Joint Aspiration / Injection (Skills)

Arthrocentesis

Aspiration of synovial fluid

What features are found on synovial fluid analysis

Appearance

Cell Count

Crystal Analysis

Gram Stain

C&S

Indications for Arthrocentesis

Crystalline arthropathy (Gout / Pseduogout)

Septic arthritis

Evaluation of joint effusion

Reactive arthritis (Monoarticular)

Psoriatic arthritis (Monoarticular)

Osteoarthritis (Monoarticular)

Lyme disease (Monoarticular)

Rheumatoid arthritis (Monoarticular)

Gonococcal infection (Monoarticular)

Hemarthosis

Blood in the joint

Causes of Hemarthrosis

Trauma

Coaguloaptyh

Neuropathic Arthropathy

Tumor

What joint conditions are non-inflammatory (WBC < 2000 on synovial)

OA

Trauma

AVN

Charcot’s

Hemochromatosis

Pigmented villonodular synovitis

What joint conditions are inflammatory (WBC > 2000 on synovial)

Septic Arthitis

Crystal Monoarthritis

RA / JIA

Spondyloarthriis

SLE

Lyme

What is the crystal in gout

Monosodium urate

Negative befringemnt

Needle Shaped

What is the crystal in pseudogot

CPP dehydrate

Postive befringement

Rods / Rhombodi

Risk Factors for Gout

Hyperuricemia

Obese

HTN

HLD

ETOH Ingestion

Lead Ingestion

Genetics

Relative Contraindication for Arthrocentesis

Overlying soft tissue infection (cellulitis/dermatitis)

Bacteremia

Adjacent osteomyelitis

Uncooperative or combative patients

Joint prosthesis

Recent joint surgery (within last 8 weeks)

Complications of arthrocentesis

Pain

Infection

Bleeding

Allergic reaction

Nerve damage

Tendon rupture

Contraindications for Joint Steroid Injections

Infections (cellulitis, osteomyelitis, septic joint, sepsis)

Hemarthrosis / bleeding disorder / coagulopathy

Osteochondral fracture

Joint prosthesis

Impending joint replacement (within days)

Poorly controlled diabetes mellitus

Complications of Steroid Joint Injection

Postinjection flare

Facial flushing

Tendon rupture

Hyperglycemia

Fat atrophy

Depigmentation

Cartilage damage

Steps for Joint Arthrocentesis / Injection

Identify and palpate boney landmarks

Decide on approach

Mark site prior to skin prep

Impressing the skin with a hard object leaves temporary mark

Skin Preparation

Anesthetic

Aspirate fluid, milk joint

If injection is indicated at time of aspiration Aspirate fluids but keep needle in joint Grasp needle hub with clamp and switch to pr

Withdraw needle and hold pressure to stop bleeding

Dispose all sharps properly

Apply adhesive bandage

How is skin prepped for joint injection

Three separate concentric outward spirals

Use Povidone-iodine or Chlorhexidine

What skin prep is safe for seafood allergy

Povidone-iodine

When should sterile technique be used for joint aspiration

severely immunocompromised patients

What anesthetic agents can be used for joint aspiration

Lidocaine (Xylocaine)

Ethyl chloride spray

Timing of Lidocaine

provide analgesia

Onset: minutes

Duration: 30 - 60 minutes

Timing of Ethyl Cholride Spray

Spray short burst

10 to 15 seconds

Provides approximately 15 seconds of anesthesia

Is ethyl chloride sterile

no

How long do you spray ethyl cholride

Aim directly at injection site

Skin will turn white

When do we give joint steroid injections

Gout / CPPD

Rheumatoid arthritis

Psoriatic arthritis

Osteoarthritis

Why do we combine steroids and anstehteics

Immediate relief

Confirms placement

Reduces steroid induced atrophy

Viscosupplementation

Intraarticular hyaluronic acid derivatives

Indication for Viscosupplementation

Symptomatic knee osteoarthritis

What sized needle is used for joint aspiration

16-18g

How much fluid is aspirated from the knee

20-60 mL

How much fluid is aspirated from the finger

0.5-1 mL

What are the approaches to knee injections

Anterior (Lateral or Medial)

Supreolateral

Supreomedial

Steps for Superolateral Approach

Patient lies supine with the knee almost fully extended 0-30 degrees of flexion

Rolled towel or thin pad supports underneath the knee

Clinician's thumb stabilizes the patella

Needle is inserted underneath the supralateral surface of the patella

Direct needle toward the center of the patella then directed inferomedial into the knee joint

Anterior Approach Knee Injection

Patient seated or supine with the knee flexed 90° (opens joint space)

Needle is inserted approximately 1 cm above the tibial plateau directed 15-45° toward the joint space

Steps for Shoulder Injections

Place patient in seated upright position

Palpate and mark the needle insertion site according to the approach chosen

Prep the skin and allow to dry

Administer local anesthetic

Insert 18-gauge needle and aspirate as the needle is advanced until synovial fluid is obtained

If injection is warranted, exchange the syringe for a corticosteroid-filled syringe and inject

Remove the needle, and apply pressure and a bandage

Divide the fluid among the specimen tubes

What are the approaches to the shoulder injection

Posterior

AC / Superior

Lateral / Subacromial

Anterior / GH

Posterior Shoulder Approach

Insert needle 2-3cm inferior and medial to the posterolateral corner of the acromion and direct anteriorly towards the coracoid process

Indications for Posterior Approach to Shoulder

Shoulder arthritis,

adhesive capsulitis,

subacromial impingement

Superior Shoulder Approach

Insert needle from an anterior and superior angle and directed inferiorly

Medial direction of the needle accommodates typical AC joint angle

≤ 2ml should be injected

Indications for Superior Approach to Shoulder

AC Joint OA

Lateral Shoulder Approach

Place needle 1-1.5 cm below midpoint of lateral edge of acromion

Indications for Lateral Approach to Shoulder

Subacromial impingement.

subdeltoid bursitis,

rotator cuff impingement,

biceps tendinosis/ tendinitis

Anterior Shoulder Approach

Place needle just medial to the head of the humerus and 1 cm lateral to the coracoid process

Indications for Anterior Shoulder Approach

Shoulder arthritis,

adhesive capsulitis