Overview of Elbow Arthrocentesis
Elbow arthrocentesis is a medical procedure where doctors use a needle to draw out fluid from an elbow joint. This is often done to examine and treat a condition called elbow effusion, which is when extra fluid builds up in the elbow joint causing it to swell. While it is a minor surgery, it does carry some risks such as infection, or injury to nerves, blood vessels, tendons, or other types of connective tissue. This is why only health care professionals who are specifically trained in this procedure and understand the structure of the elbow inside and out should carry it out.
Doctors use elbow arthrocentesis to look for the causes of joint effusion. They do this by studying the fluid they’ve drawn from the joint. The causes could be an infection, inflammation, or bleeding into the joint space. As well as helping doctors understand the cause of the swelling, removing this fluid can relieve pressure in the joint capsule which can, in turn, reduce pain. The procedure also allows doctors to inject the joint with medicines for pain relief or to treat joint diseases that cause wear and tear.
Among all the causes of joint effusion, a specific type of joint infection called septic arthritis is important to identify correctly. This is because cultures, a type of lab test, are key to proper and timely treatment of this condition.
Anatomy and Physiology of Elbow Arthrocentesis
The elbow joint is made up of three major parts: the distal end of your upper arm bone (humerus), the top of your forearm bone (radial head), and a prominent bone of your elbow (olecranon). Together, they form a hinge joint that allows your arm to bend and straighten. The radial head is kept in place by a ring-like ligament, and this space in the elbow joint is filled with a lubricating fluid called synovial fluid, which is often the target of procedures that remove fluid from the joint, known as elbow aspirations.
Now, let’s talk about the muscles around your elbow. On the front of your elbow, you have a muscle named the biceps, which helps to bend your elbow. On the other hand, the triceps at the back of your elbow assist in straightening it. Some other muscles, originating from a bony bump on the inner side of your elbow, help in rotating and bending your wrist, and receive signals mainly through the median nerve (a major nerve in your arm). There are also muscles that originate from a bony bump on the outer side of your elbow that help in straightening and rotating your wrist, which receive signals mainly via the radial nerve.
When it comes to blood supply, the elbow gets its nutrients from an extensive network of blood vessels that stem from the main arteries in your arm.
If you’re having a medical procedure involving your elbow, you’ll likely be positioned with your elbow bent at a 90-degree angle and your hand turned so the palm is facing down. This position moves some of the bone structures out of the way, making the procedure more streamlined.
The doctor will target the needle insertion at the meeting point of the three major parts of your elbow joint. This area is also known as the “anconeus triangle.” They will then insert the needle in a certain direction, targeting the lower end of the front hollow part of your elbow.
To ensure accuracy and safety during the procedure, ultrasound guidance is typically used. This technology allows doctors to see fluid collections and guide the needle more effectively.
Why do People Need Elbow Arthrocentesis
Elbow arthrocentesis, or the process of using a needle to remove fluid from the elbow joint, is carried out for two main purposes – for diagnosing medical conditions and for relieving pain caused by excess fluid pressure. The fluid extraction helps in identifying several medical problems like septic arthritis (a severe infection in the joint), hemarthrosis (bleeding into joint spaces), and inflammation. Often, in cases where there is suspicion of joint infection or crystalline arthropathy (a condition caused by accumulation of crystals in the joint), this procedure can be very useful.
Furthermore, arthrocentesis is beneficial in monitoring how well the treatment for septic arthritis or other unexplained arthritis with joint fluid buildup is working. Apart from these, although not a focus of this discussion, the procedure also allows physicians to inject therapeutic medications into the joint, or to assess the health of the joint capsule by observing their response to fluid, especially when there might be injuries like a laceration over the joint.
When a Person Should Avoid Elbow Arthrocentesis
There is only one main reason why a doctor wouldn’t perform arthrocentesis, a procedure to remove fluid from a joint: if a skin infection known as cellulitis is present over the area, it could cause bacteria to enter the joint.[2] Other factors that may make this procedure more difficult or risky include coagulopathy (a condition that affects the blood’s ability to clot), having an artificial joint, a recent bone fracture, and nearby bone infection (osteomyelitis).
If someone has an artificial joint, it’s important to discuss with an orthopedic surgeon before trying to drain fluid from it. This is because some surgeons feel that this procedure should only be done in a surgery setting when an artificial joint is involved.
Equipment used for Elbow Arthrocentesis
Here is a list of items that are typically used for a medical procedure:
* Iodine solution or chlorhexidine: These are disinfectant solutions that help clean the skin to prevent infection.
* Sterile gloves, drape, and gauze: These are used to maintain cleanliness and sterility during the procedure.
* Sterile fenestrated drapes: These are special covers with an opening. They keep the rest of the body untouched and expose only the specific area where the procedure is going to take place.
* Lure-Lok syringes including one 5cc and another 5 to 20cc syringe: These are syringes used to inject or withdraw fluid.
* 20G and 27G needle: These are sizes of needles used with the syringes.
* 1% Lidocaine or 0.5% bupivacaine: These are local anesthetic drugs used to numb the area and help reduce pain during and after the procedure.
* Collection tubes including a hematology tube, sterile tube, heparinized tube: These tubes are used for collecting samples for lab tests. Each type of tube is used for a specific kind of sample.
* Ultrasound with a sterile cover, if available: This is used to guide the procedure by giving a real-time internal view of the body part. The sterile cover keeps it clean and prevents spread of germs.
Who is needed to perform Elbow Arthrocentesis?
This procedure can be done on its own, but sometimes, having an extra pair of hands can make things a bit easier. For instance, if a patient is very nervous or if unexpected complications arise, an assistant can help to ensure everything runs smoothly.
Preparing for Elbow Arthrocentesis
Elbow arthrocentesis, or draining fluid from the elbow, is not an immediate medical procedure. Taking additional time to carefully prepare can help increase the chances of success on the first try and decrease any related risks. It’s important to make sure all the required tools are ready and working properly. Also, knowing exactly where to insert the needle (the landmarks) can guide the process. Lastly, keeping everything clean and free from germs (sterile technique) is a must to prevent infection.
How is Elbow Arthrocentesis performed
The procedure described here involves drawing out fluid from the elbow joint, also known as joint aspiration. The patient’s elbow should be bent at a 90-degree angle with the palm facing down. This position exposes the joint space for the procedure. The doctor may use an ultrasound to locate the fluid buildup and guide the needle. The needle insertion site is under a bony prominence on the outside of the elbow (lateral humeral epicondyle), in front of the bony part at the back of the elbow (olecranon), and behind another bone (radial head) present in the elbow.
The area is then cleaned extensively with a germ-killing solution. The healthcare provider will wear a sterile gown and gloves and keep the cleaned area covered with a sterile drape. The doctor numbs the skin at the insertion site with 1% lidocaine to reduce any discomfort during the procedure. After the area becomes numb, a syringe attached to a small needle (18 to 22 gauge) is inserted into the joint space. The doctor pulls back the plunger (retracts) on the syringe to check for blood. The healthcare provider will then draw out (aspirate) any fluid present, which could be related to joint inflammation, blood, or infection. If needed, the doctor might inject a steroid medication into the joint space to help reduce inflammation. Finally, a bandage is applied after the needle is removed, and the collected fluid is sent off for various lab tests.
Certain factors are taken into consideration for patients who are taking blood thinning medications (anticoagulants), such as warfarin or direct oral anticoagulants (DOACs). For these patients, a smaller needle may be used to decrease the risk of bleeding. If the doctor suspects a joint infection but isn’t able to extract any fluid (dry tap), an ultrasound may be employed to guide the needle more accurately. Trimming or shaving off hair before this procedure offers no added benefit.
Possible Complications of Elbow Arthrocentesis
Even though it’s not common, there are some risks involved in the medical procedure called arthrocentesis. In this procedure, a needle is used to remove fluid from a joint in your body. It’s the doctor’s responsibility to ensure you are aware of these risks before the procedure begins. There are two main types of complications that could occur: infectious and noninfectious.
The most serious infectious complication is called septic arthritis, which is an infection in your joint. It’s quite rare, happening between 1 in 2,000 to 1 in 15,000 cases. To prevent this, the doctor will keep the area sterile, limit how many needle attempts are made, use fresh needles and avoid injecting a needle through skin that’s already infected. Another infectious complication is septic bursitis, an infection in your bursa (a small, fluid-filled sac near your joint). This happens when the needle goes through the bursa on the way to the joint, allowing bacteria from the skin to enter the bursa.
Noninfectious complications could also happen, including tendon rupture, vascular damage (harm to blood vessels), and neurologic damage (harm to nerves). These risks are usually due to the needle causing trauma. They’re more likely when steroids are injected, rather than when fluid is removed. To reduce these risks, the doctor will plan their approach carefully and choose the safest place to insert and move the needle. If bleeding occurs, it can be managed with pressure.
Lastly, it’s important to know that your joint may fill with fluid again until the root cause of the problem is resolved.
What Else Should I Know About Elbow Arthrocentesis?
Arthrocentesis is a medical procedure used to determine the cause of swelling in your joints. By taking out and examining the fluid in the joint, doctors can classify the swelling as non-inflammatory, inflammatory, infected, or due to bleeding.
There is a type of joint infection called septic arthritis, and it usually involves only one bacterium. This type of infection is categorized into two groups: gonococcal and non-gonococcal, depending on the age of the patient and their medical history. For instance, in adults who are younger than 35, the infections are usually caused by the bacterium N. gonorrhea. On the other hand, for those older than 35, they are more likely to have joint infections caused by the bacterium S. aureus.
Various factors, like recent travels or being in a health state where the immune system is compromised, might indicate other bacteria that could be causing the infection. These can include a variety of bacteria, including Strep. spp, aerobic gram-negative, anaerobic gram-negative, Brucella, Mycobacteria spp, fungi, and Mycoplasma hominis.
Conditions, such as crystalline arthritis and autoimmune disease, can lead to an inflammatory swelling of the joint. Trauma or injury is the most common cause of joint swelling due to bleeding. There have been a few cases, however, of patients with bleeding joints that were not caused by injury but through a medical condition that results in an overabundance of blood coagulation factors.
Please refer to the attached graph for additional information. Conditions like gout are associated with “negatively birefringent crystals,” while “positive birefringent crystals” are associated with a condition called pseudogout.