Intraarticular Shoulder Injections—Anterior Approach: Fluoroscopic Guidance

Abstract

Glenohumeral joint injections can be used for diagnosing intraarticular sources of pain (e.g., labral tears, degenerative joint disease), performing capsular distention for adhesive capsulitis, delivering contrast prior to magnetic resonance (MR) imaging, and instilling therapeutic agents into the joint space (e.g., corticosteroids, platelet rich plasma).

Keywords

Acromioclavicular joint, Fluoroscopy, Glenohumeral joint, Rotator cuff, Shoulder joint, Subacromial Bursa, Subdeltoid Bursa

Note: Please see pages ii , iii for a list of anatomic terms/abbreviations used throughout this book.

Glenohumeral joint injections can be used for diagnosing intraarticular sources of pain (e.g., labral tears, degenerative joint disease), performing capsular distention for adhesive capsulitis, delivering contrast prior to magnetic resonance (MR) imaging, and instilling therapeutic agents into the joint space (e.g., corticosteroids, platelet rich plasma).

In this chapter, we describe the anterior approach targeting the upper medial aspect of the humeral head for access into the joint space. This “upper one-third” target for an intraarticular injection has been found to be accurate, safe, and less painful to patients compared with targeting the inferior aspect of the joint. This places the needle in the rotator cuff interval between the subscapularis and supraspinatus. Studies have also shown the upper medial approach to be quicker with less radiation exposure time. Initial contrast spread away from the needle tip, with contrast dispersion into the axillary recess, subscapular recess, and biceps tendon (BiTen) sheath, confirms an intraarticular injection.

Trajectory View ( Fig. 34A.1 )

The Trajectory View Is Also a Multiplanar View

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Confirm the correct side of the procedure (right or left shoulder).
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Position the patient supine on the fluoroscopy table.
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Place the shoulder in slight external rotation with the arm resting at the patient’s side (palm up). Shoulder external rotation will minimize risk of puncturing the long head of the BiTen.
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A sandbag can be placed on the patient’s fingers to help maintain this position.
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Position the C-arm over the target shoulder joint.
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The posteroanterior (PA) view of the shoulder is obtained.
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Slight contralateral oblique (∼5–10 degrees) of the image intensifier may be used to optimize GH joint visualization.
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The optimal position is on the superomedial humeral head at the level of the coracoid process. This position corresponds to an imaginary line drawn at the intersection of the AC joint and the superior aspect of the coracoid process. Mark the skin at this site ( Fig. 34A.1A ).
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Because this is the trajectory view, the needle should be placed parallel to the fluoroscopic beam.
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Advance the needle until the needle tip contacts the humeral head.