The Hot Joint Daniel Mantuani MD/MPH Assistant Director Emergency - - PDF document

Daniel Mantuani MD/MPH Assistant Director Emergency Ultrasound Alameda Health System Highland General Hospital

The Hot Joint

Disclosures

None

Anatomy

Ultrasound-guided Arthrocentesis

Summary Rationale

Outline

Rationale

20% had more the ONE Joint Involved Increasing incidence (10-40 per 100,000) = aging population and more Ortho interventions Risk Factors Signs and Symptoms WBC >10K : LR 1.3 ESR > 30 : LR 1.4 CRP > 100 : LR 1.6 Arthrocentesis is the BEST test to determine the presence of a septic joint

Laboratory Blood Tests

Not Sensitive/Specific

32 primary studies “Because H&P and serum markers are not helpful to significantly adjust postest probability of septic arthritis, synovial fluid analysis is essential”

Septic Arthritis

• Cant miss Diagnosis: Meningitis of the Joint?
• Suspicion should be high
• Threshold to tap should be low

Arthrocentesis

Before We Start

Does your patient even have an effusion?

Physical Exam XRY CT MRI

Ultrasound? Ultrasound?

US prevented 27/39 planned arthrocentesis US changed management 35/54 patients

Soft Tissue Joint Capsule VS Knee

Femur Quadriceps Tendon Effusion Patella

Soft Tissue VS Joint Capsule Knee

Quadriceps Tendon Patella Femur Abscess

Joint Capsule VS Soft Tissue Abscess Knee Joint Capsule VS Soft Tissue Shoulder

Humerus

Effusion

Humerus Glenoid

Joint Capsule VS Soft Tissue Shoulder

Left Right

Glenoid Glenoid Humerus Humerus

???

Joint Capsule VS Soft Tissue Shoulder Joint Capsule VS Soft Tissue Septic Bursitis

Million Dollar Question

Can you have a Septic Joint if there is no JOINT CAPSULE effusion on Ultrasound??

REVELATION Joint Capsule!!

Arthrocentesis Options

Vs Ultrasound-Guided Dry Tap?

Ultrasound Basics

Linear Probe

3-4cm

Increased Resolution Decreased Depth Elbow Ankle Small Joints Easiest Needle Visualization Pediatric

Curvilinear Probe

> 9cm

Increased Depth Decreased Resolution

Hip Shoulder

Difficult Needle Visualization

• 1st: Examine the unaffected extremity first
• 2nd: Identify classic bony landmarks
• 3rd: Look for the distended JOINT CAPSULE

Landmark Based Ultrasound

In-plane technique

Out-of plane technique

ANKLE KNEE SHOULDER HIP

Identify Classic Landmarks Aim at the Umbilicus

Identify Ultrasound Landmarks Compare Hips

>5mm or asymmetry >2mm

In-plane with clear view of screen Gentle Aspiration

In-Plane Hip Arthrocentesis ED Hip Clinic Steroid Injections Hip Arthritis

ANKLE KNEE SHOULDER HIP

Identify Classic Landmarks Identify Ultrasound Landmarks Compare Ankles Compare Ankles

Tibia Talus Effusion

Locate the Tendon Locate Tendon Aspirate Medially

Out-of-Plane

Out-of-plane Aspiration Out-of-plane Aspiration

Talus Tibia Talus Tibia

Path of Needle

Out-of-plane Aspiration

ANKLE KNEE SHOULDER HIP

Identify Classical Landmarks

someone show cor also can s looking at

Identify Ultrasound Landmarks

glenoid fossa humeral head

HH

G

Identify Ultrasound Landmarks

Glenoid Humeral Head

Open the GH Joint Compare Shoulders

glenoid humeral head

Effusion

Identify the Effusion

Anterior Posterior

In-plane Medial Aspiration In-plane Lateral Aspiration Out-of-plane Aspiration

ANKLE KNEE SHOULDER HIP

Identify Classic Landmarks

Quadriceps Femoris Tendon Patella Patella Femur Quadriceps Femoris Tendon Suprapatella Fat Pad

Identify Ultrasound Landmarks Identify Ultrasound Landmarks

Patella Femur Quadriceps Femoris Tendon Effusion

Locate Effusion

Rotate probe above Effusion In-plane Aspiration In-plane Aspiration In-plane Aspiration

Summary **Fluid Analysis

>10 mmol/L : essentially RULES IN a septic joint

Summary

1.Find ultrasound bony landmarks 2.Look at unaffected extremity FIRST 3.Look for distended Joint Capsule