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.

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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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