Toe Joint Aspiration

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 18ga needle (for larger joints) 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

Metatarsophalangeal

• Patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction
• Insert needle dorsally just medial or lateral to midline between the metatarsal head and base of proximal phalanx

Interphalangeal

• Patient supine with joint flexed 15-20 degrees with gentle traction
• Insert needle dorsally, medial or lateral to midline between head of proximal phalanx and base of more distal phalanx

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

Complications

General arthrocentesis complications

• Pain
• Infection
• Re-accumulation of effusion
• Damage to tendons, nerves, or blood vessels

External Links

• Merck Manual - How To Do Metatarsophalangeal Joint Arthrocentesis