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Glenohumeral Joint Injection

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Other Names

  • Shoulder Injection
  • Shoulder Arthrocentesis
  • Shoulder aspiration
  • Glenohumeral Injection
  • Glenohumeral aspiration

Background

Illustration of the glenohumeral joint[1]
  • This page refers to injections of the glenohumeral joint
    • This includes both injection and aspiration as the technique and approach are the same

Key Points

  • This procedure should be performed with ultrasound guidance
  • Posterior approach using the curvilinear array transducer is preferred
  • Recommend in-plane needle approach

Anatomy

Palpation vs Ultrasound Guidance

  • Accuracy of palpation guidance ranges from 45.7% to 88.9%[2][3][4]
  • In contrast, ultrasound guidance improves accuracy to between 95% and 100%
  • Sibbitt et al found that US guided injections were more clinically effective, reduced patient cost per year[5]

Aspiration

Indications

  • Rule out Septic Arthritis
  • Diagnose Gout or other spondyloarthropathy
  • Symptomatic relief
  • Unexplained joint effusion or monoarthritis

Contraindications

  • Absolute
    • No absolute contraindications
  • Relative
    • Abnormal or altered anatomy
    • Overlying infection or bacteremia
    • Coagulation
    • Prosthetic joint
    • Uncooperative patient
    • Diagnosis can be made with less invasive method

Injection

Indications

Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Glenohumeral injection using the posterior approach

Equipment

  • Ultrasound Machine
    • Either the linear or curvilinear transducer can be used depending on body habitus, approach
    • Ultrasound probe cover
    • Sterile gel
  • Needle
    • Gauge is preference but can vary from 18 to 25
    • Length is usually at least 2 inches, some recommend 3.5 inch spinal needle
  • Syringe
    • Typically 5-10 cc
  • Injectate
    • Typically corticosteroids, can consider other
    • Local anesthetic
  • Additional
    • Skin prep (chloraprep, chlorhexadine, iodine, etc)
    • Gloves
    • Gauze
    • Ethyl Chloride (optional)
    • Bandage

Ultrasound Findings

  • Common ultrasound findings include:
    • Cortical irregularities
    • Osteophytes
    • Joint effusion
    • Labral tears

Preparation

Ultrasound image of the right shoulder glenohumeral joint as viewed from the posterior aspect. L, labrum.[7]
  • Positioning
    • Optimize patient positioning
    • We recommend the posterior approach with the patient in the lateral decubitus position
    • This maximizes stability of the patient during the procedure and increases shoulder accesibility
  • Ultrasound
    • Should be placed in a position opposite of the patient
    • Allow for physician, patient, machine in a straight line to minimize movement

Palpation Guided Technique

  • Posterior Approach
    • Patient is seated, arm resting at side in neutral position
    • Sulcus between head of humerus, acromion is identified
    • Needle is inserted 2-3 cm inferior, meial to posterior lateral corner of acromion, directed towards coracoid process
    • Needle should sink completely into the joint and push with ease indicating you are in the joint
  • Anterior Approach
    • Patient is seated, arm resting in a neutral position
    • Needle inserted medial to the head of the humerus, lateral to the coracoid process
    • Needle is is lateral to coracoid process by 1 cm, directed posteriorly at a slight lateral angle
    • Needle should slip into the joint completely and push with ease, indicating you are in the joint

Ultrasound Guided Technique: Posterior Approach

Posterior approach. The glenoid process and humeral head both appear as hyperechoic structures with anechoic shadow. The insert on the top shows the position of the patient and the ultrasound probe while one below shows the probe position and the structures underneath; IS=-infraspinatus muscle; H=humeral head; GP=glenoid process; *=glenoid labrum; •=the articular cartilage of the humeral head.[8]
Anterior approach. The insert shows the position of the probe and corresponding anatomical structures underneath. The LHB tendon (*) is always hyperechoic at this level and sandwiched between the supraspinatus tendon (SS) laterally and subscapularis tendon (SC) medially. The coracohumeral ligament (arrow heads) forms the roof of the interval. The needle (indicated by the dashed arrow) is inserted from lateral to medial into the rotator cuff interval.[8]
  • General
    • Posterior approach is superior to anterior approach[9]
    • Posterior approach avoids the axillary neurovascular structures
  • Patient Position[7]
    • In the posterior approach, the patient can be prone, upright or semiprone/ lateral decubitus
    • Recommended: lateral decubitus position: physician stands behind patient, symptomatic shoulder is upright
      • Preferred by most authors as patient is more stable, less likely to flinch
    • Upright position: physician stands behind patient, ipsilateral hand positioned on patients symptomatic shoulder
  • Transducer Position
    • Transducer is placed over the long axis of the myotendinous junction of the infraspinatus
    • The posterior glenoid rim, labrum and posterior humeral head should be brought into view
    • This is the optimal injection spot
  • Insert needle into the joint
    • This approach uses an in-plane technique
    • Maintaining visualize of the joint, the needle is injected lateral to medial towards the glenohumeral space
    • Lateral to medial approach avoids the suprascapular and circumflex scapular neurovascular structures
    • Optimal target is between the glenoid labrum and humeral head
  • Pearls and Pitfalls
    • Can use anesthetizing needle to determine trajectory before performing intra-articular injection
    • Do not confuse the suprascapular notch for the joint space
    • Gently internally and externally rotate the humerus to orient yourself
    • Needle trajectory is fairly steep
    • Gevel should be facing articular surface of humerus to avoid gouging articular cartilage
    • Turn the bevel 90 degrees or withdraw needle slightly if encountering resistance

Ultrasound Guided Technique: Anterior Approach

  • Patient Position
    • Supine, arm in neutral rotation to slightly externally rotated
    • Target for this approach is the rotator cuff interval
  • Transducer position
    • Anatomic axial plane directly over the anterior GH joint
  • Needle orientation/ approach
    • We recommend an in-plane technique
    • Note, an out of plane technique has been described
    • Needle approach is lateral to medial
  • Target
    • Anterior GH joint space on either side of the long head of the biceps, deep to the coracohumeral ligament
    • Needle directly visualized entering down between subscap tendon, articular cartilage or glenoid labrum, articular cartilage
  • Pearls and Pitfalls
    • Slight external rotation of the arm reduces needle angle trajectory
    • This can improve needle visualization

Aftercare

  • Apply bandage
  • Consider ace wrap to help prevent recurrence of effusion
  • No major restrictions in most cases
  • Can augment with ice, NSAIDS

Complications

  • Pain
  • Infection
  • Recurrence of effusion
  • Damage to surrounding soft tissue structures

See Also


References

  1. Image courtesy of kenhub.com, "Glenohumeral Joint"
  2. Powell, Scott E., et al. "Accuracy of palpation-directed intra-articular glenohumeral injection confirmed by magnetic resonance arthrography." Arthroscopy: The Journal of Arthroscopic & Related Surgery 31.2 (2015): 205-208.
  3. Tobola, Allison, et al. "Accuracy of glenohumeral joint injections: comparing approach and experience of provider." Journal of shoulder and elbow surgery 20.7 (2011): 1147-1154.
  4. Patel, Deepan N., et al. "Comparison of ultrasound-guided versus blind glenohumeral injections: a cadaveric study." Journal of shoulder and elbow surgery 21.12 (2012): 1664-1668.
  5. Sibbitt, Wilmer L., et al. "A randomized controlled trial of the cost-effectiveness of ultrasound-guided intraarticular injection of inflammatory arthritis." The Journal of rheumatology 38.2 (2011): 252-263.
  6. Khallaf, Soha F., et al. "Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in patients with adhesive capsulitis: Glenohumeral versus subacromial approaches." The Egyptian Rheumatologist 40.4 (2018): 277-280.
  7. 7.0 7.1 Chen, Carl PC, Henry L. Lew, and Chih-Chin Hsu. "Ultrasound-guided glenohumeral joint injection using the posterior approach." American journal of physical medicine & rehabilitation 94.12 (2015): e117.
  8. 8.0 8.1 Image courtesy of asra.com, "How I Do It: Ultrasound-Guided Injection for the Shoulder (Part 2)"
  9. Ogul H, Bayraktutan U, Ozgokce M, et al. Ultrasound-guided shoulder MR arthrography: Comparison of rotator interval and posterior approach. Clin Imaging 2014; 38: 11–7
Created by:
Jesse Fodero on 10 July 2019 21:08:30
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Last edited:
23 March 2024 21:35:12
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