Arthrocentesis: Difference between revisions
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== Indications ==
==Indications==
{{Hip anatomy background images}}
[[File:Gray344.png|thumb|Cross section of the right hip at the level of the acetabulum.]]
{{Arthrocentesis indications}}


Diagnosis
==Contraindications==
{{Arthrocentesis contraindications}}


*suspicion of septic arthritis, crystal induced arthritis
==Equipment Needed==
*evaluation of therapeutic response for septic arthritis
{{Arthrocentesis equipment}}
*unexplained arthritis with synovial effusion


=== Relative Indications  ===
==Procedure==
===General Setup===
*Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
*Drape joint in sterile fashion
*Inject lidocaine with 25-30ga needle superficially and then into deeper tissues
*Insert 18ga needle (for larger joints) into joint space while pulling back on syringe
*Stop once you aspirate fluid; aspirate as much fluid as possible
**Send: cell count, culture, [[Gram Stain]], crystal analysis


Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)
===Specific Procedure===
''See joint-specific page for procedures''
*[[Arthrocentesis: shoulder]]
*[[Arthrocentesis: elbow]]
*[[Arthrocentesis: wrist]]
*[[Arthrocentesis: finger]]
*[[Arthrocentesis: hip]]
*[[Arthrocentesis: knee]]
*[[Arthrocentesis: toe]]


== Contraindications  ==
==Complications==
{{General arthrocentesis complications}}


#No absolute contraindications for diagnostic arthrocentesis
==Evaluation==
#do not inject steroids into a joint that you suspect or know to be infected
{{Arthrocentesis diagnostic chart}}
#Relative Contraindications:
##coagulopathy
##local or systemic infection


== Equipment Needed  ==
==See Also==
*Arthrocentesis
**[[Arthrocentesis: shoulder]]
**[[Arthrocentesis: elbow]]
**[[Arthrocentesis: wrist]]
**[[Arthrocentesis: finger]]
**[[Arthrocentesis: hip]]
**[[Arthrocentesis: knee]]
**[[Arthrocentesis: ankle]]
**[[Arthrocentesis: toe]]
*[[Septic arthritis]]
*[[Septic arthritis (peds)]]


#Betadine or Chlorhexadine
==External Links==
#Sterile Gloves/drape
*http://www.youtube.com/watch?v=fZ2dcZhoGP8 Arthrocentesis
#sterile gauze
*http://emprocedures.com/arthrocentesis/introduction.htm
#Lidocaine
#Syringes
##small syringe (6-12cc) for injection of local anesthetic
##Large (one 60cc or 2 30cc) syringe for aspiration
#Needles
##18 gauges
##27 gauge
#Collection tubes (red tops)
#Culture bottles
#adhesive bandage


== Procedure  ==
==References==
<references/>


#Position the patient in a way so that they are comfortable and so you have easy access to the joint that you are going to tap (see below for positioning pearls)
[[Category:Procedures]]  
#Prep the area with betadine or chlorhexadine using circular motion moving away from the joint x 3. Drape the joint in a sterile fashion
[[Category:Orthopedics]]
#Inject lidocaine superficially and then into the deeper tissues
#Confirm landmarks and then insert the needle into the joint space while you are simultaneously pulling back on the plunger of the syringe. Stop once you aspirate fluid and aspirate as much fluid as possible (you may need to replace the syringe multiple times to get larger volumes)
#Once fluid is removed, remove the needle and apply adhesive bandage
 
== Approach  ==
 
=== Shoulder  ===
 
#anterior approach: have patient sitting with should in external rotation. Insert needle anteriorly below the tip of the coracoid medial to the humeral head directing it posterolaterally
#posterior approach: same as anterior approach except needle is inserted on the posterior side of the shoulder
 
=== Elbow  ===
 
#Have patient sitting with elbow in 90 degrees of flexion, forearm pronated, palm facing downward
#insert needle within triangle bounded by radial head, lateral humeral epicondyle, and olecranon directing it toward the medial epicondyle
 
=== Wrist  ===
 
#3-4 portal approach: have wrist in slight flexion and ulnar deviation. Insert needle dorsally just distal to Lister's tubercle (bony prominence over the dorsum of the distal radius) and ulnar to the extensor pollicus longus
 
=== Metacarpophalangeal  ===
 
#have palm facing down and apply gentle traction to the affected digit
#insert needle dorsally just medial or lateral to midline and proximal to the base of the proximal phalanx
 
=== Interphalangeal  ===
 
#have palm facing down and apply gentle traction to the affected digit
#insert needle dorsally medial or lateral to midline and proximal to base of middle or distal phalanx
 
=== Knee  ===
 
#Inferior-medial approach: knee flexed at 90 degrees and needle inserted between patella tendon, medial femoral condyle, and medial tibial plateau
#Medial approach: knee extended and needle inserted 1-2cm medial to patella just distal to proximal edge of the patella directing it posteriorly beneath the patella
 
=== Ankle  ===
 
#plantarflex the ankle and locate the medial malleolus and anterior tibialis tendon
#Insert needle 1/2 inch above medial malleolus, 1/2 inch lateral to anterior edge of medial malleolus, and medial to the anterior tibialis tendon advancing it posteriorly
 
=== Metatarsophalangeal  ===
 
#patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction
#insert needle dorsally just medial or lateral to midline between the metatarsal head and base of proximal phalanx
 
=== Interphalangeal  ===
 
#patient supine with joint flexed 15-20 degrees with gentle traction
#insert needle dorsally, medial or lateral to midline between head of proximal phalanx and base of more distal phalanx
 
== Complications  ==
 
#pain
#infection
#reaccumulation of effusion
#damage to tendons, nerves, or blood vessels
 
== See Also  ==
 
[[Septic Arthritis (General)]]
 
[[Monoarticular Arthritis]]
 
[[Septic Arthritis (Hip)]]
 
[[Septic Arthritis (Peds)]]
 
== Source  ==
 
http://emprocedures.com/arthrocentesis/introduction.htm
 
[[Category:Procedures]] [[Category:Ortho]]

Latest revision as of 21:51, 26 February 2025

Indications

Hip anatomy.
Extracapsular ligaments (anterior right hip).
Extracapsular ligaments (posterior right hip).
Cross section of the right hip at the level of the acetabulum.

General arthrocentesis indications

  • Suspicion of septic arthritis
  • Suspicion of crystal induced arthritis
  • Evaluation of therapeutic response for septic arthritis
  • Unexplained arthritis with synovial effusion
  • Evaluation of joint capsule integrity if overlying laceration
  • Relative: therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)

Contraindications

General arthrocentesis contraindications

  • No absolute contraindications for diagnostic arthrocentesis
  • Do not inject steroids into a joint that you suspect is already infected
  • Relative Contraindications:

Equipment Needed

General arthrocentesis equipment

  • Betadine or Chlorhexadine
  • Sterile gloves/drape
  • Sterile gauze
  • Lidocaine
  • Syringes
    • Small syringe (6-12cc) for injection of local anesthetic
    • Large syringe (one 60cc or two 30cc) for aspiration
  • Needles
    • 18 gauge: knee
    • 20 gauge: most other joints
    • 25 gauge: MTP joints
    • 27 gauge for anesthetic injection
  • Collection tubes (red top and purple for crystal analysis)
  • Culture bottles
  • Consider utilizing U/S to assess for effusion

Procedure

General Setup

  • Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
  • Drape joint in sterile fashion
  • Inject lidocaine with 25-30ga needle superficially and then into deeper tissues
  • Insert 18ga needle (for larger joints) into joint space while pulling back on syringe
  • Stop once you aspirate fluid; aspirate as much fluid as possible
    • Send: cell count, culture, Gram Stain, crystal analysis

Specific Procedure

See joint-specific page for procedures

Complications

General arthrocentesis complications

  • Pain
  • Infection
  • Re-accumulation of effusion
  • Damage to tendons, nerves, or blood vessels

Evaluation

Arthrocentesis of synoval fluid

Synovium Normal Noninflammatory Inflammatory Septic
Clarity Transparent Transparent Cloudy Cloudy
Color Clear Yellow Yellow Yellow
WBC <200 <200-2000 200-50,000

>1,100 (prosthetic joint)

>25,000; LR=2.9

>50,000; LR=7.7

>100,000; LR=28

PMN <25% <25% >50%

>64% (prosthetic joint)

>90%

Culture Neg Neg Neg >50% positive
Lactate <5.6 mmol/L <5.6 mmol/L <5.6 mmol/L >5.6 mmol/L
LDH <250 <250 <250 >250
Crystals None None Multiple or none None
  • Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
  • The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000[1]

See Also

External Links

References

  1. ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.
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