Arthrocentesis: Difference between revisions

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== Contraindications  ==
== Contraindications  ==
#No absolute contraindications for diagnostic arthrocentesis  
*No absolute contraindications for diagnostic arthrocentesis  
#Do not inject steroids into a joint that you suspect is already infected  
*Do not inject steroids into a joint that you suspect is already infected  
#Relative Contraindications:  
*Relative Contraindications:  
##Overlying cellulitis
**Overlying cellulitis
##Coagulopathy  
**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 syringe (one 60cc or two 30cc) for aspiration  
**Large syringe (one 60cc or two 30cc) for aspiration  
#Needles  
*Needles  
##18 gauge: knee
**18 gauge: knee
##20 guage: most other joints
**20 guage: most other joints
##25 guage: MTP joints  
**25 guage: MTP joints  
##27 gauge for anesthetic injection
**27 gauge for anesthetic injection
#Collection tubes (red top and purple for crystal analysis)
*Collection tubes (red top and purple for crystal analysis)
#Culture bottles
*Culture bottles
#Consider [[Ultrasound: Joint|utilizing U/S to assess for effusion]]
*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
*Prep area w/ betadine or chlorhexadine using circular motion moving away from joint x 3
#Drape joint in sterile fashion  
*Drape joint in sterile fashion  
#Inject lidocaine w/ 25-30ga needle superficially and then into deeper tissues
*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  
*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
*Stop once you aspirate fluid; aspirate as much fluid as possible
##Send: cell count, culture, [[Gram Stain]], crystal analysis
**Send: cell count, culture, [[Gram Stain]], crystal analysis


== Approach  ==
== Approach  ==
=== Shoulder  ===
=== Shoulder  ===
#Anterior approach
*Anterior approach
##Sit pt upright facing you
**Sit pt upright facing you
##Insert needle just lateral to coracoid process (between coracoid process and humeral head)
**Insert needle just lateral to coracoid process (between coracoid process and humeral head)
##Direct needle posteriorly
**Direct needle posteriorly
#Posterior Approach
*Posterior Approach
##Sit pt upright w/ back facing you
**Sit pt upright w/ back facing you
##Palpate scapular spine to its lateral limit (the acromion)
**Palpate scapular spine to its lateral limit (the acromion)
##Identify the posterolateral corner of the acromion
**Identify the posterolateral corner of the acromion
##Insert 1.5-in needle 1 cm inferior and 1 cm medial to this corner
**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
**Direct needle anterior and medial toward presumed position of coracoid process
##Glenohumeral joint is located at a depth of approximately 1-1.5in
**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
*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
*Locate radial head, lateral epicondyle , and lateral aspect of olecranon tip
##These landmarks form the anconeus triangle
**These landmarks form the anconeus triangle
#Palpate a sulcus just proximal to the radial head (in the middle of the 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
*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:
*Palpate landmarks w/ wrist in neutral position:
##Radial tubercle of distal radius
**Radial tubercle of distal radius
##Anatomic snuffbox
**Anatomic snuffbox
##Extensor pollicis longus tendon
**Extensor pollicis longus tendon
##Common extensor tendon of index finger  
**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
*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
*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)
*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
**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  
**For Suprapatellar Approach 1 cm lateral and 1 cm superior  
#Identify midpoint of patella; insert needle either 1 cm lateral or medial
*Identify midpoint of patella; insert needle either 1 cm lateral or medial
#Direct needle posterior to patella and horizontally toward the joint space
*Direct needle posterior to patella and horizontally toward the joint space
#Compression or "milking" applied to both sides of joint space may facilitate aspiration
*Compression or "milking" applied to both sides of joint space may facilitate aspiration


=== Ankle  ===
=== Ankle  ===
#Lateral approach (subtalar)  
*Lateral approach (subtalar)  
##Keep foot perpendicular to leg
**Keep foot perpendicular to leg
##Enter subtalar joint just below tip of lateral malleolus
**Enter subtalar joint just below tip of lateral malleolus
##Direct needle medially toward joint space
**Direct needle medially toward joint space
#Medial approach (tibiotalar)
*Medial approach (tibiotalar)
##Have pt supine w/ foot perpendicular to leg
**Have pt supine w/ foot perpendicular to leg
##Palpate sulcus lateral to medial malleolus and medial to TA and EHL tendons
**Palpate sulcus lateral to medial malleolus and medial to TA and EHL tendons
##Then plantarflex foot w/ needle entering skin overlying the sulcus
**Then plantarflex foot w/ needle entering skin overlying the sulcus
##Angle needle slightly cephalad as it passes between medial malleolus and TA tendon
**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
*Should only be done under US guidance
#Orient your probe along the axis of the femoral neck (indicator towards abdomen)
*Orient your probe along the axis of the femoral neck (indicator towards abdomen)
#Identify Landmarks (Femoral V/A/N, Acetabular Labrum, Femoral Head/Neck)
*Identify Landmarks (Femoral V/A/N, Acetabular Labrum, Femoral Head/Neck)
#Effusion will be seen between femoral head/neck and the iliopsoas muscle
*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
*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  
*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


===Metatarsophalangeal===
===Metatarsophalangeal===
#Patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction  
*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
*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  
*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
*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  


== Sources  ==
==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

Shoulder arthrocentesis
  • 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

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

  • 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

External Links

References

  1. *Freeman, K., A. Dewitz, et al. (2007). "Ultrasound-guided hip arthrocentesis in the ED." Am J Emerg Med 25(1): 80-86.
  2. 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.