Elbow Joint Injection

Other Names

• Elbow Arthrocentesis
• Elbow Tap
• Elbow Aspiration
• Elbow Injection

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Background

Elbow arthrocentesis, posterior approach.

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

Lateral illustration of the elbow joint showing the joint space, synovium, capsule and posterior fat pad

• Elbow Joint
  • Hinge joint formed by the humerus, radius and ulna
  • Effusion should be evaluated in lateral recess (radiocapitellar articulation) and/or posterior recess (humeroulnar articulation)

Palpation vs Ultrasound Guidance

• Studies measuring outcomes comparing ultrasound guidance to palpation or fluoroscopy are limited

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Indications

• Treat Elbow Osteoarthritis
• Rule out Septic Arthritis
• Diagnose Gout or other spondyloarthropathy
• Symptomatic relief
• Unexplained joint effusion or monoarthritis

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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

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Procedure

Demonstration of palpation guided approach with the skin marked

probe placement along posterior distal humerus in both (A) long and (B) short axis.

Ultrasound of posterior distal humerus demonstrates effusion in both (A) long-axis view and (B) short-axis view (with needle in-plane).

Probe positioning for out of plane, lateral approach

Ultrasound guided lateral, out-of-plane approach. Dots (needle path), C (capitellum), R (radius)

Ultrasound guided lateral, in-plane approach. Arrow (needle path), C (capitellum), R (radius)

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

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

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Aftercare

• Apply bandage
• Consider ace wrap to help prevent recurrence of effusio

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Complications

• Pain
• Infection
• Recurrence of effusion
• Damage to surrounding soft tissue structures

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See Also

• Arthrocentesis Main
• Procedures Main
• Ultrasound Main

External

• http://mskultrasound.net/arthrocentesis-elbow-joint/

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