Rowley wrote: "I tried this and found it completely useless. They all seem
to refill and be just as stiff the next morning."

One thing that hasn't been mentioned so far is technique, not that I'm
doubting Rowley, but technique needs to be clarified for the would be
aspirators on the List!

I always enter the joint straight through the middle of triceps tendon,
aiming for the deepest part of the olecranon fossa. That's where the last
few mls lurk and you should always be able to get 15-20mls from an adult
male who has a decent haemarthrosis. Clinically however the haemarthrosis is
only evident just behind the radio-capitellar joint, felt as a small area of
fluctuance there, but this is not the best area from which to aspirate. The
skin is more sensitive there, there is lots of "clockwork" including
superficial and deep branches of the radial nerve, and your needle's
endpoint is the delicate articular cartilage of the radiohumeral joint -
ouch! Finally you will not get your full 15-20mls worth from that site.
Conversely by using the posterior approach you can apply pressure to the
fluctuant lateral collection to force it into the olecranon fossa where it
is aspirated by your needle.

If you haven't tried the posterior approach before, start by studying elbow
x-rays. If you imagine a line drawn between the epicondyles you'll note it
passes just distal to the deepest part of the olecranon fossa - you can then
orientate your approach in a live subject. Use 2-3mls of local for skin and
tendon as you pass through, there will be a "loss of resistance" as you go
through tendon and enter the swollen joint, your needle will then continue
for another 1-2cm before hitting bone on the floor of the olecranon fossa -
a very satisfying and painless endpoint. From there you will get a maximal
aspirate which produces dramatic results with respect to movement and pain.
The relief of pain is akin to draining an abscess, which might explain why I
feel there is no need for marcain, you've already got that "result".

Other points; you can use the same syringe/needle for local and aspirate -
by the time you hit the joint your 10ml syringe should have already
deposited its 2-3mls of local so it is ready to accept aspirate (I know, I
still prefer the feel of a 10ml syringe even though I expect to get 20mls
out!). I personally don't do a sterile drape, I merely clean the entry point
with sterets and use a "non-touch" technique thereafter. Finally, like knee
haemarthroses, you can examine the aspirate afterwards to look for fat
globules but this does not materially alter your management - the students
are impressed though!

Clearly any controlled studies need to carefully take into account the
technique used. Incidentally I learnt this approach from John Ryan back in
'91 and have used it, with some of my own modifications, ever since. Shit,
that makes me feel old...

Adrian Fogarty