Arthrocentesis: Difference between revisions
 
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==Indications==
==Indications==
*Suspicion of septic arthritis
{{Arthrocentesis indications}}
*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==
==Contraindications==
*No absolute contraindications for diagnostic arthrocentesis
{{Arthrocentesis contraindications}}
*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
{{Arthrocentesis equipment}}
*Sterile gloves/drape
*Sterile gauze
*[[Lidocaine]]
*Syringes
**Small syringe (6-12cc) for injection of [[Local anesthetics|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==
===General Setup===
*Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
*Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
*Drape joint in sterile fashion  
*Drape joint in sterile fashion  
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**Send: cell count, culture, [[Gram Stain]], crystal analysis
**Send: cell count, culture, [[Gram Stain]], crystal analysis


==Approach==
===Specific Procedure===
===Shoulder===
''See joint-specific page for procedures''
[[File:Shoulder Arthrocentesis.jpg|thumb|Shoulder arthrocentesis]]
*[[Arthrocentesis: shoulder]]
*Anterior approach
*[[Arthrocentesis: elbow]]
**Sit patient upright facing you
*[[Arthrocentesis: wrist]]
**Insert needle just lateral to coracoid process (between coracoid process and humeral head)
*[[Arthrocentesis: finger]]
**Direct needle posteriorly
*[[Arthrocentesis: hip]]
*Posterior Approach
*[[Arthrocentesis: knee]]
**Sit patient upright with back facing you
*[[Arthrocentesis: toe]]
**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 90<sup>o</sup> flexion, resting on a table, with 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===
[[File:Wrist Arthrocentesis.jpg|thumb|Wrist arthrocentesis]]
*Palpate landmarks with 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 patient supine with foot perpendicular to leg
**Palpate sulcus lateral to medial malleolus and medial to TA and EHL tendons
**Then plantarflex foot with 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>===
*Should only be done under [[ultrasound]] 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 patient'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==
==Complications==
*Pain
{{General arthrocentesis complications}}
*Infection
*Re-accumulation of effusion
*Damage to tendons, nerves, or blood vessels


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


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==References==
==References==
<references/>
<references/>
==Video==
{{#widget:YouTube|id=V8idT6fwU0Q}}


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

Latest revision as of 22:39, 13 May 2021

Indications

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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