Today’s Morning Report is courtesy of Dr. Benson:
“I think I (k)nee-d some help”
42 y/o M presents for right knee pain and swelling, occurring for the last few days, notably worse today.
Differential?
Trauma
Septic arthritis
OA
RA
Lyme arthritis
Gout
Bursitis
Cellulitis
Indications for arthrocentesis:
-Evaluation and diagnosis of a red, swollen joint
-Pain relief of large effusion or heme-arthrosis
-Evaluation of joint integrity, when there is a laceration close to a joint
- Old reccomendations are for instillation of anesthetic, although there is new literature to suggest that all anesthetics are chondro-toxic and should NOT be instilled
Contraindtications:
-Overlying cellulitis – RELATIVE – if you are concerned for septic joint, do the tap, try to minimize going though possibly infected tissue
-Coagulopathy – RELATIVE
General techniques:
-Sterile procedure – be generous with chlorohexadine; if using Betadine, allow it to dry fully prior to beginning
-Give good anesthesia – be generous with local anesthetic, give something orally, if possible
-Try to keep surrounding musculature relaxed – if the muscles are tense, the joint space gets smaller
Review of techniques for specific joints to tap:
1st MCP:
Landmark – radial aspect of PROXIMAL end of MCP
Tip: find APL by ulnar deviation of hand
Technique: oppose thumb and 5th finger, traction thumb and insert needle on PALMAR side of tendon
Radiocarpal Joint – AKA wrist
Landmark: dorsal radial tubercle, extensor pollicis longus
Tip: find tendon by extending wrist and thumb
Technique: 20 degrees of flexion with ulnar deviation and traction on hand
Knee
Landmark: medial, at middle to superior patella **can do lateral too, but lateral aspect of patella juts posteriorly, so you have to get under it
Tip: flex knee to 30 degrees (rolled up sheet), foot perpendicular to floor, relax quads
Technique: keep syringe parallel to bed, lift patella anteriorly, don’t scrape cartilage with needle
References:
Roberts and Hedges
EMP on Monoarticular Arthritis, 5/2012
Thanks Dr. Benson! Leave any comments below.
Jay Khadpe MD
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