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  • Review Article
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Primer: pitfalls of aspiration and injection

Nature Clinical Practice Rheumatology volume 3, pages 464–472 (2007)Cite this article

Abstract

This review on joint aspiration and injection focuses on three common clinical problems: how to deal with 'dry taps', especially when a septic joint is suspected in the differential diagnosis; how to avoid rare complications associated with these techniques; and how to reduce pain in patients who are particularly sensitive. Solutions to these problems are proposed, and although no new data or insights are provided, this article could be used as a noncomprehensive check list for trainee rheumatologists. This review focuses on the knee, because of the common appearance of septic joints in the differential diagnosis of inflammatory knee effusion, and the paramount importance of septic joints in this setting. The five reasons for failing to aspirate fluid from a difficult knee joint that are discussed here could be applied to other more problematic joints, such as the elbow or ankle. Some additional time-consuming techniques involving more than one syringe and two operators might not be cost effective in many situations, but these should be taught for use in selected cases in which pain hinders aspiration. Training should also be provided to ensure that rheumatologists never inject against pressure, and that they switch to the lateral approach when aspirating the knee if their first attempt fails, especially if a septic joint is suspected and fluid must be obtained for diagnosis.

Key Points

  • The knee is the archetypal joint for rheumatology trainees to study when trying to understand why some joints with apparent effusion fail to yield to attempts at aspiration

  • Five reasons for this 'dry tap' scenario in knees have been well described by MRI studies

  • When facing a dry tap of a potentially septic knee, switch the approach from the medial to the lateral side of the knee

  • A variety of more complex techniques (involving two syringes or two operators) can be used in selected cases to reduce rare complications and the pain of aspiration and injection

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Figure 1: MRI of a normal knee
Figure 2: A line drawing of a technique that can be used to compress the effusion from three sides to increase the chance of obtaining fluid from a difficult knee
Figure 3: An MRI of a medial plica (black arrow), a vestigial synovial fold within the joint space
Figure 4: MRI of a normal medial fat pad
Figure 5: MRI of subcutaneous fat in a normal knee
Figure 6: An MRI of a knee in which lipoma arborescens has occurred
Figure 7: An MRI of a knee containing inspisated fluid
Figure 8: An MRI of a knee with chronic synovitis, which shows multiple causes of difficult aspiration

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Acknowledgements

CW Wise, MD, Irby Professor of Rheumatology, Virginia Commonwealth University provided an updated reference database. Professor CW Hayes MD, Bone Radiology Section Chief, Medical College of Virginia Hospital, Virginia Commonwealth University provided the images.

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Author notes

  1. Thomas Professor of Medicine, Rheumatology Training Program Director, Medical College of Virginia Hospital, Virginia Commonwealth University, PO Box 980647, Richmond, VA 23298, USA prob@aol.com

Authors and Affiliations

  1. WN Roberts is Chas W Thomas Professor of Medicine and the Rheumatology Program Director at Virginia Commonwealth University, Medical College of Virginia Hospital, Richmond, VA, USA.,

    W Neal Roberts

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Competing interests

The author has been a speaker for Bristol-Myers Squibb, for which he has received less than $10,000 per year. Also, please note that reference 8 of this review describes use of an injectable gene therapy, the protein product of which is part of a Bristol Meyers-Squibb biologic agent.

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Roberts, W. Primer: pitfalls of aspiration and injection. Nat Rev Rheumatol 3, 464–472 (2007). https://doi.org/10.1038/ncprheum0558

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