Last Updated on May 14, 2025
Wrist arthrocentesis is a diagnostic and therapeutic procedure in which synovial fluid is aspirated from the wrist joint under sterile precautions.
It is primarily performed to evaluate unexplained joint swelling, pain, or suspected infection, and also serves as a means of delivering intra-articular medications in inflammatory or crystal-induced arthropathies.
The wrist joint is anatomically complex. Proper technique, anatomical knowledge, and patient selection are essential for minimizing complications and ensuring diagnostic yield.
Wrist arthrocentesis plays a pivotal role in the early diagnosis of septic arthritis, crystal arthropathy, and inflammatory conditions, and is an important adjunct in the management of painful effusions.
In recent years, ultrasound guidance has emerged as a valuable adjunct to wrist arthrocentesis, offering improved precision in joint access and minimizing procedural complications.
This article overviews its indications, contraindications, step-by-step procedure, and potential complications.
Relevant Anatomy of the Wrist Joint
The wrist joint is a complex joint formed by the distal ends of the radius and ulna, eight carpal bones, and the proximal portions of the five metacarpal bones. It includes the radiocarpal joint, distal radioulnar joint (DRUJ), intercarpal, and carpometacarpal articulations. The main contributions to the joints are the distal radius, scaphoid, and lunate.
For wrist arthrocentesis, the joint capsule is relatively superficial, and the synovial cavity is accessible via dorsal, radial, or ulnar approaches depending on the patient’s positioning and the clinician’s preference.
The dorsal approach is most frequently used due to easier access and fewer critical structures.
Key anatomical landmarks include the Lister’s tubercle, radial styloid, and anatomic snuffbox. Tendons of the extensor carpi radialis longus/brevis (ECRL/ECRB) are in the second extensor compartment, and the extensor pollicis longus (EPL) is in 3rd. These two are separated by Lister’s tubercle.
The anatomical snuff box is a triangular depression on the radial aspect of the wrist, bordered laterally by the tendons of abductor pollicis longus and extensor pollicis brevis, and medially by the extensor pollicis longus tendon.
The medial boundary can be palpated by asking the patient to extend the thumb, which makes the extensor pollicis longus tendon prominent.
[Read about anatomical snuffbox]
{Want to understand the extensor tendon arrangement at the wrist better? Read all about the wrist anatomy.]
These tendons must be avoided during needle insertion.
Understanding these relationships is critical for safe and effective aspiration of synovial fluid.
Indications of Wrist Arthrocentesis
Wrist arthrocentesis is performed for both diagnostic and therapeutic purposes. It is especially valuable in evaluating acute monoarticular joint complaints, as well as managing symptomatic effusions.
Diagnostic Indications
- Septic arthritis – to confirm or rule out infection by analyzing synovial fluid [1]
- Crystal arthropathies – such as gout and pseudogout, for crystal identification
- Inflammatory arthritis – including rheumatoid arthritis and psoriatic arthritis
- Trauma-related effusions – to distinguish between hemarthrosis, infection, or inflammatory causes
- Reactive arthritis or undifferentiated monoarthritis
Therapeutic Indications
- Relief of painful effusion – reduces intra-articular pressure and discomfort
- Injection of medications – such as corticosteroids or hyaluronic acid
- Repeated aspiration – to reduce bacterial load in septic arthritis in selected cases. It is rarely done now as open drainage is preferred by doing arthrotomy.
Wrist arthrocentesis is particularly useful when clinical examination and imaging are inconclusive. The ability to directly evaluate joint fluid adds significant diagnostic precision.
Contraindications to Wrist Arthrocentesis
While wrist arthrocentesis is generally safe and well-tolerated, certain absolute and relative contraindications must be considered before performing the procedure.
Absolute Contraindications
• Overlying cellulitis or infected skin lesions – to avoid introducing pathogens into the joint space [2]
• Known bacteremia – increases risk of iatrogenic joint seeding
• Prosthetic joint (in adjacent area) – higher risk of periprosthetic infection
Relative Contraindications
• Bleeding disorders– such as hemophilia or thrombocytopenia
• Current anticoagulant therapy – increased risk of hemarthrosis, although procedures may be performed with reversal agents administration if required [2].
• Joint prosthesis– If there is a prosthesis near the wrist (e.g., distal radius implants), it requires individualized risk-benefit analysis
In such cases, alternate diagnostic approaches or ultrasound techniques may help minimize complications.
Procedure of Wrist Arthrocentesis
The dorsal approach is the most commonly used, but other approaches may be employed depending on anatomical landmarks and clinician preference.
Patient Preparation
- Position: Patient is placed in a supine or seated position with the forearm resting on a support. A rolled towel or sandbag under the wrist helps keep it slightly flexed and stable.
- Skin preparation: Clean the area with povidone-iodine or chlorhexidine, followed by sterile draping.
- Anesthesia: Local infiltration with 1–2% lidocaine. Alternatively, ethyl chloride spray may be used for topical anesthesia.
Needle Insertion Sites
Three needle insertion sites are discussed below. Dorsoradial is preferred over radial or ulnar.
Dorsal–Radial Approach (Preferred)
- Entry just distal to Lister’s tubercle and ulnar to the anatomic snuff box
- Avoid extensor tendons: extensor carpi radialis brevis (ECRB) and extensor pollicis longus (EPL).
- The needle is directed perpendicular to the skin. If the bone is contacted, slightly redirect toward the thumb
Radial Approach
- Palpate the joint space just medial to the extensor pollicis brevis tendon
- Useful in patients with dorsal scarring or deformity
Ulnar Approach
- Palpate just distal to the ulnar head
- Needle directed in a volar and radial direction
- Ultrasound guidance can enhance accuracy, especially in joint effusions, distorted anatomy, or prior surgery [3].
Joint Entry and Aspiration
- A “pop” or give-way sensation often indicates entry into the joint space.
- Synovial fluid is aspirated using a 22-gauge needle and syringe.
- If fluid does not flow easily-
- Rotate or reposition the needle
- Inject a small amount of saline to dislodge debris or fibrin plugs
- For therapeutic injection, once aspiration is complete
- Keep the needle held in place
- Take a new syringe and inject corticosteroids or other medications
Afterward the Procdure
- Withdraw the needle
- Apply firm pressure and a sterile dressing
The patient should be in a comfortable supine position, and the wrist should be palmar flexed. Placing a rolled towel or sandbag under the wrist would help.
Analysis after Wrist Arthrocentesis
Synovial fluid obtained via wrist arthrocentesis is typically analyzed for clarity, viscosity, white blood cell count, crystal presence, Gram stain, and culture.
This helps differentiate between non-inflammatory, inflammatory, and infectious causes of wrist pain. The presence of monosodium urate or calcium pyrophosphate crystals confirms gout or pseudogout, respectively.
A turbid appearance with WBC counts exceeding 50,000/µL and neutrophilic predominance raises concern for septic arthritis and warrants urgent intervention.
For details on interpreting the aspirated joint fluid, see our full guide on Synovial Fluid Analysis.
Complications of Wrist Arthrocentesis
Wrist arthrocentesis is generally safe when performed with sterile technique and proper anatomical understanding. However, several complications, though uncommon, must be recognized and kept in mind.
Infection
The risk of iatrogenic septic arthritis following wrist arthrocentesis as a purely diagnostic procedure is exceedingly low.
However, when corticosteroids are injected intra-articularly, the risk increases and is estimated to range between 1 in 3,000 to 1 in 50,000 procedures, depending on sterility and patient-related factors[4].
Infection can be prevented by strict aseptic technique and avoiding the procedure in patients with overlying skin infections or known bacteremia. If necessary, high-risk patients should be put on prophylactic antibiotics after joint injection, especially if corticosteroids are used.
Bleeding or Hemarthrosis
- The risk increases in patients with bleeding disorders or on anticoagulants.
- Avoid deep puncture or forceful aspiration in such patients.
Tendon or Nerve Injury
Misplaced needles may injure extensor tendons (notably the EPL and ECRB) or radial sensory nerve branches. Using proper anatomical landmarks reduces this risk. Ultrasound guidance mitigates these risks by enabling real-time visualization of anatomical structures, needle trajectory, and fluid pockets.
Gottlieb and Alerhand in 2020 recommended that ultrasound should be considered in all arthrocentesis procedures, particularly for small or complex joints like the wrist, where anatomical precision is critical[5].
Post-Procedural Pain or Swelling
Mild discomfort after the procedure is known and often self-limiting. However, in case of severe pain, infection, tendon rupture, or chemical synovitis may be suspected.
Synovial Fluid Leakage
Minor leakage from the puncture site typically resolves with a simple pressure dressing.
Clinical Significance of Wrist Arthrocentesis
Wrist arthrocentesis has significant implications in rheumatologic and orthopedic care.
Diagnostic Clarity in Acute Monoarthritis
In cases of sudden wrist swelling with pain and restricted motion, arthrocentesis helps differentiate between infectious, crystal-induced, and inflammatory causes.
Early aspiration helps to rapidly identify septic arthritis, a surgical emergency requiring immediate treatment
Guiding Treatment in Crystal Arthropathies
Synovial analysis can confirm the type of crystal arthropathy present, such as gout (monosodium urate crystals) or pseudogout (calcium pyrophosphate crystals).
This helps tailor long-term management and avoid unnecessary diagnostic delays
Therapeutic Drainage and Medication Delivery
In patients with large, tense effusions, arthrocentesis relieves pressure, improves mobility, and alleviates pain.
Additionally, intra-articular corticosteroid injections may be administered in inflammatory or autoimmune conditions like rheumatoid arthritis for rapid symptom relief.
References
- Patel A, Punnapuzha S. Wrist Arthrocentesis. 2023 May 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. [PubMed]
- Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol. 2009 Apr;23(2):161-92. [PubMed]
- Balint PV, Kane D, Hunter J, McInnes IB, Field M, Sturrock RD. Ultrasound-guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. J Rheumatol. 2002 Oct;29(10):2209-13. – PubMed
- Charalambous CP, Tryfonidis M, Sadiq S, Hirst P, Paul A. Septic arthritis following intra-articular steroid injection of the knee–a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol. 2003 Dec;22(6):386-90. doi: 10.1007/s10067-003-0757-7. Epub 2003 Oct 15. PMID: 14677011.
- Gottlieb M, Alerhand S. Ultrasound Should be Considered for all Arthrocentesis. Ann Emerg Med. 2020 Feb;75(2):261-262. – [PubMed]
