FIGURE 8.26 Lateral aspect of the right knee showing the extent of the knee joint capsule (in purple). (Adapted from Tank PW, Gest TR. Lippincott Williams & Wilkins Atlas of Anatomy. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
PATIENT POSITION
- Lying supine on the examination table with the affected knee extended or slightly flexed and supported with folded towels or chucks pads as needed for patient comfort.
- Rotate the patient’s head away from the side that is being injected. This minimizes anxiety and pain perception.
LANDMARKS
1. With the patient lying supine on the examination table, the clinician stands lateral to the affected knee.
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 knee.
ANESTHESIA
- Local anesthesia of the skin using topical vapocoolant spray
EQUIPMENT
- 20-mL syringe
- 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 tip of the needle directed toward the area of maximal fluid collection.
4. Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.27).
5. Advance the needle into the center of the bursa.
6. Aspiration should be easily accomplished. Use multiple syringes if the effusion is large.
7. (Optional) If injection following aspiration is elected, do not remove the needle. Grasp the hub of the 18-gauge 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 knee in 5 min to confirm pain relief.
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