Oberholzer (1933)
Indications:
Diagnostic arthrography is nearly obsolete
Diagnostic for MR arhrogram
Therapeutic for adhesive capsulitis with distention arthrography, steroids, radioactive synovectomy
Palpation directed arthrography:
Not a popular technique, but has been used (3)
AP (Schneider) technique:(1975)
Straight AP approach with 3.5-inch 22Gneedle directed vertically at junction of middle and lower thirds of glenohumeral joint under fluoroscopy
Pitfall - distortion of inferior GHL and anteroinferior labrum, thus creating confounding findings on MR arthrogram
Modified AP technique (rotator cuff interval):
Spares subscapularis, inferior GHL, anteroinferior labrum and long head of biceps
Arm in external rotation (palm up)
Mark the skin over upper medial quadrant of humeral head close to articular joint line with X-ray tube perpendicular to table
Advance the needle (1.5 inch 22 G) parallel to X-ray beam or with slight medial angulation until in contact with humeral head.
Low resistance 0.5–1.0 mL of anesthetic helps to ascertain intraarticular position
Then inject the required contrast
Posterior approach:
Arm midway between supination and pronation, i.e., shoulder in neutral position
Pad under patient's torso to raise the side
Glenohumeral joint to be seen tangentially
Skin marked over inferomedial quadrant of humeral head
21G needle
Ultrasound guided arthrography:
Semiprone with affected shoulder uppermost
Ipsilateral arm placed over pillow to maintain semiprone position
Anterior approach may also be used
5-12MHz linear probe
Probe along the long axis of musculotendinous junction of infraspinatus, just inferior to the scapular spine, with posterior glenoid rim and posterior glenohumeral joint line centered in the field of view with clear view of the contours of the posterior glenoid rim, posterior glenoid labrum and humeral head.
Humeral head seen as curved echogenic line, posterior glenoid rim as triangular echogenic structure, posterior glenoid labrum as homogenously echogenic triangular structure
20- to 22-gauge spinal needle through infraspinatus tendon, then feeling of capsular resistance followed by resistance-free space
Injection into the joint without any resistance
No fluid distention is seen on ultrasound at posterior glenohumeral joint recess because the injected substance runs freely into anterior joint recess which is not seen. If fluid is seen pooling around the needle tip, it means the needle tip is not in the right place
If a large volume is instilled, the posterior recess also distends
Contrast:
0.1-0.2 mL of Gd in 20 mL of saline
Inject up to 12-20 mL
References:
1. Dépelteau H et al. Arthrography of the Shoulder: A Simple Fluoroscopically Guided Approach for Targeting the Rotator Cuff Interval . AJR 2004; 182:329-332
2. Zwar RB et al. Sonographically Guided Glenohumeral Joint Injection. AJR 2004; 183:48-50
Valls R et al. Sonographic guidance of needle position for MR arthrography of the shoulder. AJR1997; 169:845 –847
3. DeMouy EH et al. Palpation-directed (non–fluoroscopically guided) saline-enhanced MR arthrography of the shoulder. AJR1997; 169:229 –231
4. Farmer KD et al. MR Arthrography of the Shoulder: Fluoroscopically Guided Technique Using a Posterior Approach. AJR 2002; 178:433-434
