Contents
A shoulder puncture is a surgical procedure during which a doctor inserts a needle into the joint. Such a procedure is carried out for the purpose of diagnosis or on the basis of existing medical indications. The purpose of this procedure is to reduce the amount of synovial fluid in the joint. Shoulder puncture is performed when inflammation (arthritis) with exudation is suspected and hemarthrosis is suspected.
Types of puncture
There are three approaches for this operation: an anterior approach, a lateral approach, and a posterior approach.
Anterior Approach – This approach is performed along the coracoid process of the scapula and can be palpated 3 cm distal to the acromial end of the clavicle. The needle is inserted distally to the coracoid process of the scapula and then it is inserted 3 to 4 cm deep between the head of the humerus and the coracoid process.
Lateral approach – in this approach, the needle is inserted from the acromion of the scapula in the frontal plane and below through the deltoid muscle. Posterior approach – with this approach, the needle is inserted from the acromion between the deltoid muscle, namely its posterior edge, and the lower edge of the supraspinatus muscle, below, perpendicularly and 4 to 5 cm deep from the insertion point.
Joint anatomy
When performing a puncture of the shoulder joint, it is necessary to take into account its characteristic anatomical features. The synovial membrane is a membrane that differs in structure and origin from serous membranes (such as pleural, abdominal, pericardial membrane). The main difference is that its inner side, facing the surface cavity, does not contain an epithelial coating and endothelial tissue. The membrane thickness is not the same. In addition, it has an increased sensitivity to thermal, infectious, traumatic and chemical influences.
Due to the fact that the sensitivity of the synovial membrane is significantly increased to various infectious lesions, it is necessary to strictly observe all the rules of asepsis before the puncture procedure, as well as before opening the joint cavity. In addition, mandatory sealing is required. The joint cavity contains a small amount of synovial fluid, approximately four milliliters.
The synovial fluid is sterile, it is straw-yellow in color and at the same time is absolutely transparent. It is characterized by high viscosity, contains leukocytes and phagocytes, but still its bactericidal qualities are very small. Since the joint fluid contains mucopolysaccharides with a high specific gravity, it accumulates in the joint, and does not dissipate from its cavity.
joint fluid
It is very difficult to get a certain amount of joint fluid and not cause a complication process due to its small amount, increased viscosity and negative pressure of the fluid.
Healthy joints exert negative pressure:
- ankle – 270-210 mm of water column;
- knee joint – 75-90 mm of water column.
The presence of such a factor as negative pressure causes osmosis of fluid from the synovial and subchondral plates, from which the cartilage tissue of the joint originates. A puncture of the shoulder joint in people without complaints is performed in rare cases.
Functions of synovial fluid
The main functions of the synovial fluid are: locomotor, metabolic, trophic. In the first case, the synovial fluid, together with the articular cartilage, allows free movement of the articulating surfaces of the bone. In the second case, the synovial fluid is involved in the metabolic processes that occur between the vascular layer and the joint fluid.
Trophic function means that the synovial fluid performs a nutritional function for the avascular layers of cartilage. If inflammation occurs in the joint, then the protein content in the synovial fluid increases. This is due to an increase in vascular permeability. The liquid subsequently becomes cloudy, the content of neutrophilic leukocytes increases, which occurs as a result of acute traumatic synovitis.
Indications for puncture
In surgical practice, punctures are divided into two types: therapeutic puncture and diagnostic puncture. The procedure of puncture of the shoulder joint is used to determine the contents of the joint cavity, to evacuate the pathological fluid, if any, for the administration of drugs, as well as the introduction of tools during arthroscopy. As with other types of punctures, the needle is inserted through the skin, moved with a finger over the puncture site, so that when the skin returns to the site, there is no direct wound channel through which the infection can enter the joint cavity. Typically, the needle passes through a previously defatted area of skin on the articular surface of the extensor, where there are no large vessels and nerves.
The puncture is carried out to determine the content of the content (to determine the presence of exudate or blood in the fluid). If the damaged joint contains blood, then synovitis, damage to the cartilage of a degenerative-dystrophic nature, may occur.
In the case of traumatic hemarthrosis, inflammation of an adhesive nature is caused more by damage to the thickness of the cartilage. Regenerates cartilaginous tissue with changes in the proliferative nature of the connective tissue. And if the membrane is damaged, blood clotting occurs quickly enough, and then clots appear, which can lead to a significant spread of the tissues of the membrane.
As a result, obliteration of the joint cavity begins. Also during the procedure, it is possible to establish the cause of damage to the meniscus in the knee joint using radiography, or pneumoarthrography.
For diagnostic purposes, the doctor prescribes a diagnostic puncture of the shoulder joint. Indications for puncture of the shoulder joint:
- to remove blood if hemarthrosis develops;
- to remove exudate, pus from the joint cavity, the introduction of antibiotic solutions;
- for the introduction of a solution of novocaine for dislocation and dislocation;
- for the introduction of corticosteroids in combination with lidase in the presence of deforming arthrosis;
- for the introduction of oxygen or air for gentle procedures for the destruction of joint adhesions formed during fibrous fusion.
Oxygen administration is also performed to restore motor function or for phased recovery. For this purpose, you can perform a puncture of the shoulder and knee joints.
The procedure for performing the procedure
Due to the extreme sensitivity of the synovial fluid to infections, when performing a puncture of the shoulder joint, all rules of antisepsis and asepsis should be followed.
Before performing the procedure, the puncture site must be completely decontaminated. It is most advisable to use 70% alcohol. After the skin at the puncture site has been lubricated with 5% iodine solution, its remnants should be removed by double rubbing with alcohol. Removal of residual iodine solution is required, especially with heavy lubrication, because iodine, together with the needle, can penetrate into the joint cavity, which causes irritation of the synovial membrane and a serious burn reaction. Among other things, iodine can, to some extent, absorb x-rays, which can affect the reliability of the image if it is required, and subsequently iodine can distort the x-ray data.
During the procedure, local infiltration anesthesia is used. The length of the puncture needle is 5-6 centimeters.
If oxygen is introduced, then the needle should be used thin, with a diameter of up to one millimeter. Otherwise, gas can penetrate into the soft tissues that surround the joint, and this provokes subcutaneous, periarticular, or muscular emphysema.
The skin at the puncture point of the shoulder joint must be moved to the side by the doctor. This allows the wound channel that was left by the needle to be twisted as the skin returns to its place after the procedure. This method avoids infection from the surface of the body into the joint cavity. The needle must be moved at a very low speed and try to determine the moment when the end of the needle will pass into the articular sac. If there is blood in the joint cavity, novocaine solution will be stained in the syringe, and if there is pus, then the solution becomes cloudy.
As for the depth from which it is necessary to perform a puncture, there are different opinions. Some literature says that the needle should penetrate a maximum of 1 centimeter, and the other – 2-3 cm. The liquid during the puncture should be disconnected from a syringe with a volume of 10 to 20 ml. If necessary, drugs are administered. After removing the needle, the displaced skin is separated, thereby bending the wound channel, then the puncture site is treated with alcohol and a sterile dressing is applied.
The puncture of the shoulder joint should be performed in different projections: in the lateral, posterior and anterior. If the doctor planned to perform the procedure from the front, the patient should be placed on the back. The surgeon will then feel for the coracoid process of the scapula, which is three centimeters below the distal end of the clavicle. The needle should be inserted under it and inserted between the head of the bones of the shoulder and its process in the direction from front to back. The needle is inserted to a depth of 4 cm.
If the puncture will be performed by the surgeon from the side, the patient should be placed on the opposite side, and his arm is located strictly along the body. With the width of the finger slightly lower from the large tubercle and the head of the humerus is located. The needle is inserted under the most protruding point of the acromial process, and then the doctor moves it through the deltoid muscle in the frontal plane.
When performing the puncture procedure from behind, the patient needs to lie on his stomach. After that, the surgeon feels the deltoid muscle, finds its lower edge. In this place there is a fossa, which is located slightly lower than the posterior edge of the acromial process. In this place, the doctor needs to pierce the skin with a needle and insert it in the direction of the coracoid process of the scapula to a depth of 5 cm.