The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Arthrocentesis

by Tarun Jolly with
Patrick Hymel

Indications
Prerequisites
Equipment
Preparation
Knee
Shoulder
Ankle
Elbow
Wrist
Digits
Complications
Fluid Analysis and Follow-up

Indications

• Therapeutic: greatly distended joint with tight effusion and pain
  
• Diagnostic: analysis of intra-articular fluid for:
  • Infection/septic joint
    
  • Trauma/hemarthrosis
    
  • Sympathetic effusion
    
  • Crystal-induced arthritis.

Prerequisites

• Patient should not exhibit:
  
• cellulitis or impetigo at aspiration site
  
• coagulopathy (relative)
  
• Exercise caution to avoid intraarticular injection of a local anesthetic.

Equipment

• Betadine solution
  
• Gauze dressings
  
• 2% lidocaine
  
• 5ml syringe and 25 gauge needle for local anesthetic administration
  
• Sterile towels
  
• 10 ml syringe
  
• A large bore needle (18 gauge, 1 1/2 inch)
  
• Sample tubes for lab specimens
  
• Heparin flush solution (100U/ml)
  
• Two microscopic slides
  
• Elastic bandages, if necessary
  

Preparation

1. Obtain consent for arthrocentesis
   
2. Pretreat collection syringes with small amount of heparin flush < 0.5 ml
   
3. Thoroughly prep the site for aspiration with serial betadine application in concentric arcs away from the site of aspiration performed in a sterile manner
   
4. Consider pretreatment of patient with ibuprofen or acetaminophen for pain control

Knee

Procedure

1. Position patient sitting with the leg hanging freely
   
2. Stand on the medial side of the leg, facing the knee
   
3. Prep and drape the medial aspect of the knee in a sterile fashion
   
4. The site for aspiration can be found over the joint line 2cm posterior from the patella
   
5. At the aspiration site, infiltrate the skin, subcutaneous tissue and periosteum with lidocaine
   
6. Using the 10ml heparin coated syringe to aspirate fluid from the joint
   
7. Removal of synovial fluid may require pressure to opposite side of joint to push fluid towards needle (elastic bandages may be wrapped around joint in order to generate fluid pressure as needed).

Shoulder

Procedure

1. Position patient sitting with arms at sides
   
2. Prep the anterior shoulder and drape in a sterile manner
   
3. Locate the groove along the anterior and medial edge of the humerus below the acromioclavicular joint approximately halfway to the axilla
   
4. Infiltrate anesthetic into the skin and subcutaneous tissue down to the medial edge of the humeral head
   
5. Move the needle around the medial edge of the humerus to find the shoulder joint
   Using the heparin-coated 10ml syringe with the 18 gauge needle, aspirate joint fluid

Ankle

Procedure

1. Position patient supine with foot in a neutral position
   
2. Stand on lateral side of ankle
   
3. Prep and drape in a sterile manner
4. Palpate the lateral malleolus and find the point 2.5 cm proximal and 1.5 cm medial to the tip of the lateral malleolus
   
5. Inject the skin and subcutaneous tissue in this area with about 2cc of 2% lidocaine
   
6. Use the 18 gauge needle and 10ml heparin-coated syringe to enter the articular space and aspirate fluid

Elbow

Procedure

1. Position patient supine with the arm abducted 45 to 90 degrees and the shoulder and elbow flexed 90 degrees with the palm flat on a table
   
2. Prep and drape in a sterile fashion
   
3. Palpate the space between the lateral epicondyle of the humerus and the head of the radius
   
4. Inject the skin and subcutaneous tissue in this area with about 2cc of 2% lidocaine
   
5. Use the 18 gauge needle and 10ml heparin-coated syringe to enter the articular space and aspirate fluid

Wrist

Procedure

1. Position patient with arm flat on table with palm down
   
2. Prep and drape in a sterile fashion
   
3. Palpate the groove just ulnar to the extensor pollicis longus tendon and directly superior to the anatomic snuff box
   
4. Inject the skin and subcutaneous tissue in this area with about 2cc of 2% lidocaine
   
5. Use the 18 gauge needle and 10ml heparin-coated syringe to enter the articular space and aspirate fluid

Digits

Procedure

1. Position patient with arm resting on a table, hand palm down, with fingers spread
   
2. Prep and drape in a sterile fashion
   
3. Prep entire hand and drape with only the appropriate digit exposed
   
4. Using your nondominant hand, flex the joint 20 to 30 degrees while applying distal traction
   
5. Just medial or lateral to the point where the extensor tendon crosses the joint space infiltrate superficially with I cc of 2% lidocaine
   
6. Using a 22 gauge, I inch needle and 5ml heparin-coated syringe, aspirate the joint fluid

Complications

• Joint infection
  
• Hemarthrosis resulting from bleeding into joint

Fluid Analysis and Follow-up

• Place fluid in red-topped, lavender-topped and culture tubes. Place a drop of fluid on a microscope slide for Gram stain.
  
• Send studies for cell count, specific gravity, pH, LDH, total protein, fluid analysis for crystals, and cultures for bacteria and mycobacterium
  
• Apply direct pressure to site for 2 minutes
  
• Address wound
  
• Apply bandage to stabilize wound if large amount of volume was aspirated
  
• Gram stain should be reviewed before giving intra-articular injections, especially corticosteroids!
  
• Apply ice and elevate to avoid swelling
  
• No excessive use of joint for a few days
  
• Report any swelling, pain, fever, or redness (possible indications of infection)
  
• Change dressing regularly
  
• Wear bandages as necessary to stabilize joint