Arthrocentesis
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Transcript of Arthrocentesis
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ARTHROCENTESIS
Cathryn Caton, MD, MSMay 23, 2013Medical University of South Carolina
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Objectives Define arthrocentesis Review reasons for procedure Describe procedural technique Review fluid analysis and related
diagnoses
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Definition Procedure in which a sterile needle and
syringe is used to draw fluid from a joint
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Why do an arthrocentesis? To diagnose and establish the cause of
monoarthritis or polyarthritis Presence of joint infection Cause of arthritis eg. Gout
To provide therapeutic relief for joint effusions
Do not tap a prosthetic joint. Call ortho for evaluation
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Procedural Technique Factors taken into account
Needle size Syringe size Skin sterilization Local anesthesia
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Procedural Technique Needle size –
22 gauge probably adequate Smaller for smaller joints Larger if effusion is large knee collection eg 20
gauge Syringe size – 5ml, larger if needed Can be done under ultrasound guidance Best strategy is to use one needle size and
one syringe size
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Procedural Technique Skin preparation – three separate
concentric outward spirals with an agent such as chlorhexidine prep
Local anesthesia – lidocaine, ethyl chloride spray. Option to use no anesthesia
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Procedural Technique http://www.nejm.org/doi/full/10.1056/NE
JMvcm051914
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What to do once fluid is obtained? Fluid analysis should include –
cell count with differential Cultures gram stain Crystal – should be done promptly to avoid
disintegration and false negative results
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Normal Synovial Fluid Highly viscous Clear Essentially acellular Protein concentration approx. 1/3 of
plasma Glucose concentration similar to plasma
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Categories of Joint Effusions Noninflammatory –
Degenerative joint disease Trauma Osteonecrosis Neuropathic arthropathy Early or subsiding inflammation Hypertrophic osteoarthropathy Rheumatic fever SLE Sarcoidosis Scleroderma
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Categories of Joint Effusions Inflammatory –
RA Acute crystal-induced synovitis Reactive arthritis Ankylosing spondylitis Psoriatic arthritis Arthritis associated with inflammatory bowel disease Rheumatic fever SLE Sarcoidosis
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Categories of Joint Effusions Septic effusions –
Bacteria Mycobacteria Fungus
Hemorrhagic – Hemophilia Anticoagulation Scurvy Trauma Tumor Neuropathic arthropathy
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Categories of Joint Effusions
Sterile processes such as reaction to intraarticular injections, flares of RA, leukemic infiltration and gout can cause synovial fluid elevations WBC>100K
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Gout vs. Pseudogout
Gout
Pseudogout
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Key Messages Know indication for procedure
Know what analysis should be performed on fluid obtained
Know how to interpret fluid results
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References Krey PR, Bailen DA. Synovial fluid leukocytosis
. A study of Extremes. Am J Med 1979; 67:436 Zuber TJ. Knee Joint Aspiration and Injection. Am
Fam Phys 2002; 66:1497 Mimoz O, Karim A. Chlorhexidine compared with
povidone-iodine as skin preparation before blood culture. A randomized, controlled trial. Ann Intern Med 1999; 131:834
Shmerling RH, Delbanco TL. Synovial fluid tests. What should be ordered? JAMA 1990; 264:1009.
Guidelines for the initial evaluation of the adult with acute musculoskeletal symptoms. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39:1