Joint aspiration or injection in children: Indications, technique, and complications
- Thomas JA Lehman, MD
Thomas JA Lehman, MD
- Section Editor — Pediatric Rheumatology
- Professor of Clinical Pediatrics
- Cornell University Medical College
Joint aspiration and injections are used for diagnostic and therapeutic purposes in the care of children with arthritis.
The indications and complications of intra-articular aspiration and injection in children are reviewed here. Details regarding the medications used and the benefits of this procedure for specific conditions are discussed separately. (See "Oligoarticular juvenile idiopathic arthritis", section on 'Initial therapy' and "Polyarticular juvenile idiopathic arthritis: Treatment".)
The primary reason for joint aspiration is to assist in the diagnosis of inflamed joints (ie, arthritis), especially to determine whether infection is the cause of inflammation. Therapeutic injection generally involves the administration of glucocorticoids to suppress joint inflammation.
Diagnostic indications — In children with arthritis, joint aspiration is most often performed to differentiate bacterial (septic) arthritis from other inflammatory conditions. Empiric antibiotic therapy is administered promptly after aspiration in all patients with signs and symptoms suggestive of septic arthritis until culture results are available. Continuation of empiric antibiotic therapy is mandatory until culture results are available if bacteria are detected by microscopic examination of the synovial fluid. (See "Bacterial arthritis: Clinical features and diagnosis in infants and children" and "Bacterial arthritis: Treatment and outcome in infants and children", section on 'Empiric therapy'.)
Arthrocentesis is of limited diagnostic value in children whose joint inflammation is not thought to be infectious in origin, with the exception that grossly bloody fluid suggests pigmented villonodular synovitis. The varied forms of noninfectious childhood arthritis are usually not reliably distinguished from one another based upon joint fluid analysis. For example, the diagnosis of the different forms of juvenile idiopathic arthritis (JIA) is based upon clinical parameters, although children with documented JIA may subsequently develop infection in a concurrently arthritic joint and thereby require joint aspiration. In addition, gout and other crystal-induced inflammatory conditions, in which diagnostic arthrocentesis is helpful, are extremely rare in children and adolescents. Other mechanical/orthopedic causes should be investigated if the fluid is noninfectious and the white blood cell count is normal. (See "Oligoarticular juvenile idiopathic arthritis", section on 'Differential diagnosis' and "Evaluation of the child with joint pain and/or swelling", section on 'Differential diagnosis'.)
- Jennings H, Hennessy K, Hendry GJ. The clinical effectiveness of intra-articular corticosteroids for arthritis of the lower limb in juvenile idiopathic arthritis: a systematic review. Pediatr Rheumatol Online J 2014; 12:23.
- Papadopoulou C, Kostik M, Gonzalez-Fernandez MI, et al. Delineating the role of multiple intraarticular corticosteroid injections in the management of juvenile idiopathic arthritis in the biologic era. Arthritis Care Res (Hoboken) 2013; 65:1112.
- Givon U, Liberman B, Schindler A, et al. Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations. J Pediatr Orthop 2004; 24:266.
- Shetty AK, Gedalia A. Management of septic arthritis. Indian J Pediatr 2004; 71:819.
- FREYBERG RH, PATTERSON M, ADAMS CH, et al. Practical considerations of the use of cortisone and ACTH in rheumatoid arthritis. Ann Rheum Dis 1951; 10:1.
- HOLLANDER JL, BROWN EM Jr, JESSAR RA, BROWN CY. Hydrocortisone and cortisone injected into arthritic joints; comparative effects of and use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc 1951; 147:1629.
- de Oliveira Fonseca-Machado M, Camargo Alves L, Scotini Freitas P, et al. Mental health of women who suffer intimate partner violence during pregnancy. Invest Educ Enferm 2014; 32:291.
- Hollander JL, Jessar RA, Restifo RA, Fort HJ. A new intra-articular steroid ester with longer effectiveness. Arthritis Rheum 1961; 4:422.
- Bird HA, Ring EF, Bacon PA. A thermographic and clinical comparison of three intra-articular steroid preparations in rheumatoid arthritis. Ann Rheum Dis 1979; 38:36.
- Gaffney K, Ledingham J, Perry JD. Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis 1995; 54:379.
- Prober CG. Current antibiotic therapy of community-acquired bacterial infections in hospitalized children: bone and joint infections. Pediatr Infect Dis J 1992; 11:156.
- Georgopoulos G, Carry P, Pan Z, et al. The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial. J Bone Joint Surg Am 2012; 94:1633.
- Aronson PL, Mistry RD. Intra-articular lidocaine for reduction of shoulder dislocation. Pediatr Emerg Care 2014; 30:358.
- Shore A, Rush PJ. Possible danger of intra-articular steroid injection in children with respiratory tract infections. Br J Rheumatol 1987; 26:73.
- Cleary AG, Murphy HD, Davidson JE. Intra-articular corticosteroid injections in juvenile idiopathic arthritis. Arch Dis Child 2003; 88:192.
- Harcke HT. Hip in infants and children. Clin Diagn Ultrasound 1995; 30:179.
- Uziel Y, Berkovitch M, Gazarian M, et al. Evaluation of eutectic lidocaine/prilocaine cream (EMLA) for steroid joint injection in children with juvenile rheumatoid arthritis: a double blind, randomized, placebo controlled trial. J Rheumatol 2003; 30:594.
- Cardone DA, Tallia AF. Joint and soft tissue injection. Am Fam Physician 2002; 66:283.
- Zuber TJ. Knee joint aspiration and injection. Am Fam Physician 2002; 66:1497.
- Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician 2002; 66:2097.
- Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the wrist and hand region. Am Fam Physician 2003; 67:745.
- Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician 2003; 67:1271.
- Allen RC, Gross KR, Laxer RM, et al. Intraarticular triamcinolone hexacetonide in the management of chronic arthritis in children. Arthritis Rheum 1986; 29:997.
- Parra DA. Technical tips to perform safe and effective ultrasound guided steroid joint injections in children. Pediatr Rheumatol Online J 2015; 13:2.
- Young CM, Horst DM, Murakami JW, Shiels WE 2nd. Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis. Pediatr Radiol 2015; 45:1212.
- Cavalier R, Herman MJ, Pizzutillo PD, Geller E. Ultrasound-guided aspiration of the hip in children: a new technique. Clin Orthop Relat Res 2003; :244.
- Arabshahi B, Dewitt EM, Cahill AM, et al. Utility of corticosteroid injection for temporomandibular arthritis in children with juvenile idiopathic arthritis. Arthritis Rheum 2005; 52:3563.
- Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ 1993; 307:1329.
- Sibbitt W Jr, Sibbitt RR, Michael AA, et al. Physician control of needle and syringe during aspiration-injection procedures with the new reciprocating syringe. J Rheumatol 2006; 33:771.
- MCCARTY DJ Jr, HOGAN JM. INFLAMMATORY REACTION AFTER INTRASYNOVIAL INJECTION OF MICROCRYSTALLINE ADRENOCORTICOSTEROID ESTERS. Arthritis Rheum 1964; 7:359.
- Hertzberger-ten Cate R, de Vries-van der Vlugt BC, van Suijlekom-Smit LW, Cats A. Intra-articular steroids in pauciarticular juvenile chronic arthritis, type 1. Eur J Pediatr 1991; 150:170.
- Padeh S, Passwell JH. Intraarticular corticosteroid injection in the management of children with chronic arthritis. Arthritis Rheum 1998; 41:1210.
- Job-Deslandre C, Menkes CJ. Complications of intra-articular injections of triamcinolone hexacetonide in chronic arthritis in children. Clin Exp Rheumatol 1990; 8:413.
- Cassidy JT, Bole GG. Cutaneous atrophy secondary to intra-articular corticosteroid administration. Ann Intern Med 1966; 65:1008.
- Breit W, Frosch M, Meyer U, et al. A subgroup-specific evaluation of the efficacy of intraarticular triamcinolone hexacetonide in juvenile chronic arthritis. J Rheumatol 2000; 27:2696.
- Ravelli A, Manzoni SM, Viola S, et al. Factors affecting the efficacy of intraarticular corticosteroid injection of knees in juvenile idiopathic arthritis. J Rheumatol 2001; 28:2100.
- Gilsanz V, Bernstein BH. Joint calcification following intra-articular corticosteroid therapy. Radiology 1984; 151:647.
- Sparling M, Malleson P, Wood B, Petty R. Radiographic followup of joints injected with triamcinolone hexacetonide for the management of childhood arthritis. Arthritis Rheum 1990; 33:821.
- Goldman RD, Benseler SM, Schneider R. Intra-articular calcifications in a child with juvenile rheumatoid arthritis. Arch Dis Child 2005; 90:1038.
- Huppertz HI, Tschammler A, Horwitz AE, Schwab KO. Intraarticular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth. J Pediatr 1995; 127:317.
- Earley A, Cuttica RJ, McCullough C, Ansell BM. Triamcinolone into the knee joint in juvenile chronic arthritis. Clin Exp Rheumatol 1988; 6:153.
- Huppertz HI, Pfüller H. Transient suppression of endogenous cortisol production after intraarticular steroid therapy for chronic arthritis in children. J Rheumatol 1997; 24:1833.
- Koehler BE, Urowitz MB, Killinger DW. The systemic effects of intra-articular corticosteroid. J Rheumatol 1974; 1:117.
- Diagnostic indications
- Therapeutic indications
- - Joint aspiration
- - Joint injections
- Needle and syringe size
- Sterile preparation
- Anatomic approaches
- Synovial fluid collection
- Additional precautions
- POSTINJECTION CARE
- Postinjection inflammatory reaction
- Subcutaneous atrophy and depigmentation
- Intra-articular calcifications
- Effects on growing articular cartilage
- SYSTEMIC EFFECTS OF INTRA-ARTICULAR GLUCOCORTICOIDS