Arthrocentesis: Wrist (Internal 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 (5-10 mL) with 20- or 22-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)
  • Sterile gloves, mask, goggles
ANATOMY
  • The wrist joint is formed by the distal radius and ulna and the carpal bones.
  • The ulnar and radial bursae lie on the palmar aspect of the proximal wrist and hand.
  • The radial artery lies lateral to the distal radius and the ulnar artery lies just medial to the ulna, next to the ulnar nerve. The median nerve lies in the mid region of the wrist on the palmar surface.
  • Palpate the extensor pollicus longus tendon on the dorsum of the wrist, and the Lister tubercle on the distal radius. The point of entry is distal to the tubercle and ulnar to the tendon.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • 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 larger joints 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 may be based on 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 until acute gouty attack has subsided.
  • 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 time of the procedure
    • Reaccumulation of the joint fluid
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