Wrist (Radiocarpal) Arthrocentesis

imagesProvide evacuation of abnormal collections of fluid from the joint space for synovial fluid analysis


   imagesSeptic arthritis


   imagesCrystal arthropathy


   imagesHemarthrosis


   imagesInflammatory process


imagesDiagnose occult fracture or ligamentous injury


imagesDecrease/relieve pressure in the joint to provide pain relief


imagesUsed to instill medication for treatment and pain relief


imagesUsed to test joint integrity by injecting methylene blue when overlying laceration is present


CONTRAINDICATIONS



imagesAbsolute Contraindications


   imagesAbscess/cellulitis in the tissues overlying the site to be punctured (infectious arthritis can often mimic an overlying soft-tissue infection)


imagesRelative Contraindications


   imagesKnown bacteremia


   imagesBleeding diatheses or anticoagulant therapy


RISKS/CONSENT ISSUES



imagesPotential for causing infection if not done with proper sterile technique


imagesPain from the procedure (mitigate with local anesthesia)


imagesBleeding from the needle


imagesReaccumulation of fluid may occur


imagesRisk of injuring articular cartilage with needle tip



imagesGeneral Basic Steps


   imagesPatient preparation


   imagesSterilize area


   imagesAnesthetize area


   imagesAspiration


LANDMARKS



imagesDorsal/Radiocarpal Approach


   imagesPlace the wrist in 20-degree flexion and extend the thumb


   imagesPalpate the dorsal radial tubercle (Lister tubercle) and the extensor pollicis longus tendon as it courses over the distal radius


   imagesPalpate the depression that is distal to the tubercle and on the ulnar side of the extensor carpi radialis brevis tendon


imagesUlnocarpal Approach


   imagesFlex the wrist 20 degrees and palpate the depression between the ulnar styloid process and pisiform bone


   imagesApproach may be problematic due to multiple tendons travel through this region


TECHNIQUE



imagesPatient Preparation


   imagesConfirm landmarks—mark the needle insertion point if needed


   imagesSterilize the area where the needle will be inserted with povidone–iodine solution or comparable skin antiseptic


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


   imagesDrape the area with sterile towels


   imagesPlace the wrist in neutral, relaxed position


   imagesApply gentle traction and ulnar deviation to the hand to open the joint space


imagesAnalgesia


   imagesUse a 25-gauge needle to infiltrate injection site with lidocaine with epinephrine


   imagesAnesthetize the subcutaneous tissue and a track toward the joint


   imagesAvoid entering the joint space if synovial fluid analysis is desired


imagesAspiration


   imagesUse a 22-gauge needle attached to a 5- or 10-mL syringe


   imagesFor the radiocarpal approach, direct the needle just distal to the border of the distal radius


   imagesInsert 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)


   imagesFor the ulnocarpal approach direct the needle between the distal border of the ulnar styloid process and the pisiformis bone (FIGURE 60.2)


   imagesProvide negative pressure on the syringe plunger as the needle is inserted in the joint cavity


   imagesEasy aspiration of fluid confirms proper needle position


   imagesWithdraw needle, apply pressure, then apply clean dressing


COMPLICATIONS



imagesIatrogenic infection


imagesIncreased pain


imagesLocalized bleeding


imagesReaccumulation of effusion


imagesInjury to articular cartilage if proper technique is not utilized



images


FIGURE 60.1 Radiocarpal arthrocentesis. (From Simon RR, Brenner BE. Emergency Procedures and Techniques. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:239, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Wrist (Radiocarpal) Arthrocentesis
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