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Clinical Procedures > Musculoskeletal Procedures
Injection, Intra-Articular Methylene Blue
Article Last Updated: Jun 11, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Editors: Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
intra-articular methylene blue injection, methylene blue, joint injection, open joint injury, open fracture, soft tissue injury, periarticular fracture, visible joint capsule, open knee injury, open joint capsule, joint capsule assessment, open injury assessment
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
Intra-articular methylene blue injection video clip.
For more information on aspiration techniques, see eMedicine Orthopedic Surgery article Aspiration Techniques and Indications for Surgery, Septic Arthritis.
For a more diverse discussion of injury diagnosis and care, see Medscape Trauma Resource Center and Wound Management Resource Center.
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, although the following situations highly suggest 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
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. See Technique for precise details.
- 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
- Positioning varies based on the joint in question.
- 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. Fill at least one 20- or 30-mL syringe with the dark 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 the within the wound and working outward. Repeat the scrubbing process at least 2 more times. Cover the joint with sterile drapes to create a sterile field.
Skin preparation. - Select a joint injection approach that is as far as possible from the skin wound. Make sure to avoid any neurovascular structures.
Identify the injection site. - Elevate a skin wheal of local anesthetic using a 25-gauge needle.
Skin wheal elevation. - Switch to a 21- or 18-gauge needle and continue to inject lidocaine in the subcutaneous and deeper soft tissues until the joint space is entered. Entry into the joint space can be confirmed by increased ease of injection and by aspiration of joint fluid (which is likely to be bloody rather than its normal straw-colored appearance).
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.
Switching syringes. - Inject the solution into the joint until it is fully distended. (The required volume to fully distend a joint varies between different joints and patients.) Watch the wound site for contrast extravasation.
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 requires immediate administration of intravenous antibiotics and emergent 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.2, 3 The authors recommend that the fluorescein solution and normal saline solution be tested for fluorescence with a Wood lamp before injection into the joint.
- 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.
- Select a joint injection approach that is as far as possible from the skin wound. Make sure to avoid any neurovascular structures.
- This is a painful procedure that involves distention of the joint capsule (similar to arthroscopy); therefore, both parenteral analgesia and local anesthesia are indicated.5, 6
- 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 requires immediate administration of intravenous antibiotics7 and emergent (within 6 hours) orthopedic evaluation for exploration and irrigation of the joint.
- Aspirate back as much fluid as possible before withdrawing the needle.
- Infection: As with any other invasive procedure, infection may be introduced.7, 8 However, if infection occurs, introduction of infectious organisms is likely to have occurred by means of an open joint injury itself.
- 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 to 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.
The authors and editors of eMedicine gratefully acknowledge the assistance of Lars Grimm with the literature review and referencing for this article.
| Media file 1:
Adding methylene blue to normal saline solution. |
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| Media file 5:
Local anesthetic infiltration and entry into the joint space. |
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| Media file 8:
Intra-articular methylene blue injection video clip. |
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- Collins DN, Temple SD. Open joint injuries. Classification and treatment. Clin Orthop Relat Res. Jun 1989;48-56. [Medline].
- 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. Feb 2008;466(2):432-5. [Medline].
- 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. Aug 2007;21(7):442-3. [Medline].
- 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. May 2007;15(5):573-7. [Medline].
- Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity in human articular chondrocytes. J Bone Joint Surg Am. May 2008;90(5):986-91. [Medline].
- Lavelle W, Lavelle ED, Lavelle L. Intra-articular injections. Anesthesiol Clin. Dec 2007;25(4):853-62, viii. [Medline].
- 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. Dec 1975;57(8):1065-70. [Medline].
- 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. Apr 2008;12(3):261-5. [Medline].
- Stewart R, Myers J, Dent S. Wounds, bites, and stings. In: Moore E, Feliciano D, Mattox K. Trauma. 5th ed. New York: McGraw-Hill; 2004.
Injection, Intra-Articular Methylene Blue excerpt Article Last Updated: Jun 11, 2008
Topic originally published: Jun 11, 2008
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