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DOI: 10.1148/rg.232025706
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(Radiographics. 2003;23:373-378.)
© RSNA, 2003

EDUCATION EXHIBIT

Aids to Successful Shoulder Arthrography Performed with a Fluoroscopically Guided Anterior Approach1

Jon A. Jacobson, MD, John Lin, MD2, David A. Jamadar, MB BS and Curtis W. Hayes, MD

1 From the Department of Radiology, University of Michigan Medical Center, 1500 E Medical Center Dr, TC-2910G, Ann Arbor, MI 48109-0326. Received April 26, 2002; revision requested May 29 and received June 14; accepted June 14. Address correspondence to J.A.J. (e-mail: jjacobsn@umich.edu).


   Abstract
Top
 Abstract
Introduction
 Shoulder Arthrographic Technique
 Summary
 References
 
One method for performing effective shoulder arthrography with a fluoroscopically guided anterior approach is described. The technique can ensure success while injury to the cartilaginous labrum is avoided, which is essential when arthrography is performed in conjunction with magnetic resonance (MR) imaging. The key features of the technique include supine positioning of the patient with the shoulder in external rotation, marking the skin just lateral to the humeral head cortex, inserting the needle perpendicular to the fluoroscopy beam, testing the injection with an anesthetic agent, and confirming intraarticular needle placement with iodinated contrast material. The procedure can be followed by an injection of dilute gadolinium solution for subsequent MR imaging. Proper patient and needle positioning as well as accurate confirmation of intraarticular needle placement are critical to a successful and atraumatic shoulder arthrographic examination.

© RSNA, 2003

Index Terms: Shoulder, arthrography, 41.122


   Introduction
Top
 Abstract
 Introduction
Shoulder Arthrographic Technique
 Summary
 References
 
Shoulder arthrography is typically performed to assess the rotator cuff (1). When performed in conjunction with magnetic resonance (MR) imaging, shoulder arthrography enables detailed evaluation of the cartilaginous structures of the glenohumeral joint (2). Accurate and atraumatic shoulder arthrographic technique is essential, especially when the examination is followed by MR imaging. Improperly placed contrast media can simulate pathologic conditions, and improper needle placement can theoretically cause injury. In this article, we review shoulder arthrographic technique, performed with a fluoroscopically guided anterior approach, and emphasize key concepts that will ensure successful shoulder arthrography.


   Shoulder Arthrographic Technique
Top
 Abstract
 Introduction
 Shoulder Arthrographic Technique
Summary
 References
 
The technique of shoulder arthrography is typically learned in radiology residency. In many cases, the technique is first demonstrated to the resident by a more experienced radiologist, who subsequently directly observes the resident performing the procedure to ensure proper technique. The radiologist demonstrating the procedure typically relies on past successes and failures to synthesize his or her own personalized technique. Although experience offers valuable lessons, we believe that there are several basic but important components of a successful shoulder arthrographic examination. When a systematic approach is used, shoulder arthrography can be performed effectively while minimizing injury to the articular structures.

Various methods of fluoroscopically guided shoulder arthrography have been described since its first use in 1933 (3). One initial report described positioning of the patient obliquely to place the glenohumeral joint space in profile while the needle was advanced into the space (3). In 1975, this technique was replaced with supine positioning of the patient to avoid injury to the glenoid labrum (4). A 1978 report suggested that the arthrographic needle be advanced with the stylet removed and with local anesthetic placed in the needle hub (5). With this technique, a drop in the fluid level of the local anesthetic agent indicated that the needle tip was correctly placed in the intraarticular space. In 1980, Neviaser (6) suggested that internal rotation of the shoulder be performed once the needle tip was at the humeral head to facilitate intraarticular needle placement. More recently, a posterior approach to shoulder arthrography has been proposed (7,8). Several aspects of the previously used techniques are incorporated into the fluoroscopically guided anterior approach described herein, and the rationale is discussed.

Scout Radiograph
The radiographic images that constitute the scout arthrographic views vary from institution to institution. However, anteroposterior radiographs of the shoulder in external and internal rotation are essential. These views are important to assess for calcium hydroxyapatite deposition in the rotator cuff. If calcium deposits are not identified before injection of contrast medium, they could be misinterpreted as extension of contrast agent into the rotator cuff and be misdiagnosed as a tendon tear. In addition, calcium hydroxyapatite deposition within a tendon may not be visualized at MR imaging because both calcification and tendon appear as regions of low signal intensity (9).

Patient Positioning
Proper positioning of the shoulder is important to ensure a successful arthrographic examination and to minimize complications. The ideal patient position for performing fluoroscopically guided arthrography from an anterior approach is with the patient supine and the shoulder slightly externally rotated. Supine positioning of the patient creates an oblique orientation of the glenoid articular surface (Fig 1). The posterior aspect of the glenoid projects over the humeral head on the frontal radiograph, whereas its anterior aspect lies medial to the humeral head. When the patient is supine, a needle tip that is advanced in an anteroposterior direction to the humeral head will not come in contact with the glenoid labrum.



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  		Figure 1.  Normal left shoulder in an 18-year-old man. MR image (400-msec repetition time, 21-msec echo time) obtained with fat saturation pulse sequences after intraarticular administration of gadolinium shows high-signal-intensity contrast material distending the glenohumeral joint and long head of the biceps brachii tendon sheath (arrowhead). Note the oblique orientation of the glenoid articular surface (curved arrow) and medial location of the anterior labrum (straight arrow) relative to the humerus.

 
It is important not to place the patient in an oblique position. Although use of a posterior oblique position or Grashey view places the glenohumeral joint in profile, it also rotates the glenoid labrum into the direct path of the advancing needle tip when one aims "for the clear space" of the joint. Although damage to the labral cartilage is theoretical, the labrum could be penetrated analogous to a shish kebab if the needle were advanced while the glenoid labrum was in this position (Fig 2). If the needle were advanced between the glenoid labrum and the humerus without contacting bone, the radiologist could even continue advancing the needle tip, unaware that it was penetrating the posterior part of the rotator cuff.



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  		Figure 2.  Left shoulder in a 55-year-old man. With the shoulder placed in an oblique position to visualize the glenohumeral joint in profile, a 20-gauge spinal needle was inserted from an anterior approach directly into the joint without contact of the humeral head. Axial computed tomographic (CT) image obtained after injection of air and contrast agent demonstrates the path of the needle through the anterior labrum (open arrow) with its tip at the base of the posterior labrum (solid arrow).

 
External rotation of the shoulder exposes more of the articular surface of the humeral head anteriorly and increases the intraarticular area available for needle insertion from an anterior approach. Placing a weighted object in the patient’s hand assists the patient in maintaining this position. However, excessive external rotation of the shoulder is eventually uncomfortable for the patient and increases the tautness of the anterior capsule. Tautness places the anterior joint capsule closer to the humerus, thereby decreasing the joint space in the anterior recess and making intraarticular needle placement paradoxically difficult.

A posterior approach for fluoroscopically guided shoulder arthrography has been described (7,8). For this approach, the patient is positioned prone with the ipsilateral shoulder raised off the table with a pad so that the glenohumeral joint can be visualized tangentially. Use of a posterior approach has been suggested for patients in whom an anterior shoulder pathologic condition is clinically suspected to avoid iatrogenic injury and interpretative errors at MR imaging (7). However, we believe that similar results can be produced from a fluoroscopically guided anterior approach.

Needle Insertion
With the patient placed in the supine position as previously described, an area on the skin over the humeral head is marked to indicate the site of needle insertion. Fluoroscopy is used to determine the location of this mark, which ideally should be placed just lateral to the medial cortex of the humeral head (Fig 3a). Although the intraarticular space extends laterally to a line connecting the greater and lesser tuberosities (the anatomic neck of the humerus), the intraarticular space is increased in the anteroposterior dimension at the medial aspect of the humeral head. It is important, however, not to mark the skin medial to the medial cortex of the humeral head. A needle insertion at this site could place the anterior labrum in jeopardy. The mark on the skin should be placed near the junction of the middle and lower thirds of the humeral head and should be centered in the fluoroscopic image to avoid parallax distortion and subsequent inaccurate needle placement.



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  		Figure 3a.  Right shoulder in a 54-year-old man. (a) Anteroposterior fluoroscopic image demonstrates a spinal needle (arrow) centered over the needle hub, just lateral to the medial cortex of the humeral head. Note the sclerotic line, which approximates the lateral border of the glenohumeral joint (arrowheads). (b) Anteroposterior fluoroscopic image shows the needle (arrow), which is angled medially toward the glenohumeral joint space after making contact with the humeral head. (c) Anteroposterior fluoroscopic image demonstrates intraarticular contrast material visualized between the glenoid and humerus (arrow).

 


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  		Figure 3b.  Right shoulder in a 54-year-old man. (a) Anteroposterior fluoroscopic image demonstrates a spinal needle (arrow) centered over the needle hub, just lateral to the medial cortex of the humeral head. Note the sclerotic line, which approximates the lateral border of the glenohumeral joint (arrowheads). (b) Anteroposterior fluoroscopic image shows the needle (arrow), which is angled medially toward the glenohumeral joint space after making contact with the humeral head. (c) Anteroposterior fluoroscopic image demonstrates intraarticular contrast material visualized between the glenoid and humerus (arrow).

 


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  		Figure 3c.  Right shoulder in a 54-year-old man. (a) Anteroposterior fluoroscopic image demonstrates a spinal needle (arrow) centered over the needle hub, just lateral to the medial cortex of the humeral head. Note the sclerotic line, which approximates the lateral border of the glenohumeral joint (arrowheads). (b) Anteroposterior fluoroscopic image shows the needle (arrow), which is angled medially toward the glenohumeral joint space after making contact with the humeral head. (c) Anteroposterior fluoroscopic image demonstrates intraarticular contrast material visualized between the glenoid and humerus (arrow).

 
Once the skin over the entrance site of the needle has been marked, the area is prepped and draped in typical sterile fashion. The subcutaneous tissues are then anesthetized. Arthrographic needle choice varies from institution to institution; however, a 20- or 22-gauge 3.5-inch spinal needle is commonly used. Use of a stylet during advancement of the needle reduces soft-tissue injury and avoids obstruction of the needle by soft tissues. The needle is inserted from an anterior approach in a direct anteroposterior position. Centering the needle hub over the needle tip ensures that the needle is advanced perpendicular to the fluoroscopic beam, which increases precision of needle placement (Fig 3a). Further local anesthetic may be used if there is pain during needle advancement.

Intraarticular Needle Placement
Using intermittent fluoroscopy, the radiologist advances the needle posteriorly until it reaches the humeral head. Once contact is made with articular cartilage and the underlying cortex of the humeral head, the needle typically appears one of two ways at fluoroscopy. In one situation, the needle is angled obliquely toward the glenoid (Fig 3b). This position occurs because the needle was initially aimed at the portion of the humeral head that curves away from the needle. The needle naturally deviates in this direction when contact is made. This position is more likely to occur if the skin mark is placed close to the medial cortex of the humeral head. In the second situation, the needle remains positioned in the anteroposterior direction because its tip did not slip down the curved aspect of the humeral head. This position is more likely to occur if the skin mark is placed more laterally relative to the medial cortex of the humeral head.

A "test injection" of the local anesthetic is then made at this stage after the needle stylet is removed and the syringe plunger is drawn back to exclude intravascular needle placement. The test injection of 1–2 mL of anesthetic is performed to anesthetize the joint and to determine needle tip position within a compartment. If the needle tip is positioned within the glenohumeral joint or an adjacent bursa, there will be low resistance to the injection. In the first situation described above—that is, when the needle is oriented obliquely—the test injection typically meets low resistance. If the needle remains in the anteroposterior direction as in the second situation, low resistance to the test injection may not occur because the needle tip is located in the hyaline cartilage. In this case, the needle may be gently manipulated by rotating or slightly moving it back away from the humerus. Slight injection pressure must be maintained during this manipulation. An abrupt decrease in resistance to injection indicates that the needle tip is located in a compartment (joint space or bursa). One must not pull back the needle more than a few millimeters because the needle tip could enter the subacromial-subdeltoid bursa. If needle manipulation does not yield the desired result, the needle may be directed medially, with care taken not to advance the needle into the glenoid labrum, since positioning the needle tip medial to the humeral cortex places the cartilaginous labrum at risk for injury.

We prefer that test injections be made with a local anesthetic rather than iodinated contrast material because aberrant injections with the latter could mask the area and make further needle visualization difficult. It is essential that a gadolinium compound should not be used for this test injection before MR imaging because inadvertent injection of gadolinium outside the joint during an aberrant needle placement may be misinterpreted as rotator cuff tear or capsular injury on MR images.

When the anesthetic test injection indicates that the needle tip is located in either the glenohumeral joint or adjacent bursa, iodinated contrast material is used to differentiate between these two locations. A connecting tube is typically used between the needle and the syringe. Low resistance to injection should still be evident. In addition, movement of contrast material away from the needle tip is consistent with either an intraarticular or bursal location. To confirm intraarticular placement of contrast material, one must observe a column of contrast agent between the glenoid and the humerus (Fig 3c). Free-flowing contrast material that pools over the humeral head may be located either in the posterior glenohumeral joint recess or in the subacromial-subdeltoid bursa anteriorly. If contrast material is not seen between the glenoid and humerus, the radiologist can apply gentle inferior traction on the patient’s arm to create negative pressure in the joint space, which essentially pulls the contrast agent into the joint space proper and confirms intraarticular placement. Intraarticular contrast material may also be identified in the subscapular recess, the axillary recess, and the long head of the biceps tendon sheath because these are normal communications with the glenohumeral joint. If the needle tip is not within the joint or adjacent bursa, irregular pooling of contrast media will occur at the tip.

Final Injection of Contrast Material
Once intraarticular needle placement has been confirmed, iodinated contrast material with or without air may be injected for fluoroscopic imaging and possibly CT. If the procedure is followed by an MR imaging examination, a mixture of gadolinium and iodinated contrast agent may be injected. We typically combine 0.1 mL of gadopentetate dimeglumine (Magnevist; Berlex Imaging, Wayne, NJ), 10 mL of iohexol (Omnipaque; Nycomed, Princeton, NJ) (a nonionic low-osmolar iodinated contrast agent), 10 mL of sterile 0.9% sodium chloride (Abbott Laboratories, North Chicago, Ill), and 0.3 mL of epinephrine (1:1000) (American Regent Laboratories, Shirley, NY) in a 20-mL syringe. Combining the radiopaque iodinated contrast agent with the radiolucent gadolinium allows continual observation of the injection and provides added information at fluoroscopy. In addition, if the subsequent MR imaging examination cannot be completed, information about the integrity of the rotator cuff is still available from the arthrographic images. Although iodinated contrast material lowers the signal intensity of low-osmolality gadopentetate dimeglumine solutions (10), the intraarticular signal intensity on MR images obtained with our standard dilution is adequate. A nonionic iodinated contrast agent is used to reduce delayed discomfort or pain (11). Epinephrine is added to delay the absorption of contrast agent from the joint cavity, which may be important depending on the time interval between joint injection and MR imaging. However, it has also been shown that the use of intraarticular epinephrine increases arthrographic associated pain, either because epinephrine is a direct irritant to the synovium or because its use increases the time that the synovium is exposed to the contrast agent (11). It is very important to minimize the introduction of air bubbles during any of the injections because they produce artifacts at MR imaging.

Generally, an injection of 10–16 mL is used to distend the shoulder, although the amount varies. A patient with chronic shoulder subluxation may require more volume, whereas a patient with adhesive capsulitis requires less. Increased resistance to injection or the retrograde flow of contrast material from the connecting tubing after the syringe is disconnected indicates adequate joint distention. A volume of 15 mL of intraarticular fluid has been described as being optimal for MR arthrography (12). It has been shown that exercise after shoulder arthrography has no beneficial or detrimental effect on MR image quality or on the depiction of rotator cuff or labral tears (13).


   Summary
Top
 Abstract
 Introduction
 Shoulder Arthrographic Technique
 Summary
References
 
The technique described is one method for performing effective shoulder arthrography with a fluoroscopically guided anterior approach. The initial steps of proper patient and needle positioning are critical to a successful and atraumatic shoulder arthrographic examination. Accurate confirmation of intraarticular needle placement is also important. Avoiding injury to the glenoid labrum is essential when arthrography is performed in conjunction with MR imaging.


   Footnotes
 
2 Current address: Valley Radiologists, Ltd, Glendale, Ariz. Back

See the commentary by Manaster following this article.


   References
Top
 Abstract
 Introduction
 Shoulder Arthrographic Technique
 Summary
 References
 

  1. Resnick D. Shoulder arthrography. Radiol Clin North Am 1981; 19:243-253.[Medline]
  2. Helgason JW, Chandnani VP, Yu JS. MR arthrography: a review of current technique and applications. Am J Roentgenol Radium Ther Nucl Med 1997; 168:1473-1480.
  3. Killoran PJ, Marcove RC, Freiberger RH. Shoulder arthrography. AJR Am J Roentgenol 1968; 103:658-668.[Abstract/Free Full Text]
  4. Schneider R, Ghelman B, Kaye JJ. A simplified injection technique for shoulder arthrography. Radiology 1975; 114:738-739.
  5. Wills JS, Diznoff SB. A modified technique for needle localization in arthrography of the shoulder. Radiology 1978; 128:830-831.
  6. Neviaser TJ. Arthrography of the shoulder. Orthop Clin North Am 1980; 11:205-217.[Medline]
  7. Chung CB, Dwek JR, Feng S, Resnick D. MR arthrography of the glenohumeral joint: a tailored approach. AJR Am J Roentgenol 2001; 177:217-219.[Abstract/Free Full Text]
  8. Farmer KD, Hughes PM. MR arthrography of the shoulder: fluoroscopically guided technique using a posterior approach. AJR Am J Roentgenol 2002; 178:433-434.[Free Full Text]
  9. Burk DL, Karasick D, Mitchell DG, Rifkin MD. MR imaging of the shoulder: correlation with plain radiography. AJR Am J Roentgenol 1990; 154:549-553.[Free Full Text]
  10. Kopka L, Funke M, Fischer U, Keating D, Oestmann J, Grabbe E. MR arthrography of the shoulder with gadopentetate dimeglumine: influence of concentration, iodinated contrast material, and time on signal intensity. AJR Am J Roentgenol 1994; 163:621-623.[Abstract/Free Full Text]
  11. Hall FM, Goldberg RP, Wyshak G, Kilcoyne RF. Shoulder arthrography: comparison of morbidity after use of various contrast media. Radiology 1985; 154:339-341.[Abstract/Free Full Text]
  12. Recht MP, Kramer J, Petersilge CA, et al. Distribution of normal and abnormal fluid collections in the glenohumeral joint: implications for MR arthrography. J Magn Reson Imaging 1994; 4:173-177.[Medline]
  13. Brenner ML, Morrison WB, Carrino JA, et al. Direct MR arthrography of the shoulder: is exercise prior to imaging beneficial or detrimental? Radiology 2000; 215:491-496.[Abstract/Free Full Text]

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B. J. Manaster
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