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Elbow Joint Injection

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Other Names

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

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

Indications


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

Demonstration of palpation guided approach with the skin marked[1]
probe placement along posterior distal humerus in both (A) long and (B) short axis.[2]
Ultrasound of posterior distal humerus demonstrates effusion in both (A) long-axis view and (B) short-axis view (with needle in-plane).[2]
Probe positioning for out of plane, lateral approach
Ultrasound guided lateral, out-of-plane approach. Dots (needle path), C (capitellum), R (radius)[3]
Ultrasound guided lateral, in-plane approach. Arrow (needle path), C (capitellum), R (radius)[3]

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

  1. Image courtesy of uptodate.com, "elbow arthrocentesis"
  2. 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. 3.0 3.1 Malanga, Gerard, and Kenneth Mautner. Atlas of ultrasound-guided musculoskeletal injections. McGraw-Hill, 2014.
  4. 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
Authors:
Last edited:
14 April 2023 18:23:14
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