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

    Septic arthritis

    Crystal arthropathy

    Hemarthrosis

    Inflammatory processes

 To diagnose occult fracture or ligamentous injury

 To decrease/relieve pressure in the joint for pain relief

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

 To instill medication for treatment and pain relief

CONTRAINDICATIONS

 Absolute Contraindications

    Abscess/cellulitis in the tissue overlying the puncture site

 Relative Contraindications

    Known bacteremia

    Bleeding diathesis or anticoagulant therapy

    Prosthetic joint

LANDMARKS

 Anterior Approach

    Coracoid process and head of the humerus

 Posterior Approach

    Posterolateral edge of the acromion

SUPPLIES

 Povidone–iodine or other antiseptic solution, drapes

 Lidocaine with epinephrine

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

 Gauze pads, adhesive tape

TECHNIQUE

 Patient Preparation

    The patient should sit upright with arm in slight external rotation

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

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

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

    Drape the area with sterile towels

 Analgesia

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

    Inject lidocaine with epinephrine at the puncture site

    Anesthetize the subcutaneous tissue and a track toward the joint

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

 Aspiration

    Anterior Approach

       Insert 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

       Point the needle posterolaterally to avoid the joint capsule

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

    Posterior Approach

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

       Aim the needle anteriorly toward the coracoid process

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

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

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

    Wipe off all excess povidone–iodine on the skin

    Apply clean dressing

COMPLICATIONS

 Iatrogenic infection

 Excessive pain during procedure

 Localized bleeding

 Reaccumulation of fluid

 Injury to articular cartilage

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