Shoulder Procedures

KEY FACTS

Preprocedure

• Indication

Glenohumeral joint aspiration (suspected infection) or injection (contrast for arthrography; adhesive capsulitis symptom relief)

Subacromial-subdeltoid (SA-SD) bursal injection (symptom relief) or aspiration (suspected infection)

Calcific tendinitis (symptom relief)

Rotator cuff tendinosis or tear (symptom relief and to promote healing)

Acromioclavicular joint injection (symptomatic relief)

Procedure

• Glenohumeral joint aspiration or injection

Anterior (rotator cuff interval) or posterior approaches

Aspiration for infection or crystal analysis

Injection for arthrography, osteoarthritis, inflammatory arthropathy, or adhesive capsulitis
• SA-SD bursal injection or aspiration

Lateral, anterior, and superior approaches

Steroid and long-acting local anesthetic (LA) to SA-SD bursa
• Calcific tendinitis

Dry needling and aspiration

Percutaneous lavage and aspiration of calcific deposits

Single or double-needle techniques

Steroid and long-acting LA injected to bursa
• Rotator cuff tendinosis or tear

Steroid and LA injection to SA-SD bursa (to reduce inflammation)

Localized dry needling of tendinosis or tear (to promote healing)

Platelet-rich plasma (PRP) injection of rotator cuff partial tear (to promote healing)

– No clear proven benefit shown for PRP in tendinosis or rotator cuff tear
• Acromioclavicular joint arthropathy

Steroid and LA injection to joint via transverse approach

PREPROCEDURE

Indications

• Glenohumeral joint injection or aspiration

MR, CT, or conventional arthrography

Medication for control of inflammation or pain relief in osteoarthritis, inflammatory arthropathy, or adhesive capsulitis

Diagnosis of septic arthritis or crystal arthropathy
• Subacromial-subdeltoid (SA-SD) bursa injection

For control of inflammation and symptom relief
• Calcific tendinitis therapy

For control of inflammation, symptom relief, and to promote resorption of calcific deposits
• Rotator cuff tendinosis or partial tear therapy

For control of symptoms and to promote tissue repair
• Acromioclavicular (AC) joint injection

For control of inflammation and symptom relief

Contraindications

• Infection of overlying soft tissues
• Uncorrected severe bleeding diathesis

Getting Started

• Things to check

Patient identity, type of procedure, side of procedure, informed consent

Discuss risk of infection, allergy, bleeding

– Risk of calcific bursitis for treatment for calcific tendinitis

Sedation is rarely required
• Medications

Anesthetic

– Short-acting local anesthetic (LA) for skin: 1-3 mL 1% lignocaine

– Short- or long-acting anesthetic for intraarticular injection: 1-2% lignocaine or 0.25-0.50% bupivacaine

Steroid

– Short (hydrocortisone) or long acting (methylprednisolone, dexamethasone)

Contrast

– CT arthrography: Iodinated contrast, e.g., Omnipaque 300 ± 0.1 mL of 1:1,000 epinephrine

– MR arthrography: Diluted 0.1 mL gadolinium in 10 mL normal saline solution
• Equipment list

Sterile set

Spinal needles

– 18- to 22-g intravenous or spinal needle

– Needle size depends on consistency of fluid injected or aspirated

Extension tube (thin, 250 mm long, 8.5 Fr, 0.4 mL dead space) and 3-way connector

Syringes for LA, aspiration, and injection

Sterile specimen bottles

PROCEDURE

Procedure Steps

• General preparation of all percutaneous intervention

Sterile technique (operator, probe, patient)

– LA to skin at puncture site

For some quick straightforward procedures (e.g., joint injection), anesthesia optional
• Glenohumeral j oint injection or aspiration

General practical points irrespective of anterior (rotator cuff interval) or posterior approach

– Use free-hand technique to advance needle into joint space under real-time imaging

18- to 22-g spinal needle for injection or aspiration

Larger needle for aspiration of viscous fluid

– Can use long-axis or short-axis approaches

– Ensure needle tip is within joint space

Aspirate joint fluid prior to injection if moderate to large effusion present

– Avoid injection of bubbles by first flushing syringe and tubing with injectate

– Free flow of fluid with low-pressure injection and minimal patient discomfort helps confirm intraarticular position of needle tip

– Avoid active exercise to prevent leakage of solution along needle track for 20 minutes

Posterior approach

– Various positions can be used

Lateral decubitus position; arm mildly adducted

Prone position with arm in external rotation, palm facing down, and shoulder resting on pillow

Sitting position with back toward you, ipsilateral hand resting on contralateral shoulder (be alert for vasovagal syncope)

– In longitudinal plane, identify posterior glenohumeral joint, glenoid, labrum, and humeral head deep to infraspinatus musculotendinous junction

Slight passive rotation of arm while scanning will help identify glenohumeral joint

– Either short-axis (preferable) or long-axis needle approach can be used

– Short-axis approach allows joint to be approached more vertically than with long-axis approach

– Long axis is preferable as needle path easier to see

Can approach from medial or lateral sides

Approaching from lateral side allows direction of needle tip deep to posterior larum

Lateral approach goes through infraspinatus tendon and therefore may be slightly more painful

– “Pop” felt when needle transverses joint capsule

Rotator interval approach

– Supine position; arm partially externally rotated

Avoid extreme external rotation as it increases tension on anterior shoulder and increases risk of extraarticular leakage

– Identify coracoid process and adjacent superomedial aspect of humeral head with probe aligned transverse to joint line

– Needle entry point is just superior to subscapularis tendon and lateral to coracoid process

Needle is advanced until tip contacts articular cartilage of humeral head
• Arthrography

10-20 mL of contrast solution is injected until joint capsule is satisfactorily distended

Volume of injection is determined according to patient’s comfort level and resistance to injection

Patients with severe adhesive capsulitis will feel distension after only small volume (5-10 mL) of fluid injected into joint

Patients following shoulder dislocation can accommodate larger volumes (15-20 mL)

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Apr 9, 2020 | Posted by admin in MUSCULOSKELETAL IMAGING | Comments Off

KEY FACTS

Preprocedure

PREPROCEDURE

Indications

PROCEDURE

Procedure Steps

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Shoulder Procedures

Shoulder Procedures

Procedure

Contraindications

Getting Started

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Shoulder Procedures

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