Merck Manual

Please confirm that you are a health care professional

honeypot link

How To Do Wrist Arthrocentesis

By

Alexandra Villa-Forte

, MD, MPH, Cleveland Clinic

Last full review/revision Nov 2020| Content last modified Nov 2020
Click here for Patient Education
Topic Resources

Arthrocentesis of the wrist is the process of puncturing the radiocarpal joint with a needle to withdraw synovial fluid.

Indications

Contraindications

Absolute contraindications

  • Infection of skin or deeper tissues at the anticipated site of needle insertion

If possible, an alternate, uninfected site should be used. However, acutely inflamed joints may be generally warm, tender, and red, thus mimicking extra-articular infection and making it hard to find an uninvolved insertion site. Ultrasonography can be done; visualization of a joint effusion can reinforce the decision to do arthrocentesis despite surrounding erythema. NOTE: If infectious arthritis is strongly suspected, arthrocentesis should be done regardless of erythema or negative ultrasonographic results because joint infection must not be missed.

Relative contraindications

  • Severe bleeding diathesis, which may need to be corrected before arthrocentesis; routine therapeutic anticoagulation is not a contraindication, particularly if infection is suspected

Complications

Complications are uncommon and include

  • Infection

  • Damage to tendon, nerve, or blood vessels (traumatic tap)

Equipment

  • Antiseptic solution (eg, chlorhexidine, povidone iodine, isopropyl alcohol), sterile gauze, sterile bandage, and sterile gloves

  • Nonsterile underpads

  • Local anesthetic (eg, 1% lidocaine, 25- to 30-gauge needle, 3- to 5-mL syringe)

  • For joint aspiration, a 25-mm (1-inch) 22- to 20-gauge needle and 10-mL syringe

  • Appropriate containers for collection of fluid for laboratory tests (eg, cell count, crystals, cultures)

  • For intra-articular therapeutic injection, a syringe containing a corticosteroid (eg, triamcinolone acetonide 40 mg or methylprednisolone acetate 40 mg) and/or a long-acting anesthetic (eg, 0.25% bupivacaine), and a hemostat to help switch syringes

Additional Considerations

  • Sterile technique is necessary to prevent microbial contamination of both the joint space and the aspirated synovial fluid.

Relevant Anatomy

  • Needle insertion is just distal to the Lister tubercle (dorsal radial tubercle) and ulnar to the extensor pollicis longus tendon.

  • Neurovascular injury may occur if needle entry is on the radial side of the extensor pollicis longus tendon (ie, in the anatomic snuffbox).

Arthrocentesis of the wrist

Synovial fluid is withdrawn from the radiocarpal joint. To help identify the extensor pollicis longus tendon, the patient should actively extend the wrist and thumb. To puncture the joint, the wrist is flexed and ulnar-deviated about 20 to 30°. Traction is applied to the hand. Needle entry occurs just distal to the Lister tubercle, ulnar to the extensor pollicis longus tendon.

Arthrocentesis of the wrist

Positioning

Position the patient sitting or supine with the wrist on a bedside table.

Step-by-Step Description of Procedure

  • Palpate the dorsal aspect of the wrist to identify the Lister tubercle, which is the bony prominence palpable on the distal dorsal radius. Isolate and identify the extensor pollicis longus tendon by directing the patient to extend the thumb. Needle entry occurs distal to the tubercle and ulnar to the tendon. If desired, mark the insertion site with a skin-marking pen.

  • Rest the forearm and hand on an underpad. Prepare the area with a skin-cleansing agent, such as chlorhexidine or povidone iodine, then use an alcohol wipe to remove the agent.

  • Place a wheal of local anesthetic over the needle entry site using a 25- to 30-gauge needle. Then inject more anesthetic along the anticipated trajectory of the arthrocentesis needle (about 0.5 to 1 cm), but do not enter the joint space.

  • Aspirate the joint suing a 22- or 20-gauge needle on a 10-mL syringe.

  • Have an assistant apply axial traction, slight flexion (20 to 30°), and ulnar deviation to the hand to facilitate needle entry into the joint space.

  • Insert the needle perpendicular to the skin, just distal to the Lister tubercle and on the ulnar side of the extensor pollicis longus tendon. Direct the needle volarly toward the joint space, and pull back gently on the plunger as you advance. Synovial fluid will enter the syringe when the joint is entered.

  • If the needle hits bone, retract almost to skin surface and then redirect at a different angle.

  • Drain all fluid from the joint.

  • If intra-articular drugs (eg, anesthetic, corticosteroid) are to be given, use a hemostat to hold the hub of the needle motionless while removing the synovial fluid-containing syringe and attaching the drug-containing syringe. If the needle has remained in place in the joint space, there will be no resistance to drug injection. Injections into the radiocarpal joint should not exceed 40 mg of corticosteroid or 1 mL in volume.

  • After injecting a corticosteroid, move the joint through full range of motion to distribute the drug throughout the joint.

  • Apply an adhesive bandage or sterile dressing.

Aftercare

  • Ice, elevation, and oral nonsteroidal anti-inflammatory drugs may help relieve pain.

  • If an intra-articular anesthetic has been given, limited joint activity should be prescribed for 4 to 8 hours.

  • If an intra-articular corticosteroid has been given, a period of immobilization lasting about 24 to 48 hours may be needed.

  • If the patient has increased redness, pain, and/or swelling > 12 hours after the procedure, the joint should be examined for possible infection.

Warnings and Common Errors

  • Carefully ensure optimal positioning before joint puncture.

  • Allow adequate time for local anesthesia to take effect before proceeding.

  • To avoid damaging the synovium and articular cartilage, do not advance the needle against resistance and do not move the needle once it has begun draining synovial fluid.

  • If the needle tip must be relocated, first withdraw it almost to the skin surface and then redirect; do not try to change the angle of insertion while a needle is embedded in tissue.

Tips and Tricks

Consider doing ultrasonography if there is no obvious large effusion.

Note also that warmth, tenderness, and redness may overlie an acutely inflamed arthritic joint, mimicking extra-articular infection.

  • Joint effusion

  • Circumferential joint pain

  • Severe pain with passive joint motion

When inspecting fluid, consider the following:

  • The hemarthrosis of a traumatic tap tends to be nonuniformly bloody and tends to clot.

Drugs Mentioned In This Article

Drug Name Select Trade
MEDROL
KENALOG
MARCAINE
XYLOCAINE
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Test your knowledge

Metastatic Bone Tumors
Any cancer can metastasize to bone, but metastases from carcinomas are the most common. Of these carcinomas, which of the following is most likely to metastasize to bone?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
 

Also of Interest

 
TOP