Ankle Joint Aspiration: Difference between revisions
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==Overview== | ==Overview== | ||
[[File:Ankle anatomy | [[File:Ankle anatomy injection.png|thumb|Medial approach: enter space between anterior border of the medial malleolus and the tibialis anterior tendon]] | ||
[[File:Ankle | [[File:Ankle injection positioning.png|thumb|Medial approach: have patient lie supine, and plantar flex the ankle so the angle is close to 90 degrees.]] | ||
==Indications== | ==Indications== | ||
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==Procedure== | ==Procedure== | ||
[[File:Ankle | [[File:Ankle injection.png|thumb|Lateral and medial ankle arthrocentesis approaches]] | ||
===General Setup=== | ===General Setup=== | ||
*Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3 | *Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3 | ||
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===Ultrasound Guided=== | ===Ultrasound Guided=== | ||
[[File:Ankle us anatomy. | [[File:Ankle us anatomy.jpg|thumb|Axial view of TA tendon and EHL tendon (locate also anterior tibial artery, and deep fibular nerve).]] | ||
==Evaluation== | ==Evaluation== | ||
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==Complications== | ==Complications== | ||
{{General arthrocentesis complications}} | {{General arthrocentesis complications}} | ||
==External Links== | ==External Links== | ||
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<references/> | <references/> | ||
[[Category:Foot | [[Category:Foot and Ankle Procedures]] | ||
[[Category: | [[Category:Pages with broken file links]] |
Latest revision as of 18:49, 5 May 2022
Overview
Indications
General arthrocentesis indications
- Suspicion of septic arthritis
- Suspicion of crystal arthropathy
- Evaluation of therapeutic response for septic arthritis
- Unexplained arthritis with synovial effusion
- Evaluation of joint capsule integrity if overlying laceration
- Relative: therapeutic (decrease intra-articular pressure, injection of anaesthetics/steroids)
Contraindications
General arthrocentesis contraindications
- No absolute contraindications for diagnostic arthrocentesis
- Do not inject steroids into a joint that you suspect is already infected
- Relative Contraindications:
- Overlying cellulitis
- Coagulopathy
- Joint prosthesis (refer to ortho)
Equipment Needed
General arthrocentesis equipment
- Betadine or Chlorhexadine
- Sterile gloves/drape
- Sterile gauze
- Lidocaine
- Syringes
- Small syringe (6-12cc) for injection of local anesthetic
- Large syringe (one 60cc or two 30cc) for aspiration
- Needles
- 18 gauge: knee
- 20 gauge: most other joints
- 25 gauge: MTP joints
- 27 gauge for anaesthetic injection
- Collection tubes (red top and purple for crystal analysis)
- Culture bottles
- Consider utilizing U/S to assess for effusion
Procedure
General Setup
- Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
- Drape joint in sterile fashion
- Inject lidocaine with 25-30ga needle superficially and then into deeper tissues
- Insert 20ga needle into joint space while pulling back on syringe
- Stop once you aspirate fluid; aspirate as much fluid as possible
- Send: cell count, culture, Gram Stain, crystal analysis
Medial approach (tibiotalar)
- Have patient supine with foot perpendicular to leg
- Palpate sulcus lateral to medial malleolus and medial to TA and EHL tendons
- Then plantarflex foot with needle entering skin overlying the sulcus
- Angle needle slightly cephalad as it passes between medial malleolus and TA tendon
Lateral approach (subtalar)
- Keep foot perpendicular to leg
- Enter subtalar joint just below tip of lateral malleolus
- Direct needle medially toward joint space
Ultrasound Guided
Evaluation
Arthrocentesis of synoval fluid
Synovium | Normal | Noninflammatory | Inflammatory | Septic |
---|---|---|---|---|
Clarity | Transparent | Transparent | Cloudy | Cloudy |
Color | Clear | Yellow | Yellow | Yellow |
WBC | <200 | <200-2000 | 200-50,000 |
>1,100 (prosthetic joint) >25,000; LR=2.9 >50,000; LR=7.7 >100,000; LR=28 |
PMN | <25% | <25% | >50% |
>64% (prosthetic joint) >90% |
Culture | Neg | Neg | Neg | >50% positive |
Lactate | <5.6 mmol/L | <5.6 mmol/L | <5.6 mmol/L | >5.6 mmol/L |
LDH | <250 | <250 | <250 | >250 |
Crystals | None | None | Multiple or none | None |
- Viscosity of synovial fluid may actually be decreased in inflammatory or infectious etiologies, as hyaluronic acid concentrations decrease
- The presence of crystals does not rule out septic arthritis; however, the diagnosis is highly unlikely with synovial WBC < 50,000[1]
Complications
General arthrocentesis complications
- Pain
- Infection
- Re-accumulation of effusion
- Damage to tendons, nerves, or blood vessels
External Links
References
- ↑ Shah K, Spear J, Nathanson LA, Mccauley J, Edlow JA. Does the presence of crystal arthritis rule out septic arthritis?. J Emerg Med. 2007;32(1):23-6.