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JOINTS
Injections &
Aspirations
Rationale
• Primary care providers should master the
technique of joint aspiration and injection
for many reasons:
– Diagnosing an inflamed joint
– Pain relief of a distended joint
– Injection of steroids for painful joint
Indications
• Diagnostic
– To evaluate synovial fluid
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Infections
Rheumatic
Traumatic
Crystal-induced etiology
• Therapeutic
– Remove exudate from septic joint
– Relieve pain in grossly swollen joint
– Inject lidocaine, saline, corticosteroids
Contraindications
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Cellulitis or broken skin over entry site
Anticoagulant therapy not well tolerated
Septic effusion of a bursa
More than 3 previous injections to weight bearing
joint in last 12 months
• Suspected bacteremia
• Unstable joint
• Inaccessible joint
Contraindications
• Absolute
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Local sepsis
Suspicion of infection
Sepsis
Hypersensitivity
Early trauma
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Hemarthrosis
Prosthetic joint
Very unstable joint
Reluctant patient
Children
Contraindications
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Diabetic
Anticoagulated
Bleeding disorder
Immunosuppressed
Psychogenic pain
Severe anxiety
Gut feeling
Equipment
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Betadine
Sterile gloves
22- to 27-gauge needle for injections
18-gauge needle for aspirations
10cc syringe
30cc syringe is aspirating large amount
Lidocaine
Culture tubes
Pre-procedure Patient Education
• Risks
• Benefits
• Possible complications
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Pain
Infection
Bleeding
Tendon damage
Technique
• Before injection, consider differential.
– X-rays if tumor or fracture possible
• Identify entry site and mark
• Prep with betadine
• Inject wheel of lidocaine and advance for deeper
anesthesia with 27-gauge needle
• Use 18-gauge needle inserted into desired location
and aspirate or 22-gauge and inject medication
Lab Analysis of Fluid
• White blood cell count
– <50,000 inflammatory
– >50,000 infectious
• Polymorphonucleocyte percentage
• Crystals
• If fluid cloudy, culture
Septic Arthritis
• Infection occurs by :
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Hematogenous spread
Contiguous source
Direct implantation
Postoperative complication
Septic Arthritis
• Early diagnosis essential:
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Growth impairment
Articular destruction
Osteomyelitis
Soft tissue expansion
Septic Arthritis
• Neisseria gonorrheoae
– Adolescents and young adults
• Staphylococcus
– Patients> 40, medical illnesses
• Streptococcus
N. gonorrhoeae
• Majority in women
– With or without anogenital symptoms
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Occurs during menstruation/pregnancy
Positive culture 25%-60%
Positive Gram stain 65%
WBC and glucose helpful
Synovial Fluid Analysis
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String sign
Cell count
Glucose
Gram stain
Crystals
Synovial Fluid Interpretation
Diagnosis
Appearance
WBCs
Glucose %
blood level
Crystals
Culture
Normal
Clear
<200
95+
None
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DJD
Clear
<4000
95+
None
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Traumatic
Arthritis
Straw, bloody,
xanthochromic
<4000
95+
None
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Acute Gout
Turbid
200050,000
80-100
Needle
like
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Pseudogout
Turbid
200050,000
80-100
Rhomboid
like
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Septic
Arthritis
Purulent/turbid
5000>50000
<50
None
+
usually
Nontraumatic
Arthritis
Turbid
200050,000
75
None
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Joint Injection
The Drugs
Corticosteroids
Rationale for Using Steroid Injection
– Suppressing inflammation
Short acting: Hydrocortisone
Intermediate acting:
Methylprednisone/Triamcinolone
Long acting: Dexamethasone
Side Effects
• Systemic
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Facial flushing
Uterine bleeding
Deterioration of Diabetic glycemic control
Significant falls in the ESR and CRP levels
Other rare side effects
Anaphylaxis
Side Effects
• Local
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Post-injection flare of pain
Subcutaneous atrophy
Bleeding or bruising
Soft-tissue calcification
Steroid arthropathy
Tendon rupture
Joint sepsis
Soft tissue infection
Local Anesthetics
• Rationale for using
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Diagnostic
Analgesic
Dilution
Distension
• Commonly used
– Lidocaine
– Bupivacaine
Safety Precautions
• Aseptic Technique
• Adverse Reactions
– Syncope
– Anaphylaxis
Aspiration
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Frank blood
Serous fluid
Serous fluid streaked
Xanthochromic fluid
Turbid fluid
Frank pus
Other
Injection Technique
• Equipment
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Syringes
Needles
Corticosteroids
Local anesthetic
Dosage and volume
Injection Technique
• Technique
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Tissues
Bursa and joint
Tendons and ligaments
Tendons with sheaths
Blood vessels
Aspirations
Preparation Protocol
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Prepare patient
Prepare equipment
Prepare site
Assemble equipment
Sterile technique
Most Common Aspirations and
Injections
The Knee
The Knee
Landmarks:
Medial patella –
middle to superior
portion
Insertion
1 cm medial to
anteromedial patella
edge. Directed
between posterior
surface of patella and
intercondylar
femoral notch
Knee Joint
Lateral
Medial
Knee slightly flexed
The Elbow
The Elbow
Landmarks
Lateral epicondyle and
radial head
With elbow extended –
the depression is
palpated
Insertion
22-ga needle from lateral
aspect just distal to
lateral epicondyle and
direct medially
The Elbow
Lateral Epicondylitis
(Tennis Elbow)
Symptoms: pain with
elevation of third digit against
resistance, with wrist and
elbow held in extension
Approach: Point of Max
Tenderness
The Elbow
Olecranon Bursitis
Diagnosis obvious
Approach: 20-ga needle
into dependent aspect of sac
The Wrist
De Quervain’s Synovitis
Injection: The needle is
placed into the first
extensor compartment and
directed proximally toward
the radial styloid.
Questions?