the joint space.

Once the joint capsule is entered, secure the needle in the joint space with the nondominant hand while using the dominant hand to switch to the 20- to 30-mL syringe that contains the normal saline and dye solution (see the image below).

Switching syringes. Switching syringes.

Inject the solution into the joint until it is fully distended. (The volume required to distend a joint fully varies among different joints and patients.) Watch the wound site for contrast extravasation (see the image below).

Dye extravasation from an open knee injury. Dye extravasation from an open knee injury.

Aspirate back as much fluid as possible and withdraw the needle.

Clean the skin and wound with remaining preparation solution, and apply a sterile dressing over the wound and injection site. Extravasation of contrast from an open joint injury calls immediate administration of IV antibiotics and emergency orthopedic evaluation for exploration and irrigation of the joint.

The procedure is depicted in the video below.

Intra-articular methylene blue injection video clip.

Complications

Potential complications of intra-articular injection of methylene blue include the following:

  • Infection - As with any other invasive procedure, infection may be introduced [10, 11] ; however, if infection occurs, introduction of infectious organisms is likely to have occurred by means of the open joint injury itself rather than the injection
  • Bleeding or nerve injury - Proper technique and awareness of normal anatomy should minimize the chances of injuring a neurovascular structure
  • False-negative result from injection - Small open defects in a joint capsule or failure to inject enough dye into the joint to allow dye extravasation might lead to a false-negative intra-articular dye injection result; consultation with an orthopedic surgeon is recommended in all cases of suspected open joint injury
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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.

References
  1. Collins DN, Temple SD. Open joint injuries. Classification and treatment. Clin Orthop Relat Res. 1989 Jun. 48-56. [Medline].

  2. Nord RM, Quach T, Walsh M, Pereira D, Tejwani NC. Detection of traumatic arthrotomy of the knee using the saline solution load test. J Bone Joint Surg Am. 2009 Jan. 91(1):66-70. [Medline].

  3. Metzger P, Carney J, Kuhn K, Booher K, Mazurek M. Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies. J Orthop Trauma. 2012 Jun. 26(6):347-9. [Medline].

  4. Konda SR, Howard D, Davidovitch RI, Egol KA. The Saline Load Test of the Knee Redefined: A Test to Detect Traumatic Arthrotomies and Rule-out Periarticular Wounds Not Requiring Surgical Intervention. J Orthop Trauma. 2013 Jan 2. [Medline].

  5. US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when methylene blue is given to patients taking certain psychiatric medications. Available at http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm. Accessed: July 27, 2011.

  6. Tornetta P 3rd, Boes MT, Schepsis AA, Foster TE, Bhandari M, Garcia E. How effective is a saline arthrogram for wounds around the knee?. Clin Orthop Relat Res. 2008 Feb. 466(2):432-5. [Medline].

  7. Keese GR, Boody AR, Wongworawat MD, Jobe CM. The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. J Orthop Trauma. 2007 Aug. 21(7):442-3. [Medline].

  8. Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity in human articular chondrocytes. J Bone Joint Surg Am. 2008 May. 90(5):986-91. [Medline].

  9. Lavelle W, Lavelle ED, Lavelle L. Intra-articular injections. Anesthesiol Clin. 2007 Dec. 25(4):853-62, viii. [Medline].

  10. Patzakis MJ, Dorr LD, Ivler D, Moore TM, Harvey JP Jr. The early management of open joint injuries. A prospective study of one hundred and forty patients. J Bone Joint Surg Am. 1975 Dec. 57(8):1065-70. [Medline].

  11. Hoelzer BC, Weingarten TN, Hooten WM, Wright RS, Wilson WR, Wilson PR. Paraspinal abscess complicated by endocarditis following a facet joint injection. Eur J Pain. 2008 Apr. 12(3):261-5. [Medline].

  12. Esenyel C, Demirhan M, Esenyel M, Sonmez M, Kahraman S, Senel B, et al. Comparison of four different intra-articular injection sites in the knee: a cadaver study. Knee Surg Sports Traumatol Arthrosc. 2007 May. 15(5):573-7. [Medline].

  13. Stewart R, Myers J, Dent S. Wounds, bites, and stings. Moore E, Feliciano D, Mattox K. Trauma. 5th ed. New York: McGraw-Hill; 2004.

 
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Adding methylene blue to normal saline solution.
Skin preparation.
Identify the injection site.
Skin wheal elevation.
Local anesthetic infiltration and entry into the joint space.
Switching syringes.
Dye extravasation from an open knee injury.
Intra-articular methylene blue injection video clip.
 
 
 
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