Shoulder Joint Injection

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Shoulder Joint Injection
Indication	Adhesive Capsulitis
Syringe	5mL
Needle	21g 40-50mm
Steroid	40mg triamcinolone
Local	4mL 1%
Volume	5mL

Glenohumeral joint injections (often referred to as shoulder injections ) are performed as part of a number of therapeutic and imaging procedures using a variety of approaches and modalities. The underlying principles shared by all techniques are to avoid damage to the glenoid labrum, long head of biceps tendon, surrounding neurovascular structures and articular cartilage.

Indications

Injection into the glenohumeral joint may be necessary in the following settings:

• diagnostic and/or therapeutic corticosteroid +/- local anaesthetic injection
• glenohumeral (shoulder) arthrography
• glenohumeral (shoulder) hydrodilatation

Contraindications

Anticoagulation is a relative contraindication and should be assessed in the context of the risks of ceasing anticoagulation versus the risk of haemarthrosis. It some settings it will be best to avoid arthrography entirely or consider using indirect arthrography.

Pre-procedural Evaluation

Routine patient interactions are carried out (the procedure is explained to the patient, informed consent obtained, allergy and comorbidity history obtained, time-out performed including ensuring the correct side is being investigated, etc).

The shoulder needs to be exposed and skin examined for active infection.

Equipment

• sterile procedure pack, wash, gloves and gown
• local anaesthetic for skin (e.g. 1%/2% lignocaine) with needle (e.g. 23 or 25 G needle) and syringe
• 21 or 22-gauge spinal needle (length depends on the size of the patient)
• syringe for injectable (this will depend on the indication - see above)
• syringe for contrast if needed (depending on indication, modality and operator preference)
• short connecting tube (optional)
• dressing

Technique

A variety of approaches, both anterior and posterior, have been described to cannulate the glenohumeral joint using a variety of modalities, most commonly fluoroscopy or ultrasound. The procedure is carried out with sterile technique, without sedation and only requires local anaesthetic to skin. A 21-gauge spinal needle is typically used 4.

A normal joint will usually have a capacity of 8-15 mL. This will be reduced in adhesive capsulitis 5.

Ultrasound Guided

Both anterior and posterior approaches (see below) can also be performed under ultrasound guidance.

Fluoroscopy Guided

Regardless of technique meticulous sterile technique and generous antiseptic prep to the skin should be applied.

Anterior approach

The patient is placed supine with the arm somewhat externally rotated (palm facing upwards). Note, excessive external rotation not only may be painful, it will also tighten the anterior capsule reducing the space anteriorly 3.

Skin entry is marked over the upper medial quadrant of the humeral head 4. This is the rotator cuff interval, avoiding the tendons of supraspinatus, subscapularis and biceps tendon 4. Alternatively, a location somewhat lower down along the humeral head can be chosen, requiring passing through the subscapularis tendon 5,6. This notwithstanding, what is critical is that the needle is lateral to the medial humeral articular edge to avoid damaging the glenoid labrum.

The needle is then introduced vertically (needle tip overlying the hub) along the axis of the x-ray beam at the marked site until articular cartilage is encountered 4.

Intra-articular position is confirmed by the introduction of a small amount of contrast that should be seen to outline the joint space and the subcoracoid recess 4.

Posterior approach

The patient is placed prone with the shoulder to be injected elevated. Imaging is then orientated to see the joint line tangentially (i.e. joint space is visualised without overlap of glenoid and humeral head) 1.

Skin entry is marked over the inferomedial aspect of the articular surface, superomedial to the anatomical neck of the humerus (the site of capsular attachment) 1.

The needle is then introduced vertically along the axis of the x-ray beam at the marked site until articular cartilage is encountered 1.

Intra-articular position is confirmed by the introduction of a small amount of contrast 1.

Landmark Guided

• Posterior Approach
  • Patient position: sitting with arms folded, thus opening up the posterior joint space
  • Identify posterior angle of acromion with thumb, and coracoid process with index finger
  • Insert needle directly below angle and pass anteriorly obliquely towards coracoid process until needle gently touches intra-articular cartilage
  • Injection solution as a bolus
• Anterior Approach
  • Patient position: arm is held is slight lateral rotation
  • The needle is inserted on the anterior surface between the coracoid process and the lesser tuberosity of the humerus, aimed posteromedially towards the spine of the scapula
  • This is less preferable to the posterior approach due to patient visualisation, sensitive flexor skin surfaces, and more neurovascular structures present.

Complications

Extracapsular injection is probably the most common complication. The most serious complication is septic arthritis. Haemarthrosis is also rarely encountered.

See Also

Shoulder

Shoulder Anatomy

Shoulder Conditions

Shoulder Procedures

Shoulder Examination

Shoulder Pain Differential Diagnoses

References

Part or all of this article or section is derived from Glenohumeral joint injection (technique) by Andrew Murphy and Assoc Prof Frank Gaillard et al., used under CC BY-NC-SA 3.0

1. Farmer KD, Hughes PM. MR arthrography of the shoulder: fluoroscopically guided technique using a posterior approach. (2002) AJR. American journal of roentgenology. 178 (2): 433-4. doi:10.2214/ajr.178.2.1780433 - Pubmed
2. Dépelteau H, Bureau NJ, Cardinal E, Aubin B, Brassard P. Arthrography of the shoulder: a simple fluoroscopically guided approach for targeting the rotator cuff interval. AJR. American journal of roentgenology. 182 (2): 329-32. doi:10.2214/ajr.182.2.1820329 - Pubmed
3. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids to successful shoulder arthrography performed with a fluoroscopically guided anterior approach. Radiographics : a review publication of the Radiological Society of North America, Inc. 23 (2): 373-8; discussion 379. doi:10.1148/rg.232025706 - Pubmed
4. Lungu E, Moser TP. A practical guide for performing arthrography under fluoroscopic or ultrasound guidance. Insights into imaging. 6 (6): 601-10. doi:10.1007/s13244-015-0442-9 - Pubmed
5. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids to successful shoulder arthrography performed with a fluoroscopically guided anterior approach. Radiographics : a review publication of the Radiological Society of North America, Inc. 23 (2): 373-8; discussion 379. doi:10.1148/rg.232025706 - Pubmed
6. Berná-Serna JD, Redondo MV, Martínez F, Reus M, Alonso J, Parrilla A, Campos PA. A simple technique for shoulder arthrography. (2006) Acta radiologica (Stockholm, Sweden : 1987). 47 (7): 725-9. doi:10.1080/02841850600774050 - Pubmed

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