Puncture of the shoulder joint is a surgical procedure during which the doctor inserts a needle into the joint bag. A similar procedure is carried out for diagnostic purposes or for medical reasons. The purpose of this procedure is to reduce the amount of synovial fluid in the joint.
Two types of puncture
Surgeons divide puncture into two types:
Joint anatomy
When carrying out 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 in its structure and origin differs from serous membranes (such as the pleural membrane, peritoneum, pericardium). The main difference is that its inner side, facing the surface cavity, does not contain epithelial cover and endothelial lining. The thickness of the membrane is not the same. In addition, it has an increased sensitivity to thermal, traumatic, infectious and chemical influences.
Due to the increased sensitivity of the synovial membrane to various infections, strict adherence to asepticity is required before the puncture procedure, as well as before opening the joint cavity. In addition, its mandatory sealing is necessary. The joint cavity contains a small amount of synovial fluid, approximately four milliliters. The synovial fluid is sterile, has a yellowish-straw color and is completely transparent. It has a high viscosity, it contains phagocytes and leukocytes, but its bactericidal properties are very small. Due to the fact that the synovial fluid is saturated with mucopolysaccharides with a high specific gravity, it accumulates in the joint, and does not diffuse from its cavity.
The technique for performing a puncture of the shoulder joint will be discussed below.
About joint fluid
It is very difficult to obtain joint fluid and not cause a pathological process due to its small amount, negative pressure and increased viscosity. Healthy joints have negative pressure:
- Ankle: 270-210 millimeters of water.
- Knee joint: 75-90 millimeters of water.
The presence of negative pressure causes osmosis of fluid from the subchondral and synovial plates, from where the cartilage tissue of the joint comes from.
Puncture of the shoulder joint in healthy people is rare.
Synovial fluid functions
The main functions that the synovial fluid performs include:
- Locomotor function. Synovial fluid in tandem with articular cartilage provides free movement of articulated bone surfaces.
- Metabolic function. Synovial fluid takes part in metabolic processes occurring between the vascular bed and articular fluid.
- Trophic function. Synovial fluid feeds the avascular layers of cartilage.
If an inflammatory process occurs in the joint, then the protein content in the synovial fluid increases. This occurs due to increased vascular permeability. The liquid becomes cloudy, the content of neutrophilic leukocytes in it increases as a result of acute traumatic synovitis.
Puncture of the shoulder joint: 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, 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 spilled blood. Cartilage tissue regeneration occurs with proliferative changes in the connective tissue. In the case of damage to the membrane, blood coagulates quite quickly, and then clots form, which can lead to significant overgrowth of the membrane tissue. As a result, obliteration of the joint cavity begins.
- Establishment of meniscus lesions in the knee joint using pneumoarthrography or radiography.
- Establishment of the presence of “rice bodies” or “articular mice” in the articular cavity.
For this, a diagnostic puncture of the shoulder joint is prescribed.
Indications for the treatment of puncture of the medical type
- Removal of blood with the development of hemarthrosis.
- Removal of exudate, pus from the joint cavity, the introduction of antibiotic solutions.
- The introduction of novocaine solution in the setting of dislocation.
- The introduction of corticosteroid drugs in combination with lidase in the presence of deforming arthrosis.
- The introduction of oxygen or air for a gentle destruction procedure formed in the case of fibrous fusion of joint adhesions. The introduction of oxygen is also possible in order to restore motor function or for staged redress.
For these purposes, puncture of the shoulder and knee joints can be performed.
Procedure execution
Due to the extreme sensitivity of synovial fluid to infections, when performing joint puncture, all the rules of antiseptics and asepsis should be adhered to.
Before performing a puncture, the puncture site should be thoroughly decontaminated. The use of seventy percent alcohol will be appropriate. After the skin at the puncture site was smeared with a 5% iodine solution, its residues should be removed by rubbing it twice with alcohol. Removing iodine residues, especially with heavy lubrication, is required because iodine, along with the needle, can penetrate the joint cavity, which causes irritation of the synovial membrane and a severe burn reaction. Among other things, iodine is capable of absorbing x-ray radiation, and this can affect the reliability of the image - additional shadows that may distort the image may be displayed on it.
Use local infiltration analgesia.
How to make a puncture?
The length of the needle for puncture is 5-6 centimeters. If the introduction of oxygen is carried out, then the needle should be used thin, up to one millimeter in diameter. Otherwise, gas can penetrate the soft tissues surrounding the joint. Which, in turn, will provoke subcutaneous, periarticular or muscle emphysema.
The skin at the point of puncture of the shoulder joint must be shifted 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. Such a 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 its end will go into the joint bag. If there is blood in the joint cavity, then the novocaine solution will stain in the syringe, and if there is pus, the solution will become cloudy.
Concerning the depth with which it is necessary to carry out a puncture, there are different opinions. Some literature says that the needle should penetrate a maximum of one centimeter, and the other - by 2-3 centimeters.
The puncture fluid must be sucked off 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 canal, then the puncture site is treated with alcohol and a sterile dressing is applied.
Shoulder puncture technique
Puncture of this joint should be done from the side, front or back. If the procedure is performed in front, then the patient must be put on his back. After this, 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 lead between the head of the bone of the shoulder 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 laid on the opposite side, and his arm should be placed strictly along the trunk. A finger’s width a little lower from the large tubercle is the head of the humerus, its head. The needle should be injected under that part of the acromial process, which is the most protruding, and then advance it through the deltoid muscle in the frontal plane.
During the puncture procedure, the patient needs to be laid on the stomach. After that, the surgeon gropes for the deltoid muscle and its lower edge. At this point there is a fossa located slightly lower than the posterior edge of the acromial process. It is necessary to insert a needle into this place and introduce it to a depth of 5 centimeters in the direction of the coracoid process of the scapula.