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HOW TO
How to
Perform a successful
joint tap
Alasdair Renwick of Willows Referral Service,
Solihull, points us in the right direction
A
joint tap, or more correctly arthrocentesis, refers to the surgical
puncture of a joint cavity for aspiration of synovial fluid. It is a vital tool in
the investigation of joint disease allowing gross examination, cytology
and bacterial culture of synovial fluid. It can be used in the investigation of any
arthropathy, but should be considered to exclude sepsis in cases with chronic
osteoarthritis presenting with an acute deterioration, in cases presenting with
single inflamed joints, and is essential in the diagnosis of immune-mediated
polyarthritis. In addition, arthrocentesis allows instillation of contrast media
for contrast arthrography and also allows injection of medications directly
into the joint cavity.
In most cases heavy sedation or general anaesthesia is required. The joint
to be aspirated should be clipped of hair and prepared aseptically. The
operator should scrub their hands and wear sterile surgical gloves. A variety of
needles should be available: 21 G 1" or 1.5" needles are appropriate for most
joints. 23 G needles may be needed for smaller joints such as the carpus or
tarsus and may be needed for smaller dogs and cats. 3" spinal needles may
be required for the hip joint in large dogs. Glass slides should be available to
make direct smears, and fluid collection tubes are required if samples are to
be submitted to an external laboratory. These tubes should be either plain or
with EDTA, depending on the individual laboratorys preference. If sepsis is
suspected, blood culture medium should be available as synovial fluid
frequently shows no bacterial growth in the presence of infection when
cultured directly on agar plates.
Figure 1: Arthrocentesis of
the left shoulder joint. The
dotted line outlines the
scapular spine and the solid
line the greater tubercle
Figure 2: Arthrocentesis of the left elbow (lateral
view). The dotted line outlines the lateral aspect of
the humeral condyle. The solid line outlines the
proximal extent of the olecranon and the dot marks
the position of the lateral epicondyle
Shoulder joint
The needle is inserted
approximately 510 mm
distal to the acromion (for a
medium sized dog) and
aimed slightly proximally until
it is felt to enter the joint
(Figure 1). If no fluid is
obtained, an assistant can
apply gentle traction on the
distal limb to open up the
joint space.
Elbow joint
Technique 1: Extend the elbow to allow the capsule to
distend caudally. The needle is inserted lateral to the
olecranon or triceps tendon and aimed into the
olecranon fossa (Figure 2). Alternatively, with the elbow
flexed, the needle can be inserted into the caudolateral
aspect of the joint between the olecranon and the
lateral epicondylar ridge.
Technique 2: With the medial surface of the elbow
uppermost, palpate and then draw an imaginary line
from the greater tubercle and through the medial
epicondyle of the humerus. The caudodistal edge of
the medial aspect of the humeral condyle can be
palpated approximately 1 cm (for a medium sized dog)
on this line distal to the medial epicondyle. A
neurovascular bundle (ulnar nerve and recurrent ulnar
artery) can usually be palpated subcutaneously and
avoided. The needle is inserted at this point and aimed
in the same line about 3045 degrees from vertical
until the needle is felt to enter the joint (Figure 3).
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HOW TO
Figure 4: Arthrocentesis of the left carpus
(craniolateral view). The dotted line outlines the
distal aspects of the radius and ulna and the solid
line marks the cranioproximal aspect of the radial
carpal bone
Figure 3: Arthrocentesis of the left elbow (medial
view) using the alternative technique. The broken
line marks the medial aspect of the humeral condyle
and the circle marks the position of the medial
epicondyle
Carpus
By palpating the dorsal aspect of the distal radius, the
level of the radiocarpal joint can be identified on
flexion and extension of the joint. With the joint flexed
the needle is inserted into the radiocarpal joint (Figure
4). Tendons and vascular structures on the dorsal
aspect of the carpus should be avoided.
Figure 5:
Arthrocentesis of
the left hip (lateral
view). The dotted
line outlines the
greater trochanter
Figure 6:
Arthrocentesis of
the right hip using
the alternative
technique (ventral
view). The dotted
line outlines the
pectineus muscle.
Great care must be
taken with this
technique
Hip
Technique 1: The needle is inserted cranial and
proximal to the greater trochanter and directed slightly
ventrally and caudally (Figure 5). This technique can
be difficult in large, well muscled breeds due to the
distance of the joint from the skin.
Technique 2: With the animal in dorsal recumbency
allow the hindlimbs to abduct. The ventral aspect of
the hip joint can be palpated caudal to the band of the
pectineus muscle. The femoral artery and vein can be
palpated cranial to this muscle. The needle is inserted
in line with the long axis of the femur, with the tip of the
needle angled slightly medially from the sagittal plane
(Figure 6). Care must be taken with this technique to
identify the femoral artery. There is a slight risk of injury
to deep femoral artery and vein.
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HOW TO
Figure 10:
Arthrocentesis of
the left hock
(cranial view). The
dotted line outlines
the talocrural joint
Figure 7: Arthrocentesis of
the left stifle (craniolateral
view). The solid lines
outline the patella and the
tibial tuberosity and the
dotted line outlines the
lateral aspect of the
patellar tendon
Figure 8: Arthrocentesis of
the left stifle (cranial view)
using the alternative
technique. The solid lines
outline the patella and the
tibial tuberosity and the
dotted line outlines the
patellar tendon
Perform a successful
joint tap
Figure 9: Arthrocentesis of the left hock (lateral
view). The solid line outlines the lateral malleolus of
the fibula
Stifle joint
Technique 2: With the stifle
partially flexed, digital
pressure is applied either
medial or lateral to the
patellar tendon. The needle
is inserted on the opposite
side of the patellar tendon
and directed proximally
towards the patella, aiming
to enter either the medial or
lateral recess (Figure 8).
Alternatively, the needle can
be directed into the
femoropatellar space. Fluid
can often be more reliably
obtained with this method.
Technique 1: With the stifle
partially flexed, the needle is
inserted medial or lateral to
the patellar tendon half way
between the patella and
tibial tuberosity and is
directed caudally (Figure 7).
Fluid frequently cannot be
obtained with this method as
the needle tip lies within the
fat pad or cruciate ligaments.
Hock
Technique 1: Hyperflex the hock joint. The needle is
inserted perpendicular to the long axis of the tibia,
medial to the lateral malleolus of the fibula (Figure 9). If
the joint is more effused dorsally, try technique 2.
Technique 2:
Palpate the
talocrural joint
space on its cranial
aspect and insert
the needle
perpendicular to the
long axis of the tibia
(Figure 10). It is best
to insert the needle
slightly off the
midline so that it
enters the medial or
lateral tibial sulcus.
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Collection and analysis
Once the needle has been inserted into the joint space,
apply gentle suction via a 2.5 or 5 ml syringe. Once
fluid is obtained, release the negative pressure and
remove the needle. If blood is obtained withdraw the
syringe immediately and try again with a new syringe
and needle at an adjacent site. Blood contamination is
unavoidable in some cases. While this will increase the
cell counts, a relative increase in leucocytes can
usually be appreciated when present. Once the needle
is withdrawn a visual estimate of viscosity can be made
by the string test (Figure 11), with a normal joint giving a
2.55 cm or more string. In diseased joints this may be
reduced to 12 cm. Viscosity is related to hyaluronan
concentration or hyaluronan chain length, which can
vary with dilution due to effusion or reduced production
due to synovitis. However, normal viscosity can be
maintained in some osteoarthritic joints. In cats and
small dogs, only a few drops of synovial fluid may be
obtained, which should be used to make direct smears.
If greater volumes are obtained these should be placed
into collection tubes as above. A visual estimate of fluid
quality can be made; fluid should be clear and
colourless or very pale straw coloured. Abnormal
synovial fluid may be turbid or contain visible clots of
purulent exudate (Figure 12). Inability to read printed
text through a sample indicates increased turbidity.
Cytology of synovial fluid is often the most useful
test. This can be done in house, on stained smears, for
example with Diff Quik, or by an external laboratory.
External laboratories offer the advantage of accurate
cell counts as long as sufficient volumes of fluid have
been obtained. Normal synovial fluid contains < 3 x 10
9
cells/l, which should be > 90% monocytes (see Table 1
overleaf). Osteoarthritic joints usually contain < 5 x 10
9
cells/l which contains > 90% monocytes (Figure 13),
but effusion often allows aspiration of greater volumes
of fluid; in addition, the fluid is often slightly more
discoloured than normal fluid. In some cases, such as
traumatic arthritis, a greater proportion of
polymorphonuclear cells may be seen (2030%);
however, total cell counts are generally < 5 x 10
9
/l in
these cases. Septic joints will have increased numbers
of leucocytes (> 510 x 10
9
/l) with a high proportion
(usually > 90%) of polymorphonuclear cells, and
bacteria may be visualised (Figure 14). Cases of
Figure 11: Visual estimate of viscosity of synovial
fluid from a normal joint
Figure 12: Synovial fluid from a septic joint.
The fluid is turbid
Figure 13: Monocytes in synovial fluid from a joint
with osteoarthritis
Courtesy of Cytopath Diagnostic Veterinary Pathology Laboratory
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Perform a successful
joint tap
Figure 15: Synovial fluid from a dog with immune-
mediated polyarthritis. The cells are predominantly
polymorphonuclear leucocytes
In summary, arthrocentesis is a quick and
relatively straightforward procedure that can provide
vital information in obtaining a definitive diagnosis and
should be considered in any animal presenting with
an arthropathy.
Figure 14: Mixed cells but predominantly
polymorphonuclear leucocytes in synovial fluid
from a septic joint. Intracellular bacteria can be
seen (arrowed)
Courtesy of Cytopath Diagnostic Veterinary Pathology Laboratory
immune-mediated polyarthritis have variable total white
cell counts (generally > 5 x 10
9
/l) but those present are
predominantly polymorphonuclear cells (Figure 15). It
is important to realise that there is considerable overlap
of these values between different conditions. Thus a
normal and an osteoarthritic joint can be very similar.
Likewise septic joints and those affected by immune-
mediated polyarthritis can be difficult to differentiate on
cytology. Correlation with clinical findings is thus
Cell count
(x 10
9
)
cells/l
Cell types
Normal < 3 >90% monocytes
Osteoarthritis < 5 Usually >90%
monocytes
Immune-
mediated
polyarthritis
Variable Predominantly
polymorphonuclear
cells
Septic > 510 Predominantly
polymorphonuclear
cells
Table 1: Typical cell counts from various
arthropathies
important. A single joint with increased
polymorphonuclear cells is more likely to be septic,
whereas multiple joints with similar cytology are more
likely to be associated with immune-mediated
polyarthritis. If sepsis is suspected, synovial fluid
should be placed in blood culture medium for transport
to an external laboratory. In this situation it is especially
important that aseptic technique is used as sample
contamination and false positive cultures may be seen.
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