eMedicine Specialties > Clinical Procedures > Musculoskeletal Procedures

Arthrocentesis, Wrist: Treatment & Medication

Author: Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Contributor Information and Disclosures

Updated: Jan 8, 2010

Anesthesia

• For local anesthesia, the skin and subcutaneous tissues may be infiltrated down to the level of the periarticular lesion or joint capsule using 1% or 2% lidocaine and a small needle (25 ga). For more information, see Local Anesthetic Agents, Infiltrative Administration.
• Many experienced clinicians prefer to use topical ethyl chloride or no anesthetic at all. This is often appropriate for joint aspiration because anesthetizing the capsule is difficult. A single quick needle thrust may be much less painful than the administration of local anesthesia.

Equipment

Aspiration of the wrist does not require specialized equipment.

• Sterile technique must be followed during the procedure.
• Many experienced operators do not use sterile gloves. In this case, a "no touch" technique is employed, in which palpation and marking of the puncture site precedes application of the antiseptic. The area is not touched after the initial marking. Nonsterile gloves should still be worn to protect the operator.
• A 20-ga needle should be used. Occasionally, for septic arthritis, an 18-ga needle may be required, if the fluid is too viscous to allow aspiration through a smaller needle.
• A 5-mL syringe is usually the most appropriate size.
• Forceps may be useful for holding the needle when changing the syringe between aspiration of the joint and injection of medication into the synovial cavity.
• A "reciprocating syringe" has been developed to improve procedural performance. Some randomized data suggest benefits when compared to conventional syringes for joint aspiration.¹

Positioning

• The patient should be placed in a comfortable supine or recumbent position. This aids relaxation and guards against possible fainting.
• The wrist should be slightly palmar flexed to facilitate the procedure.
• Prior to cleaning the skin, bone and other landmarks need to be identified by palpation, and the needle site needs to be marked (eg, with a thumbnail imprint in the skin or a skin marker).
• Insert the needle dorsally just distal to the radius and just ulnar to the anatomic snuff box. Avoid the associated tendons (extensor carpi radialis brevis and extensor pollicis longus). Direct the needle perpendicular to the skin. If bone is hit, pull the needle back and redirect it slightly toward the thumb.

Technique

• The skin must be carefully cleaned with an antiseptic agent.
• With the proper technique, the needle passes freely through the extra-articular tissues and a "pop" is felt as the needle enters the joint. The ease with which the fluid can be withdrawn depends on needle size, viscosity of the fluid, degree of effusion, and presence of any fibrin clots. See images below.
  • 
    

    

    Injection of the wrist joint.

    [ CLOSE WINDOW ]

    

    Injection of the wrist joint.

  • 
    

    

    Arthrocentesis of the wrist, medial and lateral approaches.

    [ CLOSE WINDOW ]

    

    Arthrocentesis of the wrist, medial and lateral approaches.

• Free flow of fluid is often suddenly interrupted when the needle end is clogged by synovial membrane or debris. Rotating the needle, withdrawing it slightly, or even re-injecting a little of the fluid often helps to unclog the needle and allow additional fluid to be withdrawn.
• A 22- to 25-ga needle, 0.5-1 inch long, is usually adequate. Occasionally, up to 3-5 mL of fluid may be obtained from the wrist by aspiration, and, if indicated, 0.5 mL of steroid may be injected into the space.
• At the end of any injection procedure, the needle should be swiftly withdrawn, and light pressure should be put on the needle site in the skin.
• Bedside ultrasonography may be useful as an adjunct for joint aspiration by helping to localize the optimal site for needle placement.² Ultrasonography may also help differentiate joint effusion from periarticular disease.

Pearls

• Synovial fluid analysis allows distinction between inflammatory and noninflammatory conditions and provides direct proof of crystal arthropathy, infection, and hemarthrosis.
• If the nature of an effusion is assumed and not confirmed, major diagnostic errors can result.
• Corticosteroid injections and infiltrations are basic treatment tools in rheumatology, orthopedics, physiatry, and general medicine.
• Synovial aspiration and corticosteroid injections and infiltrations carry minimal risk to the patient when properly indicated and performed.

Complications

Surprisingly few complications arise as results of these procedures.

• The most significant issue is the risk of infection. Care must always be taken to use sterile technique. Corticosteroids are contraindicated in patients with septic arthritis. The estimated risk of septic arthritis following aspiration or corticosteroid injection is estimated to be between 1 in 2,000 and 1 in 15,000 procedures.
• Other complications can arise from misplaced injections.
  • The best described complication is tendon rupture following corticosteroid injections for tendonitis. The risk of this complication can be minimized by avoiding injection into the tendon itself. No therapeutic agent should be injected against any unexpected resistance.
  • Occasionally, nerve damage can also result from a misplaced injection (eg, median nerve atrophy following attempted injections for carpal tunnel syndrome).

Other Indications

Other indications exist for performing aspiration or injections about the wrist.

Dorsal wrist tendons

• Inflammation and swelling of the extensor tendon sheaths over the dorsal wrist may be due to a number of inflammatory processes (most commonly, rheumatoid arthritis [RA], but occasionally crystal-induced arthritis or infectious processes).
• The areas of swelling are often well defined and close to the surface, and they are easily entered with direct aspiration, usually at a 30- to 45-degree angle, with the needle directed along the course of the swollen tendon.
• Fluid is often easily obtained. In some patients (those with rheumatoid arthritis, in particular), proliferative synovial tissue limits the amount of fluid that can be aspirated.
• After aspiration, the area can be injected with 0.5 mL of corticosteroid mixed with 0.5-1 mL of lidocaine, if indicated.

• This common overuse syndrome, which involves the tendons at the radial aspect of the anatomic snuff box, is often helped by local injection of the tendon sheath.
• After examination, the area of most tenderness along the course of the tendon should be marked and the needle should be inserted either proximally or distally, directed almost parallel to the skin.
• As the needle is advanced, 0.5 mL of steroid with 0.5-2 mL of lidocaine can be injected along the tendon sheath, and a palpable bulge is usually felt along the tendon.

• Inflammation with swelling in the many flexor tendons in the carpal tunnel area may result in median nerve compression. Injection in this area has the potential to relieve symptoms by reducing this inflammation.
• This area should be defined by making a mark on the volar aspect of the wrist along the flexor tendons, on the ulnar side of the long palmar tendon, approximately 1 inch proximal to the distal wrist crease.
• A 22- to 25-ga needle may be introduced perpendicular to the skin or at a 30- to 45-degree angle, directing the needle proximally or distally along the course of the tendon.
• The needle should be introduced about 0.5-1 inch, and the area should be injected with 0.5 mL of steroid with 0.5-1 mL of lidocaine. If the needle meets obstruction, or if the patient experiences paresthesias, the needle should be withdrawn and redirected to avoid injecting into the body of a tendon or into the median nerve itself.

Ganglia

• Small, often hard, nodular structures known as ganglia are frequently present around the hands and wrists, and they may occur in many other areas near joints or tendons.
• These structures usually contain a thick gelatinous substance that is difficult to aspirate.
• In cases in which pain, tendon dysfunction, or nerve entrapment symptoms are bothersome to the patient, aspiration may be attempted, usually with an 18- to 20-ga needle.
• Even if no fluid is obtained, the process of puncture occasionally causes the structure to dissipate its contents, and symptoms are relieved.
• A small amount (0.2-0.5 mL) of steroid with lidocaine may be injected in an attempt to prevent reaccumulation of fluid.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor Ritu Khurana, MD, to the development and writing of this article.

• Search for CME/CE on This Topic »

• Wrist Dislocation (Sports Medicine)
• Fracture, Wrist (Emergency Medicine)
• Wrist Arthrodesis (Orthopedic Surgery)
• Ulnar-Sided Wrist Pain (Orthopedic Surgery)

• Surgery Provides Modest Benefit for Carpal Tunnel Syndrome
• Hylan G-F 20 Injection Reduces Knee Osteoarthritis Pain for 6 Months
• Thiazolidinediones Linked to Bone Fracture Risk

• Arrow Shaft Injury of the Wrist and Hand: Case Report, Management, and Surgical Technique
• Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures
• Polymyalgia Rheumatica Can Be Distinguished From Late Onset Rheumatoid Arthritis at Baseline: Results of a 5-yr Prospective Study