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Arthrocentesis

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Arthrocentesis

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Arthrocentesis

  1. 1. ARTHROCENTESIS A STAB IN THE DARK
  2. 2. LEARNING OUTCOMES Arthrocentesis • Indications • Contraindications • Basic technique • Guided techniques • Synovial fluid analysis • Complications Joint injection • Use in ED • Medications
  3. 3. Mr Arthur Ritis • 52 year old man • 24 hours of hot, swollen, painful right knee. • PMHx T2DM, HTN, A Touch Overweight, Gout • Meds Olmesartan/HCT, Metformin • NKDA
  4. 4. Mr Arthur Ritis • General Exam Temp 37.7 Knee • Warm, large effusion, mild tenderness • ROM reduced
  5. 5. Mr Arthur Ritis • Investigations
  6. 6. Mr Arthur Ritis • Blood tests FBP (WCC)1 CRP2 ? ESR1 ? Pro-calcitonin3 ? uric acid • Imaging Plain film Xray
  7. 7. Mr Arthur Ritis • Blood tests WCC 12.5 CRP 60
  8. 8. ARTHROCENTESIS • Indications Investigation of unexplained mono- articular arthritis. Confirm diagnosis of first episode crystal arthropathies. Symptomatic tap for large effusion.
  9. 9. ARTHROCENTESIS • Contra-indications Non compliant patient • Relative Overlying Cellulitis4 Uncontrolled bleeding disorder5,6 Prosthetic joint
  10. 10. ARTHROCENTESIS • Technique Sterile gloves Skin prep • SCGH ED Guideline • Springer et al. Joint Arthrocentesis in the Emergency Department.
  11. 11. ARTHROCENTESIS UPPER LIMB LANDMARKS
  12. 12. ARTHROCENTESIS UPPER LIMB
  13. 13. ARTHROCENTESIS LOWER LIMB LANDMARKS
  14. 14. ARTHROCENTESIS LOWER LIMB LANDMARKS
  15. 15. ARTHROCENTESIS ULTRASOUND GUIDED
  16. 16. ARTHROCENTESIS SYNOVIAL FLUID ANALYSIS
  17. 17. ARTHROCENTESIS SYNOVIAL FLUID ANALYSIS Macroscopic assessment Microscopy Gram stain7 Crystals Cell count (WCC, % Polymorphonuclear)7,8 Culture
  18. 18. ARTHROCENTESIS MR ARTHUR RITIS Macroscopic assessment: yellow, slightly cloudy Microscopy Gram stain: no bacteria seen. Crystals: urate crystals Synovial WCC: 15000 PMN: 60% Culture: pending
  19. 19. THOUGHTS?
  20. 20. STEROID INJECTIONS
  21. 21. EVIDENCE • Osteoarthritis9 • Rheumatoid arthritis10 • Gout 11
  22. 22. WHICH STEROID?12
  23. 23. REFERENCES 1. Li S, Cassidy C, Chang C et al. Diagnostic utility of laboratory tests in septic arthritis. Emergency Medicine Journal. 2007;24(2): 75- 77. 2. Hugle T, Scheutz P, Mueller B et al. Serum procalcitonin for discrimination between septic and non septic arthritis. Clin Exp Rheum. 2008;26:305-8. 3. Maharajan et al. Serum Procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis. J Orth Surg Research. 2013;8. 4. Dooley DP. Aspiration of the possibly septic joint through potential cellulitis: Just do it! J Emerg Med 2002;23:210. 5. Yui J etal. Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants. Mayo clinic proceedings. 2017;92(8):1223-26. 6. Ahmed I. Safety of Arthrocentesis and Joint Injection in Patients Receiving Anticoagulation at Therapeutic Levels. Am J Medicine. 2012;125(3):265-9. 7. Carpenter C et al. Evidence based diagnostics: septic arthritis. Academic Em Med. 2011;18(8): 782-96. 8. Coutlakis PJ. Another look at synovial fluid leukocytosis and Infection. J Clin Rheumatol 2002; 8:67–71. 9. Godwin. Intra-articular steroid injections for painful knees. Systematic review with meta-analysis. Can Fam Phys. 2004;50(2):241- 248. 10. Wallen M, Gillies D. Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis. Cochrane Musculoskeletal group. 2006. 11. Wechalekar M et al. Intra-articular glucocorticoids for acute gout. Cochrane musculoskeletal group. 2013. 12. Stephens M et al. Musculoskeletal injections: a review of the evidence. Am Fam Phys. 2008;78(8):971-6.

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