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

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

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