Shoulder puncture is a surgical procedure in which a doctor inserts a needle into the joint capsule. A similar procedure is carried out for diagnostic purposes or according to available medical indications. The purpose of this procedure is to reduce the amount of synovial fluid in the joint.
Two types of puncture
Surgeons divide punctures into two types:
- Healing.
- Diagnostic.
Anatomy of the joint
When performing a puncture of the shoulder joint, it is necessary to take into account the characteristic features of its anatomy. The synovial membrane is a membrane that differs in structure and origin from serous membranes (such as the membrane of the pleura, peritoneum, pericardium). The main difference is that its inner side, facing the superficial cavity, does not contain an epithelial cover and endothelial lining. The membrane thickness is not the same. In addition, she has an increased sensitivity to thermal, traumatic,infectious and chemical effects.
Due to the increased sensitivity of the synovial membrane to various infections, strict observance of asepsis is required before the puncture procedure, as well as before opening the articular cavity. In addition, it must be sealed. The joint cavity contains a small amount of synovial fluid, about four milliliters. The synovial fluid is sterile, has a yellowish-straw color and is completely transparent. It is characterized by high viscosity, it contains phagocytes and leukocytes, but its bactericidal properties are very small. Because synovial fluid is rich in mucopolysaccharides with a high specific gravity, it accumulates in the joint rather than diffuses out of its cavity.
The technique of performing a puncture of the shoulder joint will be discussed below.
About joint fluid
Get joint fluid and not cause a pathological process is very difficult because of its small amount, negative pressure and high viscosity. He althy joints have negative pressure:
- Ankle: 270-210 millimeters of water.
- Knee joint: 75-90 millimeters of water column.
The presence of negative pressure causes osmosis of fluid from the subchondral and synovial plates, from where the cartilage tissue of the joint is nourished.
Shoulder puncture in he althy people is rare.
Functions of synovial fluid
KThe main functions that synovial fluid performs include:
- Locomotor function. Synovial fluid in tandem with articular cartilage allows free movement of articulated bony surfaces.
- Metabolic function. The synovial fluid takes part in the metabolic processes occurring between the vascular bed and the joint fluid.
- Trophic function. Synovial fluid nourishes the avascular layers of cartilage.
If an inflammatory process occurs in the joint, the protein content in the synovial fluid increases. This is due to increased vascular permeability. The fluid becomes cloudy, the content of neutrophilic leukocytes increases in it as a result of acute traumatic synovitis.
Shoulder puncture: indications
- Determination of the composition of the contents (for the presence of pus, exudate or blood in it). If the damaged joint contains blood, then synovitis, cartilage damage of a degenerative-dystrophic nature, and intra-articular adhesions may occur. In the case of traumatic hemarthrosis, stiffness and inflammation of an adhesive nature are caused to a greater extent by damage to the thickness of the cartilage, and not by the action of the outflowing blood. Cartilage tissue regeneration occurs with proliferative changes in the connective tissue. In case of damage to the membrane, blood coagulation occurs quite quickly, and then clots form, which can lead to significant growthsheath tissues. As a result, obliteration of the articular cavity begins.
- Establishment of meniscal injuries in the knee joint using pneumoarthrography or radiography.
- Establishing the presence of "rice bodies" or "joint mice" in the articular cavity.
For this, a diagnostic puncture of the shoulder joint is prescribed.
Indications for a medical type puncture procedure
- Removal of blood in the development of hemarthrosis.
- Removal of exudate, pus from the joint cavity, administration of antibiotic solutions.
- Introduction of novocaine solution during reduction of dislocation.
- Introduction of corticosteroid drugs in combination with lidase in the presence of deforming arthrosis.
- The introduction of oxygen or air for a gentle procedure for the destruction of articular adhesions formed in the case of fibrous fusion. The introduction of oxygen is also possible in order to restore motor function or for staged redress.
For this purpose, a puncture of the shoulder and knee joints can be performed.
Performing the procedure
Due to the extreme sensitivity of the synovial fluid to infections, when performing a puncture of the joint, all the rules of antisepsis and asepsis should be strictly followed.
Before performing a puncture, the puncture site should be thoroughly disinfected. It is advisable to use seventy percent alcohol. After the skin at the puncture sitewas smeared with a five percent iodine solution, its residues should be removed by wiping twice with alcohol. Removal of iodine residues, especially with abundant lubrication, is required due to the fact that iodine, together with the needle, can penetrate into the articular cavity, and this causes irritation of the synovial membrane and a severe burn reaction. Among other things, iodine is able to absorb X-rays, and this can affect the reliability of the image - additional shadows distorting the image may appear on it.
Use local infiltration anesthesia.
How is a puncture made?
The length of the needle for puncture is 5-6 centimeters. If oxygen is administered, then the needle should be used thin, up to one millimeter in diameter. Otherwise, the gas will be able to penetrate into the soft tissues surrounding the joint. Which, in turn, will provoke subcutaneous, periarticular or muscular emphysema.
The skin at the puncture point of the shoulder joint must be moved to the side. This allows you to bend the wound channel left by the needle, and after the procedure, the skin is returned to its place. This technique avoids the penetration of infection from the surface of the body into the joint cavity.
The needle should be advanced very slowly, trying to determine when the end of it will pass into the articular bag. If there is blood in the joint cavity, then the novocaine solution in the syringe will stain, and if there is pus, then the solution will become cloudy.
Regarding the depth from which it is necessary to puncture,there are different opinions. Some literature says that the needle should penetrate a maximum of one centimeter, and another - 2-3 centimeters.
Fluid during puncture must be aspirated with a syringe with a volume of 10 to 20 grams. If required, drugs are administered. After removing the needle, the displaced skin is released, thereby bending the wound channel, then the puncture site is treated with alcohol and a sterile bandage is applied.
Shoulder puncture technique
Puncture of this joint should be done from the side, front or back. If the procedure is performed from the front, then the patient must be placed on his back. After that, the surgeon should feel for the coracoid process of the scapula, which is three centimeters lower than the distal end of the clavicle. The needle should be inserted under it and led between the head of the shoulder bone and its process in the direction from front to back. The needle is inserted to a depth of 4 centimeters.
If the puncture of the shoulder joint is performed by the surgeon from the side, then the patient must be placed on the opposite side, and his arm should be placed strictly along the body. A finger width slightly below the large tubercle is the head of the humerus, its head. The needle should be inserted under the part of the acromion that is the most protruding, and then advanced through the deltoid muscle in the frontal plane.
When carrying out the puncture procedure from behind, the patient must be laid on the stomach. After that, the surgeon gropes for the deltoid muscle and its lower edge. There is a hole at this locationslightly lower than the posterior margin of the acromial process. In this place, it is necessary to prick the needle and insert it to a depth of 5 centimeters in the direction of the coracoid process of the scapula.
