Provide evacuation of abnormal collections of fluid from the joint space for synovial fluid analysis
Septic arthritis
Crystal arthropathy
Hemarthrosis
Inflammatory process
Diagnose occult fracture or ligamentous injury
Decrease/relieve pressure in the joint to provide pain relief
Used to instill medication for treatment and pain relief
Used to test joint integrity by injecting methylene blue when overlying laceration is present
CONTRAINDICATIONS
Absolute Contraindications
Abscess/cellulitis in the tissues overlying the site to be punctured (infectious arthritis can often mimic an overlying soft-tissue infection)
Relative Contraindications
Known bacteremia
Bleeding diatheses or anticoagulant therapy
RISKS/CONSENT ISSUES
Potential for causing infection if not done with proper sterile technique
Pain from the procedure (mitigate with local anesthesia)
Bleeding from the needle
Reaccumulation of fluid may occur
Risk of injuring articular cartilage with needle tip
General Basic Steps
Patient preparation
Sterilize area
Anesthetize area
Aspiration
LANDMARKS
Dorsal/Radiocarpal Approach
Place the wrist in 20-degree flexion and extend the thumb
Palpate the dorsal radial tubercle (Lister tubercle) and the extensor pollicis longus tendon as it courses over the distal radius
Palpate the depression that is distal to the tubercle and on the ulnar side of the extensor carpi radialis brevis tendon
Ulnocarpal Approach
Flex the wrist 20 degrees and palpate the depression between the ulnar styloid process and pisiform bone
Approach may be problematic due to multiple tendons travel through this region
TECHNIQUE
Patient Preparation
Confirm landmarks—mark the needle insertion point if needed
Sterilize the area where the needle will be inserted with povidone–iodine solution or comparable skin antiseptic
Wipe injection site with alcohol to avoid introduction of iodine solution into the synovium
Drape the area with sterile towels
Place the wrist in neutral, relaxed position
Apply gentle traction and ulnar deviation to the hand to open the joint space
Analgesia
Use a 25-gauge needle to infiltrate injection site with lidocaine with epinephrine
Anesthetize the subcutaneous tissue and a track toward the joint
Avoid entering the joint space if synovial fluid analysis is desired
Aspiration
Use a 22-gauge needle attached to a 5- or 10-mL syringe
For the radiocarpal approach, direct the needle just distal to the border of the distal radius
Insert the needle in the depression on the ulnar side of the extensor carpi radialis brevis tendon and between the distal radius and lunate bone (FIGURE 60.1)
For the ulnocarpal approach direct the needle between the distal border of the ulnar styloid process and the pisiformis bone (FIGURE 60.2)
Provide negative pressure on the syringe plunger as the needle is inserted in the joint cavity
Easy aspiration of fluid confirms proper needle position
Withdraw needle, apply pressure, then apply clean dressing
COMPLICATIONS
Iatrogenic infection
Increased pain
Localized bleeding
Reaccumulation of effusion
Injury to articular cartilage if proper technique is not utilized