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Arthrocentesis of the Hand

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Authors

Eric Friedman, MD
Attending Physician
Director of Sports Medicine
Trident Medical Center Emergency Medicine Residency

Yana Klein, DO
Sports Medicine Track
Loyola University Medical Center

Summary

  • Hand arthrocentesis should be used in the ED to help evaluate for septic or crystal arthritis
  • Ultrasound assistance will provide better accuracy and save time
  • Use the linear probe for higher frequency for this procedure
Finger US Normal MCP Joint
Ultrasound demonstrating a normal appearing metacarpalphalangeal joint. The metacarpal is left, joint centered and proximal phalanx on the right.
Ultrasound of the PIPJ in long axis demonstrating a joint effusion.[1]Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 27669
Out-of-plane injection of the thumb MCP joint. Note the same technique would be used to peform an arthrocentesis.

Introduction

  • Hand pain and injury most commonly occurs via injury, repetitive work, or hobby related activities and are associated with significant morbidity.
  • Disease commonly occurs at the first carpometacarpal (CMC) joint, which allows opposition of the thumb, and the metacarpal (MCP) and interphalangeal (IP) joints, all of which are critical for activities of daily living allowing fine, dexterous hand movements.
  • Clinical interpretation cannot always differentiate synovial hypertrophy from effusion, making ultrasound important to confirm the presence and location of fluid.
  • Ultrasound also helps to improve accuracy and efficacy of the procedures.
  • Since fluid analysis is a critical component in management, ultrasound serves as an adjunct in the emergency department.
  • Aspiration of any joint is an important diagnostic tool to exclude septic or crystal arthritis.[2]Thomsen TW, Shen S, Shaffer RW, Setnik G. Arthrocentesis of the Wrist. N Eng J Med. Published online 2017.
  • Causes of joint effusions in the hand include infection, crystal-induced arthropathy, inflammation, or chronic changes.
  • Aside from distinguishing these various etiologies based on the patient’s history and exam, joint aspiration can provide both relief to the patient with needle aspiration and help determine causes and appropriate treatment.[3]Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. 2002;15(4):527-544. doi:10.1128/CMR.15.4.527-544.2002

Anatomy

  • The osseous hand is composed of metacarpal and phalangeal bones
  • The carpometacarpal (CMC) joints connect the hand to the wrist
  • The metacarpophalangeal joint (MCP) anchor the digits and the phalangeal bones form the fingers
  • The thumb has a proximal and distal phalanx while digits 2-4 have 3 phalanges forming both a proximal and distal interphalangeal (IP) joint
Hand Anatomy Illustration
Illustration of the osseous hand anatomy including fingers, bones and joints. (click to enlarge)[4]Nanayakkara VK, Cotugno G, Vitzilaios N, Venetsanos D, Nanayakkara T, Sahinkaya MN. The role of morphology of the thumb in anthropomorphic grasping: A review. Front Mech Eng. 2017;3. … Continue reading

Ultrasound Evaluation

  • Recommended probe is linear or superficial with a higher frequency (15 MHz) to generate high resolution of superficial structures like the small joints of the hand either in long or short axis.
  • We recommend a diagnostic evaluation prior to initiating the procedure.
  • Joint effusions can be easily seen with ultrasound which aids in determining the necessity of the procedure and guiding the needle into the joint space
  • Aspiration can be performed either in either short axis or long axis position and in-plane or out-of-plane.[5]Owen DS. Aspiration and injection of joints in soft tissue. In: Kelley WN, Harris ED, eds. Textbook of Rheumatology. ; 1993.
Finger US Normal MCP Joint
Ultrasound demonstrating a normal appearing metacarpalphalangeal joint. The metacarpal is left, joint centered and proximal phalanx on the right.
Ultrasound of the PIPJ in long axis demonstrating a joint effusion.[6]Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 27669

Procedure

  • Landmark vs. Ultrasound Guided Approach
    • Both landmark and ultrasound-guided approaches to arthrocentesis of the small joints of the hand have been described.
    • Several small studies have shown the ultrasound guided approach (96% to 100% accurate) to be superior to the palpation-guided approach (59% to 100% accurate).[7]Daniels EW, Cole D, Jacobs B, Phillips SF. Existing evidence on ultrasound-guided injections in sports medicine. Orthop J Sports Med. 2018;6(2):232596711875657. doi:10.1177/2325967118756576
    • Because ultrasound improves visualization of the joint, effusion and needle, we strongly encourage emergency medicine physicians to utilize ultrasound when performing this procedure.
  • Materials
    • 18 gauge draw needle
    • 0.5 – 1.0 inch, 23-25 gauge needle for aspiration and injection
    • Note: small joint but may require larger gauge for aspiration
    • 1-3 cc syringe for injecting and aspirating
    • Local anesthetic
    • Sterile equipment (gauze, skin prep, gloves, probe cover, etc)
    • Specimen tubes (as needed)
    • Bandage

Carpometacarpal Joint

  • General
    • The procedure can be performed with one, ideally two people
    • Procedure should be done with strict sterile technique
    • Note: The thumb CMC is most commonly aspirated so that is the procedure described
  • Position
    • Position the patient upright with their hand on the bedside table.
Approximate Hand Position for Caropmetacarpal Arthrocentesis
Demonstration of patient position for thumb CMC arthrocentesis.
    • Place the hypothenar eminence down on the table and oppose the thumb against the fifth digit
  • Anatomy
    • The CMC joint space can be palpated between the trapezium and the first metacarpal at the distal palmar border of the anatomic snuffbox, which is bounded by the extensor pollicis brevis (EPB) and abductor pollicis longus (APL)
  • Palpation Guided Technique
    • Mark and apply subcutaneous lidocaine or a short burst (10 to 15 seconds) of ethyl chloride coolant spray prior to sterile preparation
    • Insert the aspirating needle at the base of the metacarpal bone away from the border of the snuff box and direct towards the proximal aspect of the first metacarpal.
    • Recommended: Have an assistant apply traction to the thumb to increase the gap between the two bones
Illustration of needle placement for thumb CMC Arthrocentesis

Illustration of of needle placement for thumb CMC arthrocentesis.[8]Owen DS. Aspiration and injection of joints in soft tissue. In: Kelley WN, Harris ED, eds. Textbook of Rheumatology. ; 1993.

Clinical demonstration of needle placement and approach for thumb CMC Arthrocentesis
  • Ultrasound Guided Technique
    • Place linear, high frequency transducer over the anatomic snuffbox in long axis
    • Visualize joint space “seagull sign”
    • In-plane: Insert needle from distal to proximal and aspirate once needle is visualized inside joint
    • Out-of-plane: insert the needle while maintaining visualization of needle tip into the joint space
Thumb ultrasound demonstrating the ‘seagull sign’.
Thumb US joint space with labels
Ultrasound CMC joint showing some synovitis and an osteophyte. Power doppler shows increased flow to the effusion. TZ = Trapezium; MC = Metacarpal.[9]Oo WM, Deveza LA, Duong V, et al. Musculoskeletal ultrasound in symptomatic thumb-base osteoarthritis: clinical, functional, radiological and muscle strength associations. BMC Musculoskelet Disord. … Continue reading
Out-of-plane injection of the thumb MCP joint. Note the same technique would be used to peform an arthrocentesis.
In-plane injection of the thumb MCP joint. Note the same technique would be used to peform an arthrocentesis.

Metacarpophalangeal & Interphalangeal Joint

  • General
    • The procedure can be performed with one, ideally two people
    • Procedure should be done with strict sterile technique
  • Position
    • Sit the patient in a position of maximal comfort likely palm on the bedside table with the digit straight or slightly flexed
    • The joint space is easily palpated in slight flexion on either side of the dorsal, midline extensor apparatus.
Clinical demonstration of patient positioning.
  • Palpation guided MCP joint arthrocentesis
    • While the joint remains flexed, apply mild axial traction, and insert the aspirating needle toward the midline of the finger.
    • Direct the needle in the proximal direction of the MCP joint with application of slight pressure against the syringe plunger during injection should make the joint bulge slightly and begin to aspirate
    • Note that the sulcus of the MCP joint line is located at the distal end of the metacarpal head (“knuckle”)
Illustration of metacarpalphalangeal joint MCPJ arthrocentesis
Illustration of needle placement for MCPJ arthrocentesis.[10]Image courtesy of merckmanuals.com, “How To Do Metacarpophalangeal Joint Arthrocentesis”
Needle position for MCP Joint Arthrocentesis
Clinical demonstration of needle placement for MCPJ arthrocentesis.
  • Palpation guided IPJ Arthrocentesis
    • Insert the needle toward the midline of the finger.
    • Direct the needle perpendicular to the skin.
Illustration of interphalangeal joint IPJ arthrocentesis
Illustration of needle placement for IPJ arthrocentesis.[11]Image courtesy of merckmanuals.com, ” Arthrocentesis of the Proximal Interphalangeal Joint”
Needle position for PIP Joint Arthrocentesis
Illustration of needle placement for IPJ arthrocentesis.[12]Image courtesy of merckmanuals.com, ” Arthrocentesis of the Proximal Interphalangeal Joint”
  • US Guided Metacarpophalangeal (MCP) and Interphalangeal (IP) Joint Arthrocentesis
    • Use linear, high frequency probe and place parallel to the other phalanges
    • Identify your target joint and center on the middle of the screen
    • Out of plane needle approach from either lateral or medial side
    • Visualize the needle tip as you advance into the joint space and aspirate
Ultrasound example of normal proximal interphalangeal joint (left) and distal interphalangeal joint (right).
Demonstration of MCP joint injection. The probe is long axis to the joint, the effusion is easily visualized and the needle is in plane. Note arthrocentesis could be performed similarly.

Additional Considerations

  • Post procedure care
    • Compression of any bleeding
    • Application of bandage
    • Avoidance of exposure to contaminants or submersion in water for a period of time, typically 24-48 hours
  • Risk factors
    • Infection
    • Injury to surrounding neurovascular bundle
    • Soft tissue injuries
  • Contraindications
    • No absolute contraindications
    • If concern is high for septic arthritis, the procedure should be performed.
  • Relative contraindications
    • Abnormal or altered anatomy
    • Overlying cellulitis, proceduralist will want to avoid seeding soft tissue infection into joint
    • Joint prosthesis
    • Acute fracture
    • Osteomyelitis
    • Uncooperative patients
    • Bacteremia

Pearls & Pitfalls

  • If there is resistance when injecting the needle, traction can be applied to the thumb or fingers with the non-aspirating hand, which can both distract the joint and palpate [7]
  • Avoid the proximal portion of the anatomic snuffbox which contains the radial artery and superficial radial nerve during CMC arthrocentesis, especially with any kind of injection procedure.[13]Ramsay O.,Deodhar, A. et al. The Journal of Musculoskeletal Medicine, The Journal of Musculoskeletal Medicine Vol 26. No 2. Volume 26 Issue 2. March 24, 2009.
  • The presence of crystals in the synovial fluid does not exclude septic arthritis. Gout and pseudogout may co-exist with infectious arthropathies.
  • Gram-stain and cultures should be obtained if septic arthritis is a diagnostic consideration.[14]Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. 2002;15(4):527-544. doi:10.1128/CMR.15.4.527-544.2002
  • Orthopedic consultation is required in cases of suspected septic arthritis

References

References[+]