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Arthrocentesis

Cathryn Caton, MD, MS May 23, 2013 Medical University of South Carolina. Arthrocentesis. Objectives. Define arthrocentesis Review reasons for procedure Describe procedural technique Review fluid analysis and related diagnoses. Definition.

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Arthrocentesis

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  1. Cathryn Caton, MD, MS May 23, 2013 Medical University of South Carolina Arthrocentesis

  2. Objectives • Define arthrocentesis • Review reasons for procedure • Describe procedural technique • Review fluid analysis and related diagnoses

  3. Definition • Procedure in which a sterile needle and syringe is used to draw fluid from a joint

  4. 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

  5. Procedural Technique • Factors taken into account • Needle size • Syringe size • Skin sterilization • Local anesthesia

  6. 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

  7. 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

  8. Procedural Technique • http://www.nejm.org/doi/full/10.1056/NEJMvcm051914

  9. 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

  10. Normal Synovial Fluid • Highly viscous • Clear • Essentially acellular • Protein concentration approx. 1/3 of plasma • Glucose concentration similar to plasma

  11. Categories of Joint Effusions • Noninflammatory – • Degenerative joint disease • Trauma • Osteonecrosis • Neuropathic arthropathy • Early or subsiding inflammation • Hypertrophic osteoarthropathy • Rheumatic fever • SLE • Sarcoidosis • Scleroderma

  12. Categories of Joint Effusions • Inflammatory – • RA • Acute crystal-induced synovitis • Reactive arthritis • Ankylosingspondylitis • Psoriatic arthritis • Arthritis associated with inflammatory bowel disease • Rheumatic fever • SLE • Sarcoidosis

  13. Categories of Joint Effusions • Septic effusions – • Bacteria • Mycobacteria • Fungus • Hemorrhagic – • Hemophilia • Anticoagulation • Scurvy • Trauma • Tumor • Neuropathic arthropathy

  14. 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

  15. Gout vs. Pseudogout Pseudogout Gout

  16. Key Messages • Know indication for procedure • Know what analysis should be performed on fluid obtained • Know how to interpret fluid results

  17. 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

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