FIGURE 6.22 Lateral aspect of left elbow. (From Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)

PATIENT POSITION

Supine on the examination table with the head of the bed elevated 30 degrees.
The affected elbow is maximally flexed.
The elbow is supported with the placement of chucks pads or towels.
Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.

LANDMARKS

1. With the patient supine on the examination table, the clinician stands lateral to the affected elbow.

2. The point of maximal fluctuance is identified.

3. At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.

4. After the landmarks are identified, the patient should not move the elbow.

ANESTHESIA

Local anesthesia of the skin using topical vapocoolant spray.

EQUIPMENT

20-mL syringe—for aspiration
3-mL syringe—for optional injection
18-gauge, 1½ in. needle
1 mL of 1% lidocaine without epinephrine—for optional injection
1 mL of the steroid solution (40 mg of triamcinolone acetonide)—for optional injection
One alcohol prep pad
Two povidone–iodine prep pads
Sterile gauze pads
Sterile adhesive bandage
Nonsterile, clean chucks pad

TECHNIQUE

1. Prep the insertion site with alcohol followed by the povidone–iodine pads.

2. Achieve good local anesthesia by using topical vapocoolant spray.

3. Position the 18-gauge needle and syringe with the needle tip directed toward the area of maximal fluid collection.

4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 6.23).

5. Advance the needle into the center of the bursa.

6. Aspiration should be easy accomplished. Use multiple syringes if the effusion is large.

7. If injection following aspiration is elected, grasp the hub of the needle, remove the large syringe, and then attach the 3-mL syringe filled with the steroid solution.

8. The injected solution should flow smoothly into the space. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.

9. Following complete aspiration, and possible injection of corticosteroid solution, withdraw the needle.

10. Apply a sterile adhesive bandage followed by a compressive elastic bandage.

11. Reexamine the elbow in 5 min to confirm pain relief.