Intra-articular Methylene Blue Injection

Updated: Apr 17, 2023
  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Erik D Schraga, MD  more...
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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 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. [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 have suggested that the diagnostic accuracy of the saline-load test is unacceptably low; others have suggested 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 Surgical Treatment of Septic Arthritis.



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


No absolute contraindications exist for intra-articular joint injection, though the following situations are strongly suggestive of open joint injury and therefore necessitate 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

In July 2011, the US Food and Drug Administration (FDA) warned 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, 6]