If you are going to aspirate a bursitis the needle must be introduced through an area of skin that does not appear infected. Avoid introducing a skin infection into a potentially sterile space. Prep the skin with cleansing solution. We used a 21-gauge 1.5 inch needle on a 30 ml syringe. We approached from the medial side to avoid erythematous skin. You can offer the patient a lidocaine injection first, versus attempting without local anesthetic, since they will feel one poke either way. A topical anesthetic or an ice pack are other options to reduce pain. If no fluid is initially obtained, redirect the needle by withdrawing it to the skin and advancing at a new angle. The synovial fluid can be tested for cell count and culture if concerned for septic bursitis. It can also be tested for crystals if gout is a concern. Once the needle is removed, place a bandage and a compression dressing. Advise the patient to wear the compression dressing to avoid reaccumulation, and avoid the repetitive motion that is causing the inflammation.
There is controversy on the utility of this procedure, antibiotics, and the potential for development of a fistulous tract. These have been discussed on previous episodes of EM:RAP and EMA.
Thank you to our expert peer reviewer, Neha Raukar, MD.
tom f. - October 14, 2022 9:12 PM
very interesting, Jessie. thank you, as always.
just some humble thoughts:
1. in this patient, there seems to be an abrasion or puncture wound over the inflamed area. I wonder if a break in the skin caused an infectious bursitis.
2. I still wonder about the danger of tapping an elbow joint anywhere on the same extremity as a possibly infected infectious bursitis or cellulitis, especially this close. as you know, the infected tissue might not just end at the area of redness (I apologize for questioning you!)
3. I have thought that generally, one can often differentiate an infected bursa or cellulitis form an actual infected joint , septic joint, by my clinical exam. I have found there is extreme pain on range of motion in the latter, good ROM on the former two.
4. if I were to tap, I might tap the bursa, for culture, if needed, and avoid the joint.
just some humble thoughts from a rural doc in merced, 45 minutes north from your old shop...
tom f. - October 14, 2022 9:22 PM
ahh.. just read the written summary. you are NOT tapping the joint. despite the synovial fluid? you are tapping the bursa only? when its that swollen and bulging, I suspect its not a simple cellulitis. so aspirate for the bug? for culture and sensitivities?
Jess Mason - October 15, 2022 4:58 AM
It’s still a controversial procedure and you make a lot of valid points. It could be infected or just inflamed. There are arguments for and against tapping either. They did a nice job in September EMRAP discussing this and it’s also been discussed on EMA in the past.