Shoulder injection under fluoro tips?

[CarabinerSD]

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I have some beefy patients whom I do shoulder glenohumeral joint injections under fluoro. Used thepainsource site as a guide on where to put the needle but wondering if other people have tips on optimal placement of shoulder joint since my contrast flow is so so.

 

[interjectionreflection]

The best thing to do is position them with their palm facing upward. I draw a line with the AC joint intersecting with the coracoid process and that's my target site usually gets the job done. Otherwise you can go to the superior medial border of the humeral head. Also, I find it best if you're not coaxial with this injection.

 

[RoloTomassi]

I find prone is a lot better. Less painful, no tendons, less pressure during injection, more likely dye looks good on the first try

 

[lobelsteve]

Prone, arm at side.
Straight down to upper outer humeral head about 1 cm inward from edge of bone. 25g 3.5" needle.
Have never done it without fluoroscopy. I suspect you cannot be IA without image guidance based on contrast patterns once I hit os.

 

[oneforfighting]

Prone, arm at side.
Straight down to upper outer humeral head about 1 cm inward from edge of bone. 25g 3.5" needle.
Have never done it without fluoroscopy. I suspect you cannot be IA without image guidance based on contrast patterns once I hit os.

Never done shoulder injections without fluoro?

 

[lobelsteve]

Never done shoulder injections without fluoro?

SAB yes, IA- nope.
AC: doesn't last. Not reason to do it (except pre-game for state championships).

 

[BoardingDoc]

I know it's not what you asked, but doing them under US, posterior approach is stupid easy. Probe under blade of scapula, in plane approach, drop into the valley that shows up on imaging and inject. I do the picture a+b approach below. 25g needle works fine. Pajunk shows up better on US if you have it but not necessary.

 

[SSdoc33]

I know it's not what you asked, but doing them under US, posterior approach is stupid easy. Probe under blade of scapula, in plane approach, drop into the valley that shows up on imaging and inject. I do the picture a+b approach below. 25g needle works fine. Pajunk shows up better on US if you have it but not necessary.

View attachment 404194

oh, FFS.

see that big round thing? aim for it. patient supine, i can do the shot with 2 steps on the pedal. no positioning, no goop, no looking at a snowstorm.

 

[Joosbocks]

Prone, arm at side.
Straight down to upper outer humeral head about 1 cm inward from edge of bone. 25g 3.5" needle.
Have never done it without fluoroscopy. I suspect you cannot be IA without image guidance based on contrast patterns once I hit os.

I wouldn't do upper outer. Branches of the anterior circumflex humeral artery exist there and are avoidable if you use other approaches. Watching dye on fluoro probably prevents vascular injection, but why even take the risk?

Superior-medial is better, and more traditionally described as the fluoroscopy approach:

Fluoroscopic Guided Glenohumeral Joint Injection – Technique and Overview - The Procedure Guide

Technique for a glenohumeral shoulder joint injection procedure with sample fluoro images/videos, anatomy, tips, indications/contraindications, etc.

theprocedureguide.com

https://ajronline.org/doi/10.2214/ajr.182.2.1820329

https://radiopaedia.org/articles/glenohumeral-joint-injection-technique?lang=us

Also, I can't prove that it matters, but I get the sense that being superomedial also can sometimes provide you a whiff of evidence that a rotator cuff tear is present if there is upward flow of the 1cc of contrast.

 

[BoardingDoc]

oh, FFS.

see that big round thing? aim for it. patient supine, i can do the shot with 2 steps on the pedal. no positioning, no goop, no looking at a snowstorm.

Lol, you do you man. That said, I think the fact that I showed a picture makes you think that this is some big drawn out process. I don't have them lie down, the picture just shows where I put the probe and what the image looks like.

Patient sits down. Shoulder prepped. Image acquired, needle in, inject. Whole thing takes at most a minute from picking up the probe to pulling out the needle.

That said this is all predicated on 1: having an US in the room ready to go and 2: knowing how to use it.

 

[nvrsumr]

Fluoro pays more than US for joints.

 

[oneforfighting]

SAB yes, IA- nope.
AC: doesn't last. Not reason to do it (except pre-game for state championships).

Seems pretty excessive to do IA under fluoro when you can do them blind in the office with excellent results. Same with knees.
And I have had AC's last well over a year but I do those under fluoro.

 

[Status Sciaticus]

Seems pretty excessive to do IA under fluoro when you can do them blind in the office with excellent results. Same with knees.
And I have had AC's last well over a year but I do those under fluoro.

why deprive of yourself of $100 77002??

 

[lobelsteve]

Seems pretty excessive to do IA under fluoro when you can do them blind in the office with excellent results. Same with knees.
And I have had AC's last well over a year but I do those under fluoro.

You are not as good as you think you are. So says the literature.
Best you can do on a knee is 87% using superolateral approach.
Shoulders are lower.

 

[Ducttape]

Yes studies suggest that imaging - fluoro and u/s - is more likely to be positive than blind injections. I'll try to post some studies tomorrow

 

[SSdoc33]

subacromial for RTC, sure, you can do it blind. intra-articular is harder. is suspect i could do it blind as well and get in most of the time, but it would not be as accurate

 

[drusso]

I have some beefy patients whom I do shoulder glenohumeral joint injections under fluoro. Used thepainsource site as a guide on where to put the needle but wondering if other people have tips on optimal placement of shoulder joint since my contrast flow is so so.

The best fluoroscopy approach to the shoulders is under ultrasound.

 

[lobelsteve]

The best fluoroscopy approach to the shoulders is under ultrasound.

I cannot see the joint on Xray because the probe blocks my view

 

[BoardingDoc]

I cannot see the joint on Xray because the probe blocks my view

Try using your flouro in plane setting.

 

[lobelsteve]

Try using your flouro in plane setting.

If i put it in plane mode i cant get calls.

 

[oreosandsake]

I know it's not what you asked, but doing them under US, posterior approach is stupid easy. Probe under blade of scapula, in plane approach, drop into the valley that shows up on imaging and inject. I do the picture a+b approach below. 25g needle works fine. Pajunk shows up better on US if you have it but not necessary.

View attachment 404194

these images are old and bad

image A his probe and needle are in two different zip codes
image B shows needle going straight through labrum
image C OOP if that's any normal injection needle, 1.5 in he's looking at cross section about 1 inch proximal on the needle and this is def not the rotator interval

all that said, learn to do these under ULTRASOUND. fluoro you are almost always going straight through the labrum.

 

[lobelsteve]

these images are old and bad

image A his probe and needle are in two different zip codes
image B shows needle going straight through labrum
image C OOP if that's any normal injection needle, 1.5 in he's looking at cross section about 1 inch proximal on the needle and this is def not the rotator interval

all that said, learn to do these under ULTRASOUND. fluoro you are almost always going straight through the labrum.

How do I get through the labrum if I am on the upper/lateral humeral head?

 

[drusso]

How do I get through the labrum if I am on the upper/lateral humeral head?

The Map is not the Territory.

 

[maxxor]

I wouldn't do upper outer. Branches of the anterior circumflex humeral artery exist there and are avoidable if you use other approaches. Watching dye on fluoro probably prevents vascular injection, but why even take the risk?

Superior-medial is better, and more traditionally described as the fluoroscopy approach:

Fluoroscopic Guided Glenohumeral Joint Injection – Technique and Overview - The Procedure Guide

Technique for a glenohumeral shoulder joint injection procedure with sample fluoro images/videos, anatomy, tips, indications/contraindications, etc.

theprocedureguide.com

https://ajronline.org/doi/10.2214/ajr.182.2.1820329

https://radiopaedia.org/articles/glenohumeral-joint-injection-technique?lang=us

Also, I can't prove that it matters, but I get the sense that being superomedial also can sometimes provide you a whiff of evidence that a rotator cuff tear is present if there is upward flow of the 1cc of contrast.

Most rads angle the C arm to get a slight grashey view then aim for the rotator interval, like in that AJR article.

Will agree with lobel: A lot of people “think they are in” but based on flow patterns, aren’t.

 

[lobelsteve]

The Map is not the Territory.

I'm too tired to understand that.
Are people still trying to go between the humeral head and the labrum?
Like guys who do not know hips and do the same?

 

[oreosandsake]

How do I get through the labrum if I am on the upper/lateral humeral head?

Sorry I should say, Many photos posted online I see are going for the labrum.

Also, it’s really hard to define what you are going through on fluoro. It’s not like the hip joint with a huge landing spot and a thick ligament to make your contrast pretty
Some of the popular procedure sites online show contrast that gets to the ghj by way of the biceps tendon. It’s really not a good modality for the joint

 

[oreosandsake]

You are not as good as you think you are. So says the literature.
Best you can do on a knee is 87% using superolateral approach.
Shoulders are lower.

Yes this
knee studies show as low as 50-60 percent in trained ortho and sports med hands