Wrist Aspiration

Indications/Contraindications

Indication:
Concern for septic arthritis:

• Short arc ROM of wrist
• Elevated ESR/CRP
• X-rays negative for fracture/dislocation

Relative contraindication:
Cellulitis over the joint

Materials/positioning

• ChloraPrep/Iodine prep sticks
• Band-aid
• Alcohol wipes
• 3X 20G needle
• 3X 10cc sterile syringe
• 1x Red/maroon blood collection tube (gram stain/culture – microbiology lab)
• 1x Pink blood collection tube (cell count/crystals – core lab)
• Surgical marker

Technique

Step 1: Planning

Place the hand with the palm facing down on a side table

Identify EPL (have patient hyperextend the thumb) and where it passes around Lister’s tubercle dorsally over the wrist.

Palpate soft spot ulnar to the EPL and radial to the extensor tendon to the index finger and use surgical marker to mark this as the site where you will aspirate

Step 2: Aspiration

Prep the skin with either Chloraprep/Iodone prep sticks

With 20G needle attached to the 10cc syringe enter the joint at 11 degrees (reflecting volar tilt, normally 2-20 degrees).

Place band-aid once aspiration complete

Image borrowed from https://static.wixstatic.com/media/a195eb_e6aaa0b1db3f4d6c82d01ac80d681907~mv2.jpg/v1/fit/w_1000%2Ch_956%2Cal_c%2Cq_80/file.jpg

Step 3: Sample handling

Once you have the aspirate they need to go into the tubes, always start with the red (micro) tube.

Exchange the needle for a new 20G needle.

Wipe the red tube clean with an alcohol wipe.

Then transfer fluid into the red tube, hold the syringe plunger under traction otherwise all the fluid will be pulled into the tube due to the vacuum.

Next, do the same with the pink tube.

1-2cc is generally enough per tube for the lab to analyze Print your labels for: joint fluid crystals, joint fluid culture/smear, cell count/differential (fluid – not CSF), Gram Stain.

Personally bring the samples to the micro/core lab

Pearls & Pitfalls

If you only have a small sample: 1) Always fill the red/maroon tube for microbiology first 2) Hold the syringe plunger when bringing the needle into the tube, they are vacuum containers and if you do not hold the plunger your entire sample will be sucked into the tube. 3) Ask the micro lab to send the remainder of fluid to the core lab after they have analyzed. Overnight, consider ordering a STAT Gram stain.