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Small Joint Arthrocentesis

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Other Names

  • Toe Arthrocentesis
  • Finger Arthrocentesis
  • Thumb Arthrocentesis
  • Foot Arthrocentesis

Background

Transducer in long axis on index MCP joint with needle positioned out of plane[1]
  • This page covers small joint arthrocentesis
    • Includes all of the small joints in the hand and foot

Anatomy


Indications

  • 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 (3-5 mL is typically sufficient)
  • Needles (large bore for drawing up local, small gauge for injection)
    • Small joints recommend 21 - 23 gauge, 0.5 - 1 inch needle
  • Anesthetic (e.g. 1-2% lidocaine or 0.5% bupivacaine)
  • Ultrasound machine (optional, but highly recommended)
    • High frequency linear probe
    • Sterile ultrasound probe cover

Preparation

  • Patient positioning
    • For the upper extremity, the patient is seated with hand on table
    • For lower extremity, the patient is supine with hip and knee flexed, foot on table
  • Palpate joint
    • Important to try to find "dip" between bones
    • This is where the needle will be inserted
  • Ultrasound
    • Can confirm effusion is present
    • Helpful to identify optimal approach
    • Avoids any underlying neurovascular structures

Palpation Guided Technique

  • Identify bony landmark
    • Point of maximal depth between two bones of interest
  • Mark estimated point of entry
  • Sterile prep your field
  • Insert needle directed into joint space
    • Aspirate while advancing
    • Needle should "drop" into joint
    • May require subtle redirections to get into joint

Ultrasound Guided Technique

Ultrasound guided injection of the tarsometatarsal joint using out-of-plane technique
  • Identify landmark(s) sonographically
    • The joint should be centered on the screen in long axis
    • Identify optimal approach for needle
  • Technique
    • In- or out-of-plane technique can be used
    • Out-of-plane tends to be easier in small joints
  • In-plane
    • Advance needle as you advance into joint
    • Can be difficult with linear probe over small joints
  • Out-of-plane
    • Follow needle tip in a "step-wise" approach
    • Needle tip should be visualized in joint space
  • Aspirate as you advance

Aftercare

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

Complications

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

See Also


References

  1. Image courtesy of emra.com, "Small Spaces: Ultrasound-Guided Small Joint Aspiration"
Created by:
John Kiel on 26 January 2023 07:19:04
Authors:
Last edited:
26 January 2023 08:19:21
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