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Aspiration and injection of the shoulder animated demonstration

How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.

Equipment needed

Prepare a sterile field using an aseptic non-touch technique with the following:

  • Sterile gloves

  • Sterile antiseptic skin preparation (povidone-iodine or chlorhexidine are most suitable)

  • Surgical swabs

  • Sterile syringes and needles (21-gauge or 23-gauge)

  • Sterile specimen pots (if aspirating for diagnostic purpose)

  • Medication for injection (for therapeutic purpose)

  • Adhesive dressing

  • Local anaesthetic (optional).

Contraindications

  • Joint replacement or prosthesis (aspiration and injection of these joints is possible but should only be done by an experienced clinician in the sterile environment of the operating theatre)

  • Infection: broken skin at the injection site, local skin infection (e.g., cellulitis), bacteraemia, or osteomyelitis. There is a significant risk that bacteria causing the skin infection may be inoculated into the joint, causing iatrogenic septic arthritis. This may lead to severe joint destruction and systemic illness

  • Cellulitis: this is a bacterial infection and patients with cellulitis overlying the joint should not have a joint aspiration and/or injection

  • Haemarthrosis, osteochondral fracture, or suspected intra-articular fracture (injection is contraindicated; aspiration of haemarthrosis may be rarely indicated)

  • Known hypersensitivity to intra-articular corticosteroid preparations

  • Patient refusal

  • Abnormal clotting (e.g., haemophilia), anticoagulation, or thrombocytopenia is considered a relative contraindication: there is theoretically an increased risk of bleeding into the joint; however, several studies have shown that there is not a significant increase in bleeding in patients taking warfarin provided that the patient’s international normalised ratio is in the therapeutic range.[38] [42]

Indications

Joint aspiration is an essential investigation for suspected septic arthritis.

Joint aspiration may also be indicated if there is clinical suspicion of:

  • Crystal arthropathy: gout and pseudogout

  • Seronegative arthropathy (e.g., reactive arthritis, gonococcal arthropathy, ankylosing spondylitis)

  • Seropositive arthropathy (e.g., rheumatoid arthritis)

  • Monoarthropathy or joint effusion of unknown cause.

On rare occasions the shoulder joint can be aspirated to provide symptomatic relief of a very tense and painful haemarthrosis or large tense effusion.

Shoulder joint injection may be indicated for patients with:

  • Glenohumeral joint osteoarthritis

  • Adhesive capsulitis (frozen shoulder)

  • Rotator cuff disease.

Complications

  • Pain: should be short lived; after injection of medication there may be an initial flare of pain with reactive arthralgia

  • Nerve and/or vessel damage (very rare with the posterior approach)

  • Infection: using an aseptic technique helps to reduce the risk of introducing infection into a previously sterile joint space; further investigation and orthopaedic intervention is necessary if there is a suspicion of infection

  • Recurrence of effusion or symptoms

  • Failure to obtain synovial fluid.

Additional complications when injecting corticosteroid into the shoulder joint may include:

  • Local or systemic hypersensitivity to the injected substance

  • Facial flushing

  • Skin atrophy or depigmentation

  • Elevated blood glucose in people with diabetes

  • Menstrual irregularities

  • Joint destruction: injection of the joint with corticosteroids may lead to osteonecrosis and destruction of the joint surfaces despite providing intermittent symptomatic relief. Injections should be limited to three per year per large joint[43]

  • Tendon damage or rupture: associated with inadvertent corticosteroid injection into a tendon. Risk may be reduced by withdrawing the needle upon meeting resistance, or by using ultrasound guidance.

Aftercare

  • Send synovial fluid from the diagnostic aspirate to the lab for urgent microscopy, cell count, Gram stain, culture, and crystals

  • If the aspirate is frank pus, or there is a clinical suspicion of septic arthritis, immediate orthopaedic assessment and intervention is necessary. Get blood cultures and give the patient intravenous antibiotics. The patient will need to have a formal joint washout in theatre as soon as possible

  • For aspirates that are non-septic, base the management plan on clinical findings and joint fluid analysis

  • Arrange follow-up to discuss the results of the procedure with the patient. Follow-up also enables clinicians to check for any complications that may have occurred as a result of the procedure and establish whether any intervention has been successful.