Arthrocentesis: Difference between revisions
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== Contraindications == | == Contraindications == | ||
*No absolute contraindications for diagnostic arthrocentesis | |||
*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 == | == Equipment Needed == | ||
*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 guage: most other joints | |||
**25 guage: MTP joints | |||
**27 gauge for anesthetic injection | |||
*Collection tubes (red top and purple for crystal analysis) | |||
*Culture bottles | |||
*Consider [[Ultrasound: Joint|utilizing U/S to assess for effusion]] | |||
== Procedure == | == Procedure == | ||
*Prep area w/ betadine or chlorhexadine using circular motion moving away from joint x 3 | |||
*Drape joint in sterile fashion | |||
*Inject lidocaine w/ 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 | |||
== Approach == | == Approach == | ||
=== Shoulder === | === Shoulder === | ||
*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 1.5-in 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 === | ||
[[File:Shoulder Arthrocentesis.jpg|thumb|Shoulder arthrocentesis]] | [[File:Shoulder Arthrocentesis.jpg|thumb|Shoulder arthrocentesis]] | ||
*Place elbow in 90<sup>o</sup> flexion, resting on a table, w/ hand prone | |||
*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 | |||
=== Wrist === | === Wrist === | ||
[[File:Wrist Arthrocentesis.jpg|thumb|Wrist arthrocentesis]] | [[File:Wrist Arthrocentesis.jpg|thumb|Wrist arthrocentesis]] | ||
*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 | |||
===Knee=== | ===Knee=== | ||
*Can be entered medially or laterally to the patella, superior or inferior to patella | |||
*Fully extend knee and ensure quadriceps muscle is relaxed (optionally bump with 20 deg of flexion) | |||
**Place your thumb on the patella and slide it over as you enter with needle | |||
**For Suprapatellar Approach 1 cm lateral and 1 cm superior | |||
*Identify midpoint of patella; insert needle either 1 cm 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 === | === 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 | |||
=== Hip<ref>*Freeman, K., A. Dewitz, et al. (2007). "Ultrasound-guided hip arthrocentesis in the ED." Am J Emerg Med 25(1): 80-86.</ref>=== | === Hip<ref>*Freeman, K., A. Dewitz, et al. (2007). "Ultrasound-guided hip arthrocentesis in the ED." Am J Emerg Med 25(1): 80-86.</ref>=== | ||
*Should only be done under US guidance | |||
*Orient your probe along the axis of the femoral neck (indicator towards abdomen) | |||
*Identify Landmarks (Femoral V/A/N, Acetabular Labrum, Femoral Head/Neck) | |||
*Effusion will be seen between femoral head/neck and the iliopsoas muscle | |||
*Insert needle under probe, making sure that you know where pt's femoral V/A/N are | |||
===Metacarpophalangeal=== | ===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=== | ===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=== | ===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=== | ===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 == | == Complications == | ||
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*http://emprocedures.com/arthrocentesis/introduction.htm | *http://emprocedures.com/arthrocentesis/introduction.htm | ||
== | ==References == | ||
<references/> | <references/> | ||
[[Category:Procedures]] [[Category:Ortho]] | [[Category:Procedures]] | ||
[[Category:Ortho]] |
Revision as of 06:35, 6 May 2015
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
- No absolute contraindications for diagnostic arthrocentesis
- 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
- 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 guage: most other joints
- 25 guage: 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
- Prep area w/ betadine or chlorhexadine using circular motion moving away from joint x 3
- Drape joint in sterile fashion
- Inject lidocaine w/ 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
Approach
Shoulder
- 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 1.5-in 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
- Place elbow in 90o flexion, resting on a table, w/ hand prone
- 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
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
Knee
- Can be entered medially or laterally to the patella, superior or inferior to patella
- Fully extend knee and ensure quadriceps muscle is relaxed (optionally bump with 20 deg of flexion)
- Place your thumb on the patella and slide it over as you enter with needle
- For Suprapatellar Approach 1 cm lateral and 1 cm superior
- Identify midpoint of patella; insert needle either 1 cm 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
Hip[1]
- Should only be done under US guidance
- Orient your probe along the axis of the femoral neck (indicator towards abdomen)
- Identify Landmarks (Femoral V/A/N, Acetabular Labrum, Femoral Head/Neck)
- Effusion will be seen between femoral head/neck and the iliopsoas muscle
- Insert needle under probe, making sure that you know where pt's femoral V/A/N are
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
- Re-accumulation of effusion
- Damage to tendons, nerves, or blood vessels
Diagnosis
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[2]
See Also
- Septic Arthritis (General)
- Arthritis
- Monoarticular Arthritis
- Septic Arthritis (Hip)
- Septic Arthritis (Peds)