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Wrist puncture or wrist arthrocentesis is the main diagnostic tool in the evaluation and treatment of acute articular pathology. This procedure is performed not only for diagnosis, but also for therapy. Synovial fluid analysis distinguishes between inflammatory and non-inflammatory conditions, and provides direct evidence of crystalline arthropathy, infection, and hemarthrosis. Synovial aspiration and corticosteroid injections carry minimal risk to the patient when properly indicated and performed.
Doctors need to be able to recognize wrist and hand injuries that require immediate attention. A complete history and physical examination, including assessment of distal limb function, is required. It is very important to distinguish between carpal tunnel syndrome, de Quervain’s disease, osteoarthritis of the first carpo-metacarpal joint, tenosynovitis of the wrist and finger flexors, and many other diseases. Indications for puncture in carpal tunnel syndrome is median nerve neuropathy, resulting from the patient’s osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypothyroidism, repeated trauma and other damage in this area. In osteoarthritis of the first carpo-metacarpal joint, a wrist puncture may be used to treat pain secondary to osteoarthritis and rheumatoid arthritis. The pain associated with de Quervain’s disease is effectively treated with a therapeutic injection. Painful limitation in finger flexor movement, in patients with diabetes mellitus or rheumatoid arthritis, also improves with therapeutic puncture. Proper procedure technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential to achieve effective results.
Patients with ruptured vessels and amputations also need special monitoring to control bleeding. Amputations require a special understanding of the indications and contraindications for managing the amputated limb. Infectious causes include open fractures, purulent tenosynovitis, animal bites, and foreign bodies. Synovial fluid analysis distinguishes between inflammatory and non-inflammatory conditions and provides direct evidence of crystalline arthropathy, infection, or hemarthrosis. Synovial aspiration and corticosteroid injections carry minimal risk to the patient when properly indicated and performed. Although some serious hand injuries seem obvious, a thorough evaluation is needed to identify other, more hidden diseases. Failure to diagnose, treat, and rehabilitate hand injuries can result in permanent disability. That is why physicians should be able to evaluate, triage and stabilize emerging pathologies before receiving surgical consultations.
Anatomy of the wrist joint
The wrist joint is a synovial joint in the upper limb, marking the transition area between the forearm and hand.
The joint consists of:
- distally: proximal row of carpal bones, except for the pisiform;
- proximally: the distal end of the radius and the articular disc.
The ulna is not part of the carpal joint – it is partly articulated with the radius just proximal to the radiocarpal joint near the distal radioulnar joint. It is separated from the articulation with the carpal bones by a ligament of fibrous cartilage called the articular disc, which lies above the upper surface of the ulna. Together, the carotid bones form a convex surface that articulates with the concave surface of the radial bone and articular disc.
The joint capsule is two-layer, like any synovial joint. The fibrous outer layer attaches to the radius and ulna, the proximal row of carpal bones. The inner layer is made up of a synovial membrane that secretes synovial fluid that lubricates and cushions the joint.
There are four ligaments in the wrist, each running on a different side of the joint:
- Palmar radiocarpal ligament. It is located on the palmar (front) side of the hand and runs from the radius to both rows of carpal bones. Its function, in addition to maintaining stability, is to ensure that the hand follows the forearm during supination.
- Dorsal radiocarpal ligament. It is located on the back of the hand and runs from the radius to both rows of carpal bones. This promotes wrist stability, but also ensures that the hand follows the forearm during pronation.
- Lateral ulnar ligament of the wrist. It is located between the trihedral bone and the styloid process of the ulna. Works primarily in conjunction with another collateral ligament to prevent excessive displacement of the lateral joints. And is responsible for the abduction of the brush.
- Lateral radial ligament. Lies between the navicular bone and the styloid process of the radius. Also responsible for bringing the brush.
The wrist is supplied with blood from anastomoses of the volar carpal branches of the ulnar and radial arteries, and branches of the anterior interosseous artery and deep palmar arch. Innervated by three nerves – median (anterior interosseous branch), radial (posterior interosseous branch), ulnar nerve (deep and dorsal branches). The wrist is an ellipsoid-type synovial joint that allows movement along two axes. This means that flexion, extension, abduction and adduction occur in the wrist. All movements are performed by the muscles of the forearm.
The meaning of the puncture of the joint
A joint puncture is a surgical manipulation in which the doctor inserts a special needle into the periarticular bag to reduce the volume of synovial fluid from the inside. The puncture of the joint is carried out with a ten or twenty cubic syringe, a needle about five centimeters long and at the same time it should be one or two millimeters thick.
The use of thin needles is especially advisable when injecting drugs into the joint, if you do not need to take the accumulated fluid from the inside. This greatly reduces the risk of injury. If it is necessary to pump out the liquid, then two millimeter needles are used so that they are not clogged with various solid particles.
In this case, the doctor should act as carefully as possible, without introducing the needle into the articular bag by more than one and a half centimeters. It is also not advisable to even slightly shake the tip of the needle when it passes through the synovium, because this often leads to traumatic injuries.
It is better to pull the skin a little while preventing infection and leakage of the contents of the joint.
Indications for wrist arthrocentesis
Diagnostic indications for arthrocentesis include the following:
- suspected septic arthritis (required);
- suspected hemarthrosis (highly recommended);
- to differentiate between inflammatory and non-inflammatory arthritis;
- for the study of affected menisci using radiography and special preparations that delay rays;
- with synovial biopsy.
Aspiration and analysis of synovial fluid are particularly helpful in diagnosing suspected conditions such as septic arthritis, gout, or bleeding. At the same time, the nature of the contents of the liquid is determined: pus, blood or exudate. For example, synovitis leads to accumulation of blood in damaged joints, and the presence of intra-articular adhesions to degenerative-dystrophic cartilage damage. Traumatic hemarthrosis causes adhesive inflammation, which is caused by damage to the entire cartilage. Regenerated processes leave behind proliferative changes in the connective tissue. With damage to the membrane, rapid blood clotting occurs with the formation of many clots. Further, the tissues of the shell gradually grow, and the obliteration of the joint cavity begins.
Doctors can get a lot of useful information not only while waiting for laboratory tests, but also immediately during the operation itself. Namely: they begin to draw liquid into the syringe, watching it. It is important to pay attention to the color of the contents, its consistency, whether there is a purulent or blood admixture. An hour is used novocaine, which changes color, viscosity, while in contact with other biological substances. It is the laboratory diagnostics of these punctures that makes it possible to identify the pathologies of metabolic processes that occur in the articular bag.
Therapeutic indications include the following:
- removal of effusion (exudate, blood, or pus) to relieve pain and improve joint function;
- aspiration of blood in hemarthrosis;
- injections of corticosteroids, antibiotics to relieve inflammation;
- local anesthesia for surgical interventions or painful manipulations.
Also, for medicinal purposes, oxygen is injected into the joint bag. Indications are degenerative-dystrophic lesions of the musculoskeletal system, shoulder-scapular periarthritis, arthrosis of the joints, or as a preventive manipulation in post-traumatic arthrosis. But we should not forget about the main contraindication – this is the present acute purulent-inflammatory pathology in the puncture area.
In patients, synovial fluid aspiration provides rapid pain relief and allows the patient to move or function normally with the affected joint. In hemarthrosis or septic arthritis, blood or pus in the synovial cavity can damage the articular cartilage and synovial membrane. Evacuation of the inflammatory fluid may help the injured joint. Large joint effusions should be removed as quickly as possible to reduce pressure, improve synovial circulation, and prevent muscle atrophy.
Puncture technique
Since the synovial membrane is very sensitive to various infections, it is necessary to follow the rules of asepsis and antisepsis. Before the joint puncture site, this area is disinfected. After the doctor has smeared the skin with a five percent iodine solution, it is advisable to apply a 70% alcohol ethyl solution twice to completely remove all iodine residues. This moment is necessary so that during the manipulation, traces of iodine do not get into the joint cavity with the needle, and do not cause irritation, especially a burn. In addition, iodine solution can distort x-rays, as it has the ability to absorb x-rays.
The next step is local infiltration anesthesia. Most often it is a solution of lidocaine or novocaine. With a needle of five to six centimeters, we evacuate blood, pus or accumulated fluid. We work with a needle of two millimeters thick, this is quite enough to evacuate a liquid containing a large amount of protein or blood clots.
Puncture of the wrist joint is carried out on the back surface of the hand. This is due to the fact that the most massive muscles and tendons, the neurovascular bundle are located on the palmar surface, and in order not to damage them, we work on the other side. The forearm is located in the position of pronation and flexio. The site of the puncture itself is the intersection of the lines between the styloid process of the radius and the styloid process of the ulna, and the subsequent line that arises from the second metacarpal bone. The puncture needle enters the tendon of the extensor of the index finger and the long extensor of the thumb.
The doctor must advance the needle into the joint cavity no less than one centimeter, but no more than three centimeters. If the needle is inserted at a shallow depth, then it can easily jump back out, and if it is inserted too deeply, the articular cartilage is very easily damaged. Its pieces come off and clog the gaps of the needle, which prevents both the introduction of fluid and removal from the joint. The accumulated liquid is sucked off with a ten to twenty cubic syringe. When the doctor removes the needle, the skin, which is displaced before the manipulation, is already released and the channel formed during the puncture is bent, which contributes to the fluid not leaking out and the infection not getting inside. This place is lubricated with an antiseptic and sealed with a sterile adhesive plaster, while a tight bandage is applied, and sometimes a special splint for several days.
Contraindications for this manipulation
There are several absolute contraindications to injections. If a joint infection is suspected, the fluid must always be completely aspirated from the joint. For other indications, procedures should probably be avoided if infection is present in the overlying skin or subcutaneous tissue, or if bacteremia is suspected.
The presence of a significant bleeding disorder or diathesis, the presence of severe thrombocytopenia may also prevent puncture of the wrist joint. If the procedure is considered entirely necessary for diagnosis or therapy, it may be performed with appropriate precautions to control possible bleeding (eg, following a factor VIII injection in a patient with hemophilia). Anticoagulation with international normalized ratios (INR) warfarin in the therapeutic range is not a contraindication to aspiration or injection of articular tissue.
Arthrocentesis in the area of skin diseases (eg, psoriasis) should be avoided due to an increase in the number of colonizing bacteria in such areas.
Puncture of a joint with a prosthesis in it carries a particularly high risk of infection and is often best handled by surgeons using full aseptic techniques.
If the suspected infection is the underlying cause of the musculoskeletal problem, it is best to avoid corticosteroids. If the infection is confirmed, then after the introduction of corticosteroids, it may worsen.
It can be concluded that the puncture of the wrist joint is the main diagnostic tool in the assessment and treatment of acute pathology. Wrist pain is a common problem and can be caused by many conditions. Pain can radiate from the bones of the wrist, ligaments, muscles, tendons, nerves, blood vessels and connective tissue, or it can be the cause of a systemic disease in a person. It is important to consult a doctor in a timely manner so that any pathology and damage does not cause pain and could not affect your life.