Joint aspiration/corticosteroid injection [advanced]

Before you start

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)

• 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

• 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

• 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

• 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

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

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

• 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

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) → microbiology
  • Crystals (white-top) → cytology
  • Cell count (purple EDTA tube) → 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