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Joint aspiration/corticosteroid injection [advanced]

Please note content is for educational purposes only and procedures should not conducted based on this information. OSCEstop and authors take no responsibility for errors or for the use of any content. Drug doses cannot be guaranteed to be correct.

Aspiration indications: diagnose cause of swollen joint; tense effusion symptom relief

Steroid injection indications: osteoarthritis, synovitis, inflammatory arthritis, crystalloid arthropathies, tendinopathy (except achilles/patellar), bursitis, entrapment syndromes

Relative contraindications: overlying cellulitis (IV antibiotics required); coagulopathy (INR >1.4, platelets <50, therapeutic anticoagulant <24 hours, clopidogrel <7days); skin lesion over joint; known bacteraemia; adjacent osteomyelitis; joint prosthesis

Joint sizes

 

Large = knee, ankle, shoulder

Medium = wrist, elbow

Small = MCP, ICP, sternoclavicular, acromioclavicular

Introduction

  • Wash hands, Introduce self, Patients name & DOB, Explain procedure and get consent
    • Risks: pain, bleeding/haemarthrosis, infection, cartilage damage, damage to local structures
    • Corticosteroid risks: tendon atrophy/rupture, avascular necrosis, skin discoloration, local fat atrophy, soft tissue/pericapsular calcification, osteoporosis
  • **Check patients clotting screen, platelet count and if they have been on an therapeutic anticoagulant/clopidogrel**
  • Check drug allergies
  • Ensure assistant is available
  • Examine joint and confirm effusion

Preparation part

  • Wash hands and apply apron
  • Clean  a trolley
  • Gather equipment onto bottom of trolley (think through what you need in order)

Equipment list

  • Sterile pack
  • Cleansing snap-sponge (iodine or alcohol/chlorhexidine) x2
  • OPTIONAL: Sterile drape with hole in centre (or 2-3 drapes without holes in)
  • 10ml syringe and 2 needles (1 blunt fill 18G drawing-up needle, 1 orange 25G) for local anaesthetic
  • Injection/aspiration needle (green 21G if large joint, blue 23G needle if medium joint, orange 25G if small joint)
  • Syringe
    • 20-50ml syringe if doing aspiration (depending on size of effusion)
    • 1-5ml syringe if doing injection (5ml for large joint, 2.5ml for medium joint, 1ml for small joint)
  • Extra green 21G needle to draw up steroid if doing aspiration
  • Cotton gauze swabs (used whenever needed throughout procedure to dry/clean sterile area)
  • Sterile dressing
  • Equipment to be kept outside of the sterile field
    • Incontinence pad
    • Sterile gloves
    • 10ml 1% lidocaine (maximum 3mg/kg – note 1ml 1% lidocaine = 10mg)
    • Blood culture bottles or 2 white-topped sample collection bottles, and 1 purple EDTA tube if doing aspiration
    • 80mg Depo-Medrone (methylprednisolone acetate) in 2ml vial if doing large joint injection
    • 40mg Depo-Medrone (methylprednisolone acetate) in 1ml vial if doing medium/small joint injection

  • Walk to patient
  • Wash hands
  • Open sterile pack to form a sterile field on the top of the trolley
  • Open packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field
  • Pick up waste bag from sterile pack without touching anything else and stick to side of trolley

Patient part

Positioning and exposure

  • Position patient
  • Expose joint and place incontinence pad below
  • Examine the surface anatomy of patient’s joint
  • Locate insertion point
  • Mark insertion point with a skin pen/indentation

Preparation

  • Wash hands
  • Apply sterile gloves using sterile technique (open pack on a side surface)
  • Sterilize area
    • Work from middle outwards in one spiral motion (using cleansing snap-sponge)
    • Repeat with second cleansing snap-sponge
    • Discard used snap-sponges as they are no longer sterile, but note all equipment used after this (including all needles) can be returned to the sterile field after use
    • OPTIONAL: Apply the sterile drape over the patient’s body so that the hole is in the correct place to allow access to the insertion site (or apply 2-3 drapes centred around exposed insertion site if no holes)
  • Anaesthetise tract
    • Ask assistant to snap open lidocaine bottle and hold open upside-down
    • Draw up lidocaine using drawing-up needle on 10 ml syringe and expel any air (maximum 7ml if doing injection so the rest can be used with the injection)
    • Change to the orange needle and insert at an acute angle to form a single subcutaneous bleb around insertion site in order to anaesthetise the skin
    • Now use the same needle to anaesthetise the insertion tract up to the joint capsule
      • Always aspirate when advancing the needle (so you know if you enter the joint capsule) and aspirate before injecting lidocaine (to check you are not in a vessel)

Joint aspiration

  • With a 20-50ml syringe on the aspiration needle, stretch the skin and insert into the insertion tract
  • Aspirate during infiltration
  • As soon as fluid enters the syringe, stop advancing the needle and aspirate to fill the syringe/as much as possible
  • Withdraw the needle

Joint injection

  • Ask assistant to snap open Depo-Medrone bottle and hold this and the lidocaine bottle open upside-down
  • Draw up the Depo-Medrone and some lidocaine into the same syringe using a green needle and expel any air
    • Large joint: 2ml Depo-Medrone + 3ml lidocaine (in 5ml syringe)
    • Medium joint: 1ml Depo-Medrone + 1ml lidocaine (in 2.5ml syringe)
    • Small joint: 0.25ml Depo-Medrone + 0.25ml lidocaine (in 1ml syringe)
  • Change to the injection needle, stretch the skin and insert into the insertion tract
  • Aspirate during infiltration
  • When in place, aspirate to ensure you are not in a vessel and slowly expel the contents of the syringe
  • Withdraw needle

Finally

  • Dress wound

Joint specific techniques

Knee

  • Suprapatellar approach
    • Position patient lying supine with the knee extended
    • Identify the midpoint of the superolateral border of the patella
    • Insert needle 1cm above and 1cm lateral to this point
    • Direct the needle inferomedially and angle slightly posteriorly (at ~ 45˚ from horizontal plane), between the posterior surface of the patella and the intercondylar femoral notch
Knee aspirate – suprapatellar approach
  • Parapatellar approach (preferred aspiration approach)
    • Position patient lying supine with the knee extended
    • Identify the junction of the upper and middle third of the patella on its medial or lateral border
    • Apply pressure to the opposite border of the patella to open the joint space
    • Palpate the groove under the patella (~5-10mm laterally) and insert the needle here
    • Direct the needle medially and a little inferiorly in the horizontal plane, between the posterior surface of the patella and the intercondylar femoral notch
Knee aspirate – parapatellar approach
  • Infrapatellar approach
    • Position patient sitting on the side of the bed with knees at 90˚ over side
    • Identify the inferior border of the patella and the patella tendon
    • Insert the needle 5mm inferior to the inferior border of the patella, just lateral to the patella tendon
    • Direct the needle superomedially and angle slightly posteriorly (at ~ 45˚ from horizontal), between the posterior surface of the patella and the intercondylar femoral notch

Note: lateral approaches are described above but identical medial approaches may also be used

Shoulder

  • Anterior approach (preferred)
    • Position the patient in a seated position with their shoulder externally rotated
    • Palpate the coracoid from anteriorly
    • Insert the needle 1cm lateral to the coracoid (medial to head of humerus)
    • Direct the needle posteriorly and angle slightly superolaterally
Shoulder aspirate – anterior approach
  • Posterior approach
    • From posteriorly, palpate the acromium (posteriorly) and coracoid (anteriorly)
    • Insert the needle 1cm inferior to the posterior tip of the acromium
    • Direct the needle anteriorly and angle slightly medially towards the coracoid

Wrist

  • Position the patients forearm on a stable surface, with their palm facing downwards
  • Ask the patient to extend their thumb to identify the extensor pollicis longus tendon, and also locate Lister’s tubercle (bony prominence at distal end of radius)
  • Insert the needle distal the Lister’s tubercle and lateral to extensor pollicis longus tendon
  • Direct the needle ventrally, perpendicular to the forearm
Wrist aspirate

Elbow

  • Position the patients elbow at 90˚ flexion, rested on a stable surface
  • Palpate the olecranon process, the lateral epicondyle and the radial head
  • Insert the needle the centre point of this triangle, perpendicular to the skin
Elbow aspirate

Ankle

  • Anterolateral approach (preferred)
    • Position the patient lying supine with ankle at 90˚
    • Palpate the space between the lateral malleolus (laterally) and the extensor digitorum longus (medially) in the ankle joint line
    • Insert the needle midway between
    • Aim the needle posteriorly, perpendicular to the fibular shaft
Ankle aspirate – anterolateral approach
  • Anteromedial approach (risks damage to dorsalis pedis and deep peroneal nerves)
    • Position the patient lying supine with ankle at 90˚
    • Palpate the space between the medial malleolus (medially) and the tibialis anterior tendon (laterally) in the ankle joint line (just above the talus)
    • Insert the needle midway between
    • Aim the needle posteriorly and slightly laterally, perpendicular to the tibial shaft

Note: you can ask patient to dorsiflex foot against resistance to help identify tendons

Metacarpophalangeal joint

  • Rest the hand on a stable surface, palm down with the fingers slightly flexed
  • Insert the needle dorsally, either medial or lateral to the extensor tendons
MCP joint aspirate

To complete

  • Thank patient and cover them
  • Bin waste and gloves, dispose of sharps safely in sharps bin, clean trolley and wash hands
  • If required, label sample tubes and send to lab:
    • MC&S (blood culture bottles or white-top x2) β†’ microbiology
    • Crystals (white-top) β†’ cytology
    • Cell count (purple EDTA tube) β†’ haematology – if the local hospital haematology laboratory do not do synovial fluid cell counts, the MC&S should be sent in a white-top, so microbiology can do cell count
  • Fully document procedure in patients notes

Learn how to interpret the results too…

Synovial fluid result interpretation is covered here!

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