Joint Aspiration
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Contents |
More Specific Terms
Indications
- pain relief
- diagnostic
Contraindications
- absolute
- localized abscess or cellulitis at site of injection
- active Herpes simplex virus ( HSV) or tuberculosis infection
- relative
-
- anticoagulation is not a contraindication [2]
- bacteremia
- joint prosthesis
Laboratory
- cell count with differential
- Gram stain, culture & sensitivity
- crystal analysis under polarized light
- urate: needle-shaped, negative birefringence
- calcium pyrophosphate: rhomboid-shaped, positive birefringence
- hydroxyapatite (basic calcium phosphate)
- serum glucose & joint fluid glucose
- 'string test': Normal fluid when gently pushed from syringe will form a 5-10 cm 'string'. With infection, the 'string' will be shorter
- tubes: red top & lavender top
Procedure
- Preparation:
- obtain informed consent
- identify landmarks
- wide-field skin cleaning
- sterile glove
- sterile drape may be indicated
- Precautions:
- withdraw needle to subcutaneous tissue prior to redirecting needle
- avoid removing the needle completely & redirecting
- Aspiration by joint:
-
- locate inferolateral border of coracoid process, the anterior border of the acromion, & the medial border of the humeral head
- insert 4 cm, 22 gauge needle in space between inferolateral border of coracoid & humeral head, direct posteriorly toward glenoid rim
- aspirate fluid for laboratory studies
- radiohumeral joint aspiration
- elbow flexed 90 degrees with hand pronated
- locate space between distal lateral epicondyle & proximal tip of olecranon process of radial head
- insert 4 cm, 22 gauge needle at a 90 degree angle to skin, direct medially & posterior
- aspirate fluid for laboratory studies
- patient supine with leg extended
- locate space between the superolateral border of the patella & the lateral femoral epicondyle
- insert 4 cm, 20 gauge needle (for septic joint, use 18 gauge needle) parallel to floor in space 1 cm lateral to the patellar border, direct towards under surface of patella, with the quadriceps relaxed, patella may be lifted to facilitate insertion,
- aspirate fluid for laboratory studies
- knee may have as much as 50-75 mL of fluid, have 2 35 cc syringes available for aspiration of fluid
- patient supine, leg fully extended, foot partially plantar flexed
- locate joint line, 1 cm superior to the line joining the inferior borders of the malleoli, locate from medial to lateral the tibialis anterior tendon, the tendon to the extensor hallucis longus & the anterior tibial artery
- insert a 4 cm, 22 gauge needle along the joint line, avoiding the artery & tendons (lateral to the artery seems easiest), direct needle superiorly 2-3 cm into the joint space
- aspirate fluid for laboratory analysis
Complications
- seizures from local anesthetic:
- subcutaneous swelling & pain after procedure:
- ice may attenuate
- post procedural infection
- damage to tendons
Differential-diagnosis
- traumatic injury
- Charcot joint
- tumor
- sickle cell joints
- Fat Droplets: intra-articular fracture
- Purulent effusion:
-
- bacterial (including tuberculosis)
- fungal
- > 80,000 WBC/ mm3
- > 90% neutrophils
- joint glucose < 50% of serum glucose
- etiology
- 1000-50,000 WBC/ mm3
- 30-50% lymphocytes
- 50-70% neutrophils
- crystal examination:
- uric acid (gout)
- rods or needles
- negatively birefringent (yellow) under polarized light
- rods, rectangles, or rhomboids
- weakly positive birefringent (blue) under polarized light
More General Terms
Additional Terms
- gout
- infectious arthritis (septic arthritis)
- pseudogout [calcium pyrophosphate dihydrate crystal deposition] or CPPD disease
- rheumatoid arthritis (RA)
References
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 779-781
- Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
