Morning Report: 5/30/2012

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.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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