shoulder injections

[SpineandWine]

Any tips on optimzing IA shoudler injections. What's your technique.
I've been having people stay supine, using x-ray to desginate shoulder joint. Then go with needle to 1/3rd way up GH joint, when hitting os, i put contrast and see spread. If not around whole joint, I move to different area.

Is there a reliable spot that guarantees good contrast spread when using fluoro?

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[GoBeers]

AP
have arm by their side, hand supinated
imagine crosshairs from AC joint line to coracoid process (basically superomedial quadrant of humeral head) and drop needle down
reliable but every so often, if not great spread then just redirect needle a mm over

 

[runfastnow]

Position patient supine and try to get them to external rotate/supinate a bit.
Contralateral oblique until I get a good view of the joint without glenohumeral overlap. Usually 10-15 degrees in my experience.
Straight line down from the AC to the humeral head roughly parallel to coracoid or slightly below. If you stay too superior or lateral on the humeral head then you can hit the biceps tendon.

Joint can hold a lot of fluid 10+cc if you want. Used to do some arthrograms for ortho colleagues on people who couldn't have MRIs. If big RTC tear will see contrast leak into subacromial bursa superior-laterally from the joint.

 

[SpineandWine]

any pics?

 

[runfastnow]

** Edit: These are a few arthrograms I did in the past. Probably 8-10 cc contrast in above pics to try and find a leak. Normally only need 2-3 cc (if that) to confirm in joint. If dx/tx injection will do 1 cc Depo + 2 cc lido + 2 cc ropiv. Plenty of room for all of it.

 

[MitchLevi]

IA shoulder under fluoro is a 30 sec injection with 5 sec fluoro time.

I use 6cc of injectate. Particulate steroid.

Pics above are great.

 

[Tboned]

I second the contralateral oblique until joint space optimized. You should be able to recognize intra-articular pattern and shouldn’t have to move to an entirely different spot so quickly.

 

[epidural man]

View attachment 368246
View attachment 368247
** Edit: These are a few arthrograms I did in the past. Probably 8-10 cc contrast in above pics to try and find a leak. Normally only need 2-3 cc (if that) to confirm in joint. If dx/tx injection will do 1 cc Depo + 2 cc lido + 2 cc ropiv. Plenty of room for all of it.

Good pictues.

I go a little more lateral than you do. I worry about hitting cartilage.

Although the pain source guy (isn't he on this forum?) draws a nice picture of a target zone which includes where you put it - I still think you can get the same results, maybe safer, with a little more lateral entry.

Glenohumeral Joint Injection With Fluoroscopy - The Pain Source

Technique and tips for performing a glenohumeral joint injection with fluoroscopic guidance. Technique, tips, and CPT codes.

thepainsource.com

 

[SSdoc33]

Ffs. 1 shot AP. Its like throwing a hotdog down a hallway. You should not step on the gas >2x

 

[Ferrismonk]

I use ultrasound and do at bedside.

 

[oreosandsake]

Ultrasonic way better

Fluoro if you go from the posterior you only go through infraspinatus belly. Avoid going straight for the joint where the labrum is. Also anterior labrum more often injured

 

[Tboned]

I like ultrasound better than fluoro for ghj too

 

[runfastnow]

Ffs. 1 shot AP. Its like throwing a hotdog down a hallway. You should not step on the gas >2x

Ha - agree. Those are arthrograms so extra fluoro overkill. Line up shot -> needle to bone -> contrast -> injectate. 3-4 seconds fluoro time tops.

I use ultrasound and do at bedside.

I do like US for normal size people. Indifferent to fluoro vs US for BMI >35.
Most of my patients and ortho colleagues like to see the confirmation that fluoro + contrast gives.

 

[oneforfighting]

Just do blind. Always excellent results.

 

[Ferrismonk]

Ha - agree. Those are arthrograms so extra fluoro overkill. Line up shot -> needle to bone -> contrast -> injectate. 3-4 seconds fluoro time tops.


I do like US for normal size people. Indifferent to fluoro vs US for BMI >35.
Most of my patients and ortho colleagues like to see the confirmation that fluoro + contrast gives.

lol, BMI >35 is my normal person

 

[lobelsteve]

I’ve done plenty of shoulder injection, using the poster, your technique and requiring a 6 inch needle.

 

[pmrmd]

Prone, posterior approach. Fluoro.

 

[SpineandWine]

Prone, posterior approach. Fluoro.

How do you reliably get that contrast spread pattern on the first stick/touch with Os.

 

[deleted131481]

How often are you all doing GHJ vs subacromial bursa injection? I do the latter way more often. Usually I'm seeing shoulders a secondary issue and tend to be more rotator cuff than OA.

 

[pmrmd]

How do you reliably get that contrast spread pattern on the first stick/touch with Os.

Put the needle where I have it.

 

[lobelsteve]

Prone, posterior approach. Fluoro.

Is that a 27g 1.25"? Barely see the needle. Most of mine are 25g 3.5"

 

[Ducttape]

How often are you all doing GHJ vs subacromial bursa injection? I do the latter way more often. Usually I'm seeing shoulders a secondary issue and tend to be more rotator cuff than OA.

i tend to do more subacromials when "fresh", but im usually seeing them after they have failed 2 injections by ortho, who then say that theres nothing surgically wrong so go see pain management.


so they get suprascapular nerve blocks under US.

 

[pmrmd]

Is that a 27g 1.25"? Barely see the needle. Most of mine are 25g 3.5"

It’s a 25g spinal.

 

[Ferrismonk]

How often are you all doing GHJ vs subacromial bursa injection? I do the latter way more often. Usually I'm seeing shoulders a secondary issue and tend to be more rotator cuff than OA.

I do GH for OA and subacromial for rotator cuff/everything hurts.

I like ultrasound because I can see the labrum and can slide the needle underneath it.

 

[cowboydoc]

Ffs. 1 shot AP. Its like throwing a hotdog down a hallway. You should not step on the gas >2x

 

[SSdoc33]

Im glad someone is paying attention

 

[DoYouEvenLiftBro]

Ultrasound, curvilinear probe
Lateral decubitus
25 gauge 3 1/2 numbing needle once in the joint have the color Doppler on, inject more you’ll see the flow staying in the joint switch your syringe for the injectate and done. This is how I do the Arthrograms for a group as well since no fluoro in that office