Shoulder Arthrocentesis

To evacuate abnormal collections of fluid from the joint space for synovial fluid analysis, especially in the investigation of the following conditions:

Septic arthritis

Crystal arthropathy

Hemarthrosis

Inflammatory processes

To diagnose occult fracture or ligamentous injury

To decrease/relieve pressure in the joint for pain relief

To assess whether an overlying laceration extends into the joint space using methylene blue

To instill medication for treatment and pain relief

CONTRAINDICATIONS

Absolute Contraindications

Abscess/cellulitis in the tissue overlying the puncture site

Relative Contraindications

Known bacteremia

Bleeding diathesis or anticoagulant therapy

Prosthetic joint

General Basic Steps

Patient preparation

Sterile technique

Analgesia

Aspiration

LANDMARKS

Anterior Approach

Coracoid process and head of the humerus

Posterior Approach

Posterolateral edge of the acromion

SUPPLIES

Povidone–iodine or other antiseptic solution, drapes

Lidocaine with epinephrine

25- and 18-gauge needles, 20-mL syringe

Gauze pads, adhesive tape

TECHNIQUE

Patient Preparation

The patient should sit upright with arm in slight external rotation

Confirm landmarks and, if needed, mark the needle insertion point

Sterilize the needle insertion area with povidone–iodine solution or comparable skin antiseptic

Wipe injection site with alcohol to avoid introduction of iodine into synovium

Drape the area with sterile towels

Analgesia

Use a 25-gauge needle to raise a wheal of anesthetic

Inject lidocaine with epinephrine at the puncture site

Anesthetize the subcutaneous tissue and a track toward the joint

Avoid entering the joint space at this point if synovial fluid analysis is desired

Aspiration

Anterior Approach

Insert an 18-gauge needle attached to a 20-mL syringe just below and lateral to the coracoid process, medial to the head of the humerus

Point the needle posterolaterally to avoid the joint capsule

Gently aspirate while advancing the needle. The needle should be advanced approximately 3 cm or until fluid is aspirated (FIGURE 58.1).

Posterior Approach

Insert an 18-gauge needle attached to a 20-mL syringe 1 cm below and 1 cm medial to the posterolateral edge of the acromion

Aim the needle anteriorly toward the coracoid process

Gently aspirate while advancing the needle. The needle should be advanced approximately 3 cm or until fluid is aspirated (FIGURE 58.2).

Once the required amount of fluid is obtained, withdraw the needle

Apply pressure over the area of insertion for 30 seconds or until bleeding stops

Wipe off all excess povidone–iodine on the skin

Apply clean dressing

COMPLICATIONS

Iatrogenic infection

Excessive pain during procedure

Localized bleeding

Reaccumulation of fluid

Injury to articular cartilage

FIGURE 58.1 Anterior approach. (From Simon RR, Brenner BE. Emergency Procedures and Techniques. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:242, with permission.)

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