Arthrocentesis: Difference between revisions

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== Indications ==
==Indications==
*Suspicion of septic arthritis
{{Hip anatomy background images}}
*Suspicion of crystal induced arthritis
[[File:Gray344.png|thumb|Cross section of the right hip at the level of the acetabulum.]]
*Evaluation of therapeutic response for septic arthritis
{{Arthrocentesis indications}}
*Unexplained arthritis with synovial effusion


=== Relative Indications  ===
==Contraindications==
*Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)
{{Arthrocentesis contraindications}}


== Contraindications  ==
==Equipment Needed==
#No absolute contraindications for diagnostic arthrocentesis
{{Arthrocentesis equipment}}
#Do not inject steroids into a joint that you suspect is already infected
#Relative Contraindications:
##Overlying cellulitis
##Coagulopathy
##Joint prosthesis (refer to ortho)


== Equipment Needed  ==
==Procedure==
#Betadine or Chlorhexadine
===General Setup===
#Sterile gloves/drape
*Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
#Sterile gauze
*Drape joint in sterile fashion
#Lidocaine
*Inject lidocaine with 25-30ga needle superficially and then into deeper tissues
#Syringes
*Insert 18ga needle (for larger joints) into joint space while pulling back on syringe  
##Small syringe (6-12cc) for injection of local anesthetic
*Stop once you aspirate fluid; aspirate as much fluid as possible
##Large syringe (one 60cc or two 30cc) for aspiration
**Send: cell count, culture, [[Gram Stain]], crystal analysis
#Needles
##18 gauge
##27 gauge
#Collection tubes (red top)
#Culture bottles


== Procedure ==
===Specific Procedure===
#Prep area w/ betadine or chlorhexadine using circular motion moving away from joint x 3
''See joint-specific page for procedures''
#Drape joint in sterile fashion
*[[Arthrocentesis: shoulder]]
#Inject lidocaine w/ 25-30ga needle superficially and then into deeper tissues
*[[Arthrocentesis: elbow]]
#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
*[[Arthrocentesis: wrist]]
##Send: cell count, culture, Gram stain, crystal analysis
*[[Arthrocentesis: finger]]
*[[Arthrocentesis: hip]]
*[[Arthrocentesis: knee]]
*[[Arthrocentesis: toe]]


== Approach  ==
==Complications==
=== Shoulder  ===
{{General arthrocentesis complications}}
#Anterior approach
##Sit pt upright facing you
##Insert needle just lateral to coracoid process (between coracoid process and humeral head)
##Direct needle posteriorly
#Posterior Approach
##Sit pt upright w/ back facing you
##Palpate scapular spine to its lateral limit (the acromion)
##Identify the posterolateral corner of the acromion
##Insert 1.5in needle 1 cm inferior and 1 cm medial to this corner
##Direct needle anterior and medial toward presumed position of coracoid process
##Glenohumeral joint is located at a depth of approximately 1-1.5in


=== Elbow  ===
==Evaluation==
#Place elbow in 90' flexion, resting on a table, w/ hand prone
{{Arthrocentesis diagnostic chart}}
#Locate radial head, lateral epicondyle , and lateral aspect of olecranon tip
##These landmarks form the anconeus triangle
#Palpate a sulcus just proximal to the radial head (in the middle of the triangle)
#Insert needle into sulcus directed medial and perpendicular to radius toward distal end of antecubital fossa
[[File:Shoulder Arthrocentesis.jpg]]


=== Wrist  ===
==See Also==
#Palpate landmarks w/ wrist in neutral position:
*Arthrocentesis
##Radial tubercle of distal radius
**[[Arthrocentesis: shoulder]]
##Anatomic snuffbox
**[[Arthrocentesis: elbow]]
##Extensor pollicis longus tendon
**[[Arthrocentesis: wrist]]
##Common extensor tendon of index finger  
**[[Arthrocentesis: finger]]
#Insert needle perpendicular to skin, ulnar to radial tubercle and anatomic snuffbox, between extensor pollicis longus and common extensor tendons
**[[Arthrocentesis: hip]]
[[File:Wrist Arthrocentesis.jpg]]
**[[Arthrocentesis: knee]]
**[[Arthrocentesis: ankle]]
**[[Arthrocentesis: toe]]
*[[Septic arthritis]]
*[[Septic arthritis (peds)]]


=== Knee  ===
==External Links==
#Can be entered medially or laterally to the patella
*http://www.youtube.com/watch?v=fZ2dcZhoGP8 Arthrocentesis
#Fully extend knee and ensure quadriceps muscle is relaxed
*http://emprocedures.com/arthrocentesis/introduction.htm
#Identify midpoint of patella; insert needle either lateral or medial
#Direct needle posterior to patella and horizontally toward the joint space
#Compression or "milking" applied to both sides of joint space may facilitate aspiration
 
=== Ankle  ===
#Lateral approach (subtalar)
##Keep foot perpendicular to leg
##Enter subtalar joint just below tip of lateral malleolus
##Direct needle medially toward joint space
#Medial approach (tibiotalar)
##Have pt supine w/ foot perpendicular to leg
##Palpate sulcus lateral to medial malleolus and medial to TA and EHL tendons
##Then plantarflex foot w/ needle entering skin overlying the sulcus
##Angle needle slightly cephalad as it passes between medial malleolus and TA tendon
 
=== 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
 
=== 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  ==
==References==
*Tintinalli
<references/>
*http://emprocedures.com/arthrocentesis/introduction.htm


[[Category:Procedures]] [[Category:Ortho]]
[[Category:Procedures]]  
[[Category:Orthopedics]]

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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