Shoulder Arthrocentesis

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


   imagesSeptic arthritis


   imagesCrystal arthropathy


   imagesHemarthrosis


   imagesInflammatory processes


imagesTo diagnose occult fracture or ligamentous injury


imagesTo decrease/relieve pressure in the joint for pain relief


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


imagesTo instill medication for treatment and pain relief


CONTRAINDICATIONS



imagesAbsolute Contraindications


   imagesAbscess/cellulitis in the tissue overlying the puncture site


imagesRelative Contraindications


   imagesKnown bacteremia


   imagesBleeding diathesis or anticoagulant therapy


   imagesProsthetic joint



imagesGeneral Basic Steps


   imagesPatient preparation


   imagesSterile technique


   imagesAnalgesia


   imagesAspiration


LANDMARKS



imagesAnterior Approach


   imagesCoracoid process and head of the humerus


imagesPosterior Approach


   imagesPosterolateral edge of the acromion


SUPPLIES



imagesPovidone–iodine or other antiseptic solution, drapes


imagesLidocaine with epinephrine


images25- and 18-gauge needles, 20-mL syringe


imagesGauze pads, adhesive tape


TECHNIQUE



imagesPatient Preparation


   imagesThe patient should sit upright with arm in slight external rotation


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


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


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


   imagesDrape the area with sterile towels


imagesAnalgesia


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


   imagesInject lidocaine with epinephrine at the puncture site


   imagesAnesthetize the subcutaneous tissue and a track toward the joint


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


imagesAspiration


   imagesAnterior Approach


      imagesInsert 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


      imagesPoint the needle posterolaterally to avoid the joint capsule


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


   imagesPosterior Approach


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


      imagesAim the needle anteriorly toward the coracoid process


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


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


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


   imagesWipe off all excess povidone–iodine on the skin


   imagesApply clean dressing


COMPLICATIONS



imagesIatrogenic infection


imagesExcessive pain during procedure


imagesLocalized bleeding


imagesReaccumulation of fluid


imagesInjury to articular cartilage



images


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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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Shoulder Arthrocentesis
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