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

Disclosures The Hot Joint Daniel Mantuani MD/MPH Assistant Director Emergency Ultrasound Alameda Health System Highland General Hospital None Rationale Outline Rationale Anatomy Ultrasound-guided Summary Arthrocentesis

Risk Factors Signs and Symptoms Laboratory Blood Tests Not Sensitive/Speci fi c WBC >10K : LR 1.3 ESR > 30 : LR 1.4 CRP > 100 : LR 1.6 Increasing incidence (10-40 per 100,000) = aging population and more Ortho interventions Arthrocentesis is the BEST test to 20% had more the ONE Joint determine the presence of a septic joint Involved Septic Arthritis Arthrocentesis 32 primary studies • Cant miss Diagnosis: Meningitis of the Joint? “Because H&P and serum markers are not helpful to • Suspicion should be high signi fi cantly adjust postest probability of septic arthritis, • Threshold to tap should be low synovial fl uid analysis is essential”

Before We Start Ultrasound? Does your patient even have an effusion? Physical XRY CT MRI Exam Soft Tissue VS Joint Capsule Ultrasound? Knee Patella Quadriceps Tendon Effusion Femur US prevented 27/39 planned arthrocentesis US changed management 35/54 patients

Soft Tissue VS Joint Capsule Soft Tissue VS Joint Capsule Knee Knee Abscess Abscess Quadriceps Patella Tendon Femur Soft Tissue VS Joint Capsule Soft Tissue VS Joint Capsule Shoulder Shoulder ??? Left Right Effusion Glenoid Humerus Glenoid Glenoid Humerus Humerus Humerus

Soft Tissue VS Joint Capsule Soft Tissue VS Joint Capsule Shoulder Septic Bursitis REVELATION Joint Capsule!! Million Dollar Question Can you have a Septic Joint if there is no JOINT CAPSULE effusion on Ultrasound??

Arthrocentesis Options Vs Ultrasound-Guided Ultrasound Basics Dry Tap?

Linear Probe Curvilinear Probe Increased Resolution Elbow Decreased Depth Ankle Increased Depth Easiest Needle Visualization Small Joints Decreased Resolution Pediatric Dif fi cult Needle Visualization 3-4cm > 9cm Hip Shoulder In-plane technique Landmark Based Ultrasound • 1st: Examine the unaffected extremity fi rst • 2nd: Identify classic bony landmarks • 3rd: Look for the distended JOINT CAPSULE

Out-of plane technique HIP ANKLE SHOULDER KNEE 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 HIP ANKLE SHOULDER KNEE

Identify Classic Landmarks Identify Ultrasound Landmarks Compare Ankles Compare Ankles Effusion Talus Tibia

Locate the Tendon Locate Tendon Aspirate Medially Out-of-Plane Out-of-plane Aspiration Out-of-plane Aspiration Path of Needle Tibia Tibia Talus Talus

Out-of-plane Aspiration HIP ANKLE SHOULDER KNEE Identify Classical Landmarks Identify Ultrasound Landmarks someone show cor also can s looking at humeral glenoid head fossa

Identify Ultrasound Landmarks Open the GH Joint Humeral Glenoid Head G HH Compare Shoulders Identify the Effusion Posterior Anterior humeral glenoid head Effusion

In-plane Medial Aspiration In-plane Lateral Aspiration Out-of-plane Aspiration HIP ANKLE SHOULDER KNEE

Identify Classic Landmarks Identify Ultrasound Landmarks Quadriceps Femoris Quadriceps Femoris Tendon Tendon Patella Patella Suprapatella Fat Pad Femur Identify Ultrasound Landmarks Locate Effusion Quadriceps Femoris Tendon Patella Effusion Femur

In-plane Aspiration Rotate probe above Effusion 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