1 / 20

My knee hurts

My knee hurts. MSU Emergency Medicine Lansing, MI Dr. Patricia Manhire. What are the Indications for Arthrocentesis?. Indications for Arthrocentesis. Crystal-induced arthropathy Hemarthrosis Symptomatic relief of a large effusion Unexplained joint effusion Unexplained monarthritis

ayame
Télécharger la présentation

My knee hurts

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. My knee hurts MSU Emergency Medicine Lansing, MI Dr. Patricia Manhire

  2. What are the Indications for Arthrocentesis?

  3. Indications for Arthrocentesis • Crystal-induced arthropathy • Hemarthrosis • Symptomatic relief of a large effusion • Unexplained joint effusion • Unexplained monarthritis • Suspect interarticular infection

  4. What are the Contraindications to Joint Needle Aspiration?

  5. Contraindications to Joint Needle Aspiration • Absolute • Overlying infection in the soft tissues* • abscess & cellulitis • Severe coagulopathy • Severe overlying dermatitis • Relative contraindication • Bacteremia • Hemophilia • On Warfarin • Uncooperative patient *** Often Acutely arthritic joint symptoms may mimic a soft tissue infection

  6. Review of ProcedureKnee Arthrocentesis

  7. Ultrasound Ultrasound-assisted arthrocentesis can be used as an adjunct to assist in localization and aspiration of joint fluid. • Using a linear 5-10 MHz probe • Anterior transverse scan A (top)= prior to aspiration B (bottom) = following aspiration > = tip of the needle, f = femur. Filippucci E, Iagnocco A, Meenagh G, Riente L, Delle Sedie A, Valesini G, Grassi W.

  8. Position & Prep • Knee extended or slightly bent • Controversial: Studies show bent has a lower yield of fluid in small effusions but is more comfortable. • Can use medial or lateral approach • Suggest lateral with smaller effusions • Prep skin povidone-iodine or Choroprep

  9. Identify LandmarkLateral Approach Insert needle 1 cm above and 1 cm lateral to the superior lateral aspect of the patella. The needle is tilted beneath the patella at a 45-degree angle.

  10. Aspiration • Inserted needle through stretched skin. Stretching the skin can reduce discomfort • Some administer lidocaine into the skin. • The needle is directed at a 45-degree angle distally and 45 degrees into the knee, tilted below the patella • Compression applied over the joint space or "milking" of the bursae, on the patellar side opposite the needle insertion site, may facilitate aspiration. Roberts & Hedges. Clinical Procedures in Emergency Med. 4th Ed Saunders 2004

  11. You now have the Fluid Sample.What labs do you Order?

  12. Examination of Synovial Fluid NormalNoninflammatoryInflammatorySeptic RA = rheumatoid arthritis; SLE = systemic lupus erythematosus

  13. What is your interpretation of the fluid? • Normal • Noninflammatory • Inflammatory • Septic

  14. So, you have determined your patient has Inflammatory Arthritis What information would help you decide which Inflammatory Arthritis your pt has: • Gout? • Pseudogout? • Spondyloarthropathies? • RA? • Lyme disease? • SLE? Number of joints involved Crystals or no crystals

  15. Classification of Arthritis by Number of Affected Joints EMERGENCY MEDICINE: A Comprehensive Study Guide, 6th ed, The McGraw-Hill Companies, Inc.

  16. Lyme Disease • The arthritic manifestations occur in the weeks, months, or years following the primary, stage I infection • Typically, a monarticular or migratory oligoarticular • Large joints are most often affected • Arthrocentesis • inflammatory synovial fluid, usually with negative cultures • History of • endemic area exposure • history of tick bite or erythema chronicum migrans (ECM) rash is helpful but often absent • Show characteristic stage II and stage III findings—such as fatigue, neurologic abnormalities, and/or cardiac conduction disturbances • May require laboratory confirmation • Treatment is administered for 3 to 4 weeks. Rx: doxycycline, penicillin G, amoxicillin, or ceftriaxone.

  17. Rheumatoid Arthritis • Symmetric, polyarticular involvement. • Sparing of the distal interphalangeal (DIP) joints. • Stiffness of the joints after inactivity (morning stiffness). • Multisystem involvement is characteristic • depression, fatigue, and generalized myalgias. • pericarditis, myocarditis, pleural effusion, pneumonitis, • Arthrocentesis of synovial fluid - inflammatory profile. • Treatment: • Salicylates or other NSAIDs • Immobilization providing added relief from joint movement pain. • Corticosteroids may be utilized for brief periods • Long-term therapy using agents such as antimalarials, gold, and methotrexate.

  18. Ankylosing Spondylitis Seronegative spondyloarthropathies • Ankylosing Spondylitis • Similar to RA • morning stiffness and multisystem involvement with constitutional symptoms such as malaise, weakness, and fatigue. • Usually younger than age 40 • Treatment consists of pain control with short-term and long-term management with NSAIDs.

  19. Crystal-Induced Synovitis: Gout & Pseudogout • Gout & Pseudogout • Middle-aged and elderly adults. • Both often follows trauma, surgery, a significant illness, or change in medications affecting uric acid levels. • Pseudogout • Positive birefingence crystals: Calcium pyrophosphate -- rhomboid shape • Acute treatment: same as Gout. • Gout • Negative birefringence:Uric acid crystals -- needle-shaped and blue • 30 % have normal uric acid levels during an acute gout attack • Treatment: nonsteroidal anti-inflammatory drugs (NSAIDs) or Colchicine or indomethacin • Once the symptoms of an acute resolved, elimination of gout-inducing agents (diuretics, aspirin, or cyclosporine) and treatment with allopurinol or probenecid

  20. Your Diagnosis? Acute Rheumatoid Arthritis What is your Treatment Plan

More Related