Arthrocentesis: Difference between revisions
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== Indications  ==
== Indications  ==
 
*Suspicion of septic arthritis
Diagnosis
*Suspicion of crystal induced arthritis  
 
*Evaluation of therapeutic response for septic arthritis  
*suspicion of septic arthritis, crystal induced arthritis  
*Unexplained arthritis with synovial effusion
*evaluation of therapeutic response for septic arthritis  
*unexplained arthritis with synovial effusion


=== Relative Indications  ===
=== Relative Indications  ===
 
*Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)
Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)  


== Contraindications  ==
== Contraindications  ==
#No absolute contraindications for diagnostic arthrocentesis  
#No absolute contraindications for diagnostic arthrocentesis  
#do not inject steroids into a joint that you suspect or know to be infected  
#Do not inject steroids into a joint that you suspect is already infected  
#Relative Contraindications:  
#Relative Contraindications:  
##coagulopathy
##Overlying cellulitis
##local or systemic infection
##Coagulopathy
##Joint prosthesis (refer to ortho)
##Joint prosthesis (refer to ortho)


== Equipment Needed  ==
== Equipment Needed  ==
#Betadine or Chlorhexadine  
#Betadine or Chlorhexadine  
#Sterile Gloves/drape  
#Sterile gloves/drape  
#sterile gauze  
#Sterile gauze  
#Lidocaine  
#Lidocaine  
#Syringes  
#Syringes  
##small syringe (6-12cc) for injection of local anesthetic  
##Small syringe (6-12cc) for injection of local anesthetic  
##Large (one 60cc or 2 30cc) syringe for aspiration  
##Large syringe (one 60cc or two 30cc) for aspiration  
#Needles  
#Needles  
##18 gauges
##18 gauge
##27 gauge  
##27 gauge  
#Collection tubes (red tops)  
#Collection tubes (red top)  
#Culture bottles  
#Culture bottles  
#adhesive bandage


== Procedure  ==
== Procedure  ==
 
#Prep area w/ betadine or chlorhexadine using circular motion moving away from joint x 3
#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)
#Drape joint in sterile fashion  
#Prep the area with betadine or chlorhexadine using circular motion moving away from the joint x 3. Drape the joint in a sterile fashion  
#Inject lidocaine w/ 25-30ga needle superficially and then into deeper tissues
#Inject lidocaine superficially and then into the 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
#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)
##Send: cell count, culture, Gram stain, crystal analysis
#Once fluid is removed, remove the needle and apply adhesive bandage


== Approach  ==
== Approach  ==
=== Shoulder  ===
=== Shoulder  ===
 
#Anterior approach
#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
##Sit pt upright facing you
#posterior approach: same as anterior approach except needle is inserted on the posterior side of the shoulder
##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  ===
=== Elbow  ===
 
#Place elbow in 90' flexion, resting on a table, w/ hand prone
#Have patient sitting with elbow in 90 degrees of flexion, forearm pronated, palm facing downward
#Locate radial head, lateral epicondyle , and lateral aspect of olecranon tip
#insert needle within triangle bounded by radial head, lateral humeral epicondyle, and olecranon directing it toward the medial epicondyle
##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  ===
=== Wrist  ===
#Palpate landmarks w/ wrist in neutral position:
##Radial tubercle of distal radius
##Anatomic snuffbox
##Extensor pollicis longus tendon
##Common extensor tendon of index finger
#Insert needle perpendicular to skin, ulnar to radial tubercle and anatomic snuffbox, between extensor pollicis longus and common extensor tendons
[[File:Wrist Arthrocentesis.jpg]]


#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
=== Knee  ===
#Can be entered medially or laterally to the patella
#Fully extend knee and ensure quadriceps muscle is relaxed
#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  ===
=== Metacarpophalangeal  ===
#have palm facing down and apply gentle traction to the affected digit  
#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
#insert needle dorsally just medial or lateral to midline and proximal to the base of the proximal phalanx


=== Interphalangeal  ===
=== Interphalangeal  ===
#have palm facing down and apply gentle traction to the affected digit  
#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
#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  ===
=== Metatarsophalangeal  ===
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== Source  ==
== Source  ==
 
*Tintinalli
http://emprocedures.com/arthrocentesis/introduction.htm  
*http://emprocedures.com/arthrocentesis/introduction.htm  


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

Revision as of 20:09, 27 February 2012

Indications

  • Suspicion of septic arthritis
  • Suspicion of crystal induced arthritis
  • Evaluation of therapeutic response for septic arthritis
  • Unexplained arthritis with synovial effusion

Relative Indications

  • Therapeutic (decrease intra-articular pressure, injection of anesthetics/steroids)

Contraindications

  1. No absolute contraindications for diagnostic arthrocentesis
  2. Do not inject steroids into a joint that you suspect is already infected
  3. Relative Contraindications:
    1. Overlying cellulitis
    2. Coagulopathy
    3. Joint prosthesis (refer to ortho)

Equipment Needed

  1. Betadine or Chlorhexadine
  2. Sterile gloves/drape
  3. Sterile gauze
  4. Lidocaine
  5. Syringes
    1. Small syringe (6-12cc) for injection of local anesthetic
    2. Large syringe (one 60cc or two 30cc) for aspiration
  6. Needles
    1. 18 gauge
    2. 27 gauge
  7. Collection tubes (red top)
  8. Culture bottles

Procedure

  1. Prep area w/ betadine or chlorhexadine using circular motion moving away from joint x 3
  2. Drape joint in sterile fashion
  3. Inject lidocaine w/ 25-30ga needle superficially and then into deeper tissues
  4. 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
    1. Send: cell count, culture, Gram stain, crystal analysis

Approach

Shoulder

  1. Anterior approach
    1. Sit pt upright facing you
    2. Insert needle just lateral to coracoid process (between coracoid process and humeral head)
    3. Direct needle posteriorly
  2. Posterior Approach
    1. Sit pt upright w/ back facing you
    2. Palpate scapular spine to its lateral limit (the acromion)
    3. Identify the posterolateral corner of the acromion
    4. Insert 1.5in needle 1 cm inferior and 1 cm medial to this corner
    5. Direct needle anterior and medial toward presumed position of coracoid process
    6. Glenohumeral joint is located at a depth of approximately 1-1.5in

Elbow

  1. Place elbow in 90' flexion, resting on a table, w/ hand prone
  2. Locate radial head, lateral epicondyle , and lateral aspect of olecranon tip
    1. These landmarks form the anconeus triangle
  3. Palpate a sulcus just proximal to the radial head (in the middle of the triangle)
  4. Insert needle into sulcus directed medial and perpendicular to radius toward distal end of antecubital fossa

Shoulder Arthrocentesis.jpg

Wrist

  1. Palpate landmarks w/ wrist in neutral position:
    1. Radial tubercle of distal radius
    2. Anatomic snuffbox
    3. Extensor pollicis longus tendon
    4. Common extensor tendon of index finger
  2. Insert needle perpendicular to skin, ulnar to radial tubercle and anatomic snuffbox, between extensor pollicis longus and common extensor tendons

Wrist Arthrocentesis.jpg

Knee

  1. Can be entered medially or laterally to the patella
  2. Fully extend knee and ensure quadriceps muscle is relaxed
  3. Identify midpoint of patella; insert needle either lateral or medial
  4. Direct needle posterior to patella and horizontally toward the joint space
  5. Compression or "milking" applied to both sides of joint space may facilitate aspiration

Ankle

  1. Lateral approach (subtalar)
    1. Keep foot perpendicular to leg
    2. Enter subtalar joint just below tip of lateral malleolus
    3. Direct needle medially toward joint space
  2. Medial approach (tibiotalar)
    1. Have pt supine w/ foot perpendicular to leg
    2. Palpate sulcus lateral to medial malleolus and medial to TA and EHL tendons
    3. Then plantarflex foot w/ needle entering skin overlying the sulcus
    4. Angle needle slightly cephalad as it passes between medial malleolus and TA tendon

Metacarpophalangeal

  1. have palm facing down and apply gentle traction to the affected digit
  2. insert needle dorsally just medial or lateral to midline and proximal to the base of the proximal phalanx

Interphalangeal

  1. have palm facing down and apply gentle traction to the affected digit
  2. insert needle dorsally medial or lateral to midline and proximal to base of middle or distal phalanx

Metatarsophalangeal

  1. patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction
  2. insert needle dorsally just medial or lateral to midline between the metatarsal head and base of proximal phalanx

Interphalangeal

  1. patient supine with joint flexed 15-20 degrees with gentle traction
  2. insert needle dorsally, medial or lateral to midline between head of proximal phalanx and base of more distal phalanx

Complications

  1. pain
  2. infection
  3. reaccumulation of effusion
  4. damage to tendons, nerves, or blood vessels

See Also

Septic Arthritis (General)

Monoarticular Arthritis

Septic Arthritis (Hip)

Septic Arthritis (Peds)

Source

Retrieved from "https://www.wikem.org/w/index.php?title=Arthrocentesis&oldid=8259"