joint aspiration (arthrocentesis)
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Indications
- pain relief
- diagnostic
- no history of trauma
- joint injury or activity-related
- intra-articular fracture
- ligamentous tear
- synovial or capsular tear
Contraindications
- absolute
- localized abscess or cellulitis at site of injection
- active Herpes simplex virus (HSV) or tuberculosis infection
- relative
- bleeding diathesis
- anticoagulant therapy
- anticoagulation is not a contraindication[2]
- safe in patients receiving direct oral anticoagulant therapy;
- no need to withhold anticoagulation before procedure[4]
- bacteremia
- joint prosthesis (infected prosthesis is exception)
Laboratory
- cell count with differential
- Gram stain, culture & sensitivity
- gram stain negative in 20% of septic arthritis, especially common with gram-negative organisms
- crystal analysis under polarized light
- urate: needle-shaped, negative birefringence
- calcium pyrophosphate: rhomboid-shaped, positive birefringence
- hydroxyapatite (basic calcium phosphate)
- serum glucose & joint fluid glucose
- 'string test': Normal fluid when gently pushed from syringe will form a 5-10 cm 'string'. With infection, the 'string' will be shorter
- tubes: red top & lavender top
Procedure
Preparation:
- obtain informed consent
- identify landmarks
- wide-field skin cleaning
- sterile glove
- sterile drape may be indicated
- consider ultrasound guidance[5]
Precautions:
- withdraw needle to subcutaneous tissue prior to redirecting needle
- avoid removing the needle completely & redirecting
Aspiration by joint:
- glenohumeral joint aspiration
- locate inferolateral border of coracoid process, the anterior border of the acromion, & the medial border of the humeral head
- insert 4 cm, 22 gauge needle in space between inferolateral border of coracoid & humeral head, direct posteriorly toward glenoid rim
- aspirate fluid for laboratory studies
- radiohumeral joint aspiration
- elbow flexed 90 degrees with hand pronated
- locate space between distal lateral epicondyle & proximal tip of olecranon process of radial head
- insert 4 cm, 22 gauge needle at a 90 degree angle to skin, direct medially & posterior
- aspirate fluid for laboratory studies
- knee
- patient supine with leg extended
- locate space between the superolateral border of the patella & the lateral femoral epicondyle
- insert 4 cm, 20 gauge needle (for septic joint, use 18 gauge needle) parallel to floor in space 1 cm lateral to the patellar border, direct towards under surface of patella, with the quadriceps relaxed, patella may be lifted to facilitate insertion,
- aspirate fluid for laboratory studies
- knee may have as much as 50-75 mL of fluid, have 2 35 cc syringes available for aspiration of fluid
- ankle
- patient supine, leg fully extended, foot partially plantar flexed
- locate joint line, 1 cm superior to the line joining the inferior borders of the malleoli, locate from medial to lateral the tibialis anterior tendon, the tendon to the extensor hallucis longus & the anterior tibial artery
- insert a 4 cm, 22 gauge needle along the joint line, avoiding the artery & tendons (lateral to the artery seems easiest), direct needle superiorly 2-3 cm into the joint space
- aspirate fluid for laboratory analysis
Radiology
- ultrasound guidance may improve success rate & avoid unnecessary joint aspirations[5]
Complications
- seizures from local anesthetic:
- subcutaneous swelling & pain after procedure:
- ice may attenuate
- post procedural infection
- damage to tendons
Differential diagnosis
- Bloody effusion:
- Fat Droplets: intra-articular fracture
- Purulent effusion:
- septic arthritis
- bacterial (including tuberculosis)
- fungal
- > 80,000 WBC/mm3
- > 90% neutrophils
- joint glucose < 50% of serum glucose
- septic arthritis
- Inflammatory effusion:
- etiology
- joint fluid
- 1000-50,000 WBC/mm3
- 30-50% lymphocytes
- 50-70% neutrophils
- crystal examination:
- uric acid (gout)
- rods or needles
- negatively birefringent (yellow) under polarized light
- calcium pyrophosphate dihydrate (pseudogout)
- rods, rectangles, or rhomboids
- weakly positive birefringent (blue) under polarized light
- uric acid (gout)
Management
- empiric antibiotic therapy while awaiting culture results
More general terms
More specific terms
Additional terms
- gout
- infectious arthritis (septic arthritis)
- pseudogout [calcium pyrophosphate dihydrate crystal deposition] or CPPD disease
- rheumatoid arthritis (RA)
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 779-781
- ↑ 2.0 2.1 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
- ↑ Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol. 2013 Apr;27(2):137-69 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23731929
- ↑ 4.0 4.1 Yui JC, Preskill C, Greenlund LS. Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 2017 Aug; 92:1223 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28778256 <Internet> http://www.mayoclinicproceedings.org/article/S0025-6196(17)30310-5/fulltext
- ↑ 5.0 5.1 5.2 Gibbons RC, Zanaboni A, Genninger J, Costantino TG. Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial. Acad Emerg Med 2022 Feb; 29:159 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34608713 https://onlinelibrary.wiley.com/doi/10.1111/acem.14396