Arthrocentesis: Shoulder (Emergency Medicine)

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Diagnostic evaluation of acute monoarticular or polyarticular arthritis
  • Therapeutic treatment of acute joint effusions
CONTRAINDICATIONS
  • Overlying skin infections or lesions
  • Arthrocentesis is probably safe in patients with a coagulopathy, unless the coagulopathy is severe. However, the safety of arthrocentesis in patients with abnormal coagulation is not established.
  • Bacteremia
EQUIPMENT
  • Skin cleansing agent (e.g., chlorhexidine or povidone-iodine)
  • Sterile gauze
  • Local anesthetic (1% lidocaine is acceptable)
  • Small (e.g., 5 mL) syringe with 25-gauge needle for anesthetic injection
  • Syringe (10-20 mL) with 1- to 2-inch 20-gauge needle for joint aspiration
  • Specimen tubes for submission of synovial fluid to the laboratory; typically, an EDTA tube is used for cell count and differential, and a lithium heparin tube is used for crystal examination
  • Bandage
  • Elastic wrap (to be applied after large joint aspirations)
  • Gloves

ANATOMY
  • The shoulder joint is formed by the humeral head and the glenoid fossa of the scapula, bounded by the acromion.
  • There is a large subdeltoid bursa that lies just under the deltoid muscle, which covers the lateral and part of the superior aspect of the proximal humerus.
  • Palpate the coracoid process of the scapula and humeral head anteriorly to identify the point of entry.

PROCEDURE
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  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Monitor for signs of infection in the region.
  • An elastic bandage may be placed around the shoulder joint to provide patient comfort and reduce reaccumulation of the effusion.
  • Treat suspected septic arthritis before formal diagnosis.
    • The choice of antibiotic may be made empirically or based upon the gram stain results.
    • Intraarticular antibiotics are not recommended.
    • The joint capsule must be repeatedly drained until the effusion is cleared. Operative drainage may be needed.
  • Treatment of gout
    • High-dose nonsteroidal antiinflammatory agents, colchicine, and oral steroids may be used.
    • Antihyperuricemia treatment should be delayed.
  • Treatment of pseudogout
    • Treatment is identical to that for acute gout. Antihyperuricemic agents are not used.
COMPLICATIONS
  • Complications are uncommon.
    • Iatrogenic infection
    • Iatrogenic hemorrhage
    • Pain during the procedure
    • Reaccumulation of the joint fluid.
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