Elbow Joint Injection
(Redirected from Elbow Arthrocentesis)
Other Names
- Elbow Arthrocentesis
- Elbow Tap
- Elbow Aspiration
- Elbow Injection
Background
Key Points
- This page includes both injection and aspiration as the technique and approach are the same
- We recommend ultrasound guided approach posteriorly, although an ultrasound approach can be performed laterally
- Do not confuse olecranon bursitis with an elbow effusion
Anatomy
Palpation vs Ultrasound Guidance
- Studies measuring outcomes comparing ultrasound guidance to palpation or fluoroscopy are limited
Indications
- Treat Elbow Osteoarthritis
- Rule out Septic Arthritis
- Diagnose Gout or other spondyloarthropathy
- Symptomatic relief
- Unexplained joint effusion or monoarthritis
Contraindications
- Absolute
- No absolute contraindications
- Relative
- Abnormal or altered anatomy
- Overlying infection or bacteremia
- Coagulation
- Prosthetic joint
- Uncooperative patient
- Diagnosis can be made with less invasive method
Procedure
Equipment
- Sterile gloves
- Sterile gauze
- Antiseptic (e.g. chlorhexidine, iodine or alcohol)
- Syringe (5 to 10 mL is typically sufficient)
- Needles (large bore for drawing up local, small gauge for injection)
- Elbow arthrocentesis recommend 20-21 guage, 1.5 - 2 inch needle
- Anesthetic (e.g. 2% lidocaine or 0.5% bupivacaine)
- For injectate, typically 1 cc anesthetic and 1 cc corticosteroid
- Ultrasound machine (optional, but highly recommended)
- High frequency linear probe
- Sterile ultrasound probe cover
Ultrasound Findings
- Ultrasound: Anterior view
- Can see both radio-capitaller and ulnar-humeral trochlear joint in long and short axis
- Look for subtle erosion and cartilage irregularities to suggest pathology
- Ultrasound: Lateral view
- Can evaluate the radio-capitellar joint
- Joint effusion can be seen as well as pathology of the radial head
- Ultrasound: Posterior view
- Identify distal humero-ulnar articulation in long axis
- Triceps tendon should be easily visualized
- Posterior fat pad and effusion
- Can flex and extend joint to help confirm anatomy
- Olecranon bursa can also be visualized posteriorly
- Ultrasound: confirm effusion is present
- Identify landmarks in either the lateral or posterior approach
- Lateral recess: will show distended capsule
- Posterior fat pad below level of humerus, distended if effusion present
- The posterior recess is most sensitive for an effusion[4]
Palpation Guided Technique
- Identify bony landmarks
- Lateral epicondyle, olecranon process, radial head
- Palpate the radial head by supinating and pronating the elbow
- Point of entry is triangulation between these 3 landmarks (anconeus triangle)
- Mark estimated point of entry
- Sterily prepare your field
- Inject local anesthetic
- Insert needle directed into joint space
- Aspirate while advancing
- May need to redirect needle until it "drops" into joint or you aspirate fluid
- Pearls
- Arthritis can make the lateral approach difficult due to proximity of articular surfaces
Ultrasound Guided Technique: Posterior
- Position
- Patient can be prone with elbow hanging off bed
- Alternatively, seated with elbow resting on examination table
- Identify landmarks sonographically
- Triceps tendon, posterior fat pad, effusion, humeroulnar articulation
- Short axis
- Probe is in short axis of the arm
- Needle is in plane advancing from lateral to medial
- Long axis
- Probe is in long axis of the arm
- Needle is advanced from proximal to distal
- Advance needle along intended plane in either short or long axis
- Advance in plane along intended trajcetory
- Aspirate/inject when needle enters hypoechoic fluid collection
- Pearls and Pitfalls
- Keep approach to lateral side of posterior elbow to avoid the ulnar nerve
Ultrasound Guided: Lateral, Out-of-Plane
- Position
- Patient is prone, elbow propped up on pillow
- Elbow is flexed to 40°; palm down and forearm pronated
- Probe and Needle Orientation
- Probe is oblique to the radio-capitellar joint, short axis of radius
- Needle is out of plane
- Approach is posterior to anterior
- Pearls and Pitfalls
- Alternative position is patient seated, elbow on table with palm down and forearm pronated
- Radiocapitellar approach can be difficult if significant arthritis is present
- Can confirm needle position by switching to long axis
Ultrasound Guided: Lateral, In-Plane
- Position
- Patient is prone, elbow propped up on pillow
- Elbow is flexed to 40°; palm down and forearm pronated
- Probe and Needle Orientation
- Probe is transverse to radio-capitellar joint, long axis of radius
- Needle is in plane
- Needle approach is distal to proximal
- May require ultrasound gel "step off"
- Pearls and Pitfalls
- Alternative position is patient seated, elbow on table with palm down and forearm pronated
- Radiocapitellar approach can be difficult if significant arthritis is present
- Can confirm needle position by switching to long axis
Aftercare
- Apply bandage
- Consider ace wrap to help prevent recurrence of effusio
Complications
- Pain
- Infection
- Recurrence of effusion
- Damage to surrounding soft tissue structures
See Also
External
References
- ↑ Image courtesy of uptodate.com, "elbow arthrocentesis"
- ↑ 2.0 2.1 Boniface, Keith S., et al. "Ultrasound-guided arthrocentesis of the elbow: a posterior approach." The Journal of Emergency Medicine 45.5 (2013): 698-701.
- ↑ 3.0 3.1 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
- ↑ De Maeseneer M, Jacobson JA, Jaovisidha S, et al. Elbow effusions: Distribution of joint fluid with flexion and extension and imaging implications. Invest Radiol. 1998;33(2):117-125.
Created by:
Jesse Fodero on 10 July 2019 15:58:23
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Last edited:
14 April 2023 18:23:14
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