Musculoskeletal Procedures: Diagnostic and Therapeutic ppt

V
m
Musculoskeletal
Procedures:
Diagnostic and Therapeutic
Jacqueline C. Hodge
a d e m e c u
V
a d e
m
e c u m
Table of contents
1. Shoulder Arthrography
2. Elbow Arthrography
3. Wrist Arthrography
4. Hip Arthrography
5. Knee Arthrography
6. Ankle Arthrography
7. MR Arthrography
8. Myelography
9. Discography
10. Percutaneous Blocks
11. Epidural Blocks
12. Tenography
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13. Bone Biopsies
14. Percutaneous Treatment
of Osteoid Osteoma
15. Vertebroplasty
16. Ultrasound
Appendix
ISBN 1-57059- 600- X
9 781570 596001
LANDES
BIOSCIENCE
Jacqueline C. Hodge, M.D.
Lenox Hill Hospital
Department of Diagnostic Radiology
New York, New York
Musculoskeletal Procedures:
Diagnostic and Therapeutic
G
EORGETOWN
, T
EXAS
U.S.A.

vademecum
L A N D E S
B I O S C I E N C E
VADEMECUM
Musculoskeletal Procedures: Diagnostic and Therapeutic
LANDES BIOSCIENCE
Georgetown, Texas U.S.A.
Copyright ©2003 Landes Bioscience
All rights reserved.
No part of this book may be reproduced or transmitted in any form or by any
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CIP applied for but not received at time of publication.
Dedication
To my mother
Contents

Foreword xi
1. Shoulder Arthrography 1
Wilfred C.G. Peh and Jacqueline C. Hodge
Introduction 1
Indications 1
Contraindications 1
Equipment 2
Preliminary Radiographs 2
Technique 2
Contrast Agents 4
Post-Puncture Protocol 5
Complications 7
Normal Arthrogram 7
Abnormal Arthrogram 9
Acromio-Clavicular Arthrography 16
Summary 16
2. Elbow Arthrography 20
Clara G.C. Ooi and Wilfred C.G. Peh
Introduction 20
Normal Arthrogram 25
Abnormal Arthrogram 26
MR Arthrography 28
3. Wrist Arthrography 32
Isabelle Pigeau, Philippe Valenti, C. Sokolow, Stephane Romano
and Philippe Saffar
Introduction 32
Pre-Procedure Protocol 33
Post-Procedure Protocol 35
Pitfalls of Arthrography-CT 38
Complications 38

Pathological Aspects 38
4. Hip Arthrography 47
Laurent Sarazin, Alain Chevrot and Jacqueline C. Hodge
Indications 47
Prearthrogram Preparation 47
Technique 47
Postarthrogram Protocol 50
Complications 50
The Normal Arthrogram 50
Pathology 53
5. Knee Arthrography 62
Jacqueline C. Hodge
Introduction 62
Indications 63
Contraindications 63
Equipment 63
Pre-Arthrography Protocol 63
Technique 63
Normal Anatomy 65
Post-Procedure Protocol 67
Complications 70
Pathology 70
6. Ankle Arthrography 78
Mary-Josee Berthiaume and Jacqueline C. Hodge
Introduction 78
Prearthrogram Evaluation 78
Indications 79
Equipment 79
Contrast Agents 79
Technique 79

Postarthrographic Recommendations 80
Complications 81
The Normal Ankle Arthrogram 81
Pathologic Conditions 81
7. MR Arthrography 94
David R. Marcantonio, Robert D. Boutin and Donald Resnick
Introduction 94
General Information 94
Specific Joint Pathology 96
Summary 103
8. Myelography 105
Jacqueline C. Hodge
Introduction 105
Pre-Myelogram Preparation 105
Lumbar Puncture 106
Cervical Puncture 108
Contrast Agents 110
Post-Puncture Protocol 111
Post-Procedure Protocol 115
Complications 118
Pathology 118
9. Discography 124
Jacqueline C. Hodge
Introduction 124
Lumbar Discography 125
Thoracic Discography 134
Cervical Discography 134
Post-Procedure Care 137
Interpretation 137
10. Percutaneous Blocks 140

Jacqueline Hodge
Facet Blocks 140
Synovial Cysts 145
Sacroiliac Joint Block 146
Interspinous Ligament Blocks 148
C1-2 Block 148
Miscellaneous Blocks 149
11. Epidural Blocks 152
Jim Sloan
Introduction 152
Epidural Injections 152
Nerve Blocks 155
12. Tenography 163
Jacqueline C. Hodge
Introduction 163
Patient Management 168
Pathology 169
13. Bone Biopsies 175
Jacqueline C. Hodge
Introduction 175
Biopsy Instruments 179
Pre-Biopsy Considerations 183
Post-Biopsy Care 183
Specimen Handling 185
Complications 185
Additional Considerations 185
MR-Guided Intervention 186
14. Percutaneous Treatment of Osteoid Osteoma 189
Jacqueline C. Hodge
Introduction 189

Percutaneous Drill Resection 189
Percutaneous Radio-Frequency Ablation 190
Post-Procedure Care 190
15. Vertebroplasty 193
Jacqueline C. Hodge
Introduction 193
Methyl Methacrylate 194
Pre-Procedure Protocol 194
Post-Procedure Protocol 201
Assessing Your Intervention 201
Common Side Effects 202
Complications 202
Future Developments in Vertebroplasty 203
16. Ultrasound 204
Patrice-Etienne Cardinal and Rethy Chhem
Introduction 204
Pre-procedure Preparation 204
Pathological Conditions 205
Appendix 211
Contrast Reactions 211
Prophylaxis for Contrast Reactions 213
Selecting a Contrast Medium 213
Index 217
Contributors
Jacqueline C. Hodge, M.D.
Lenox Hill Hospital
Department of Diagnostic Radiology
New York, New York

Chapters 1, 4-6, 8-10, 12-15

Mary-Josée Berthiaume
Département de Radiologie
Hôpital Notre Dame
Université de Montréal
Montréal, Québec, Canada
email:
Chapter 6
Robert D. Boutin
University of California, San Francisco
San Mateo, California, U.S.A.
email:
Chapter 7
Patrice-Etienne Cardinal
Département de Radiologie
Hôpital Saint-Luc
Université de Montréal
Montréal, Québec, Canada
email:
Chapter 16
Alain Chevrot
Groupe Hospitalier Cochin
Service de Radiologie B
Paris, France
email:
Chapter 4
Rethy Chhem
Diagnostic Radiology Department
National University Hospital
National University of Singapore
Singapore

email:
Chapter 16
Maryse Guerin
Montreal General Hospital
Montreal, Quebec, Canada
Foreword
David R. Marcantonio
Division of Musculoskeletal Radiology
University of Texas Southwestern Medical
Center
Dallas, Texas, U.S.A.
email:
Chapter 7
G. Clara Ooi
Department of Diagnostic Radiology
Queen Mary Hospital
The University of Hong Kong
Hong Kong
email:
Chapter 2
Wilfred C G Peh
Department of Radiology
Singapore General Hospital
Queen Mary Hospital
Singapore
email:
Chapters 1, 2
Isabelle Pigeau
Département de Radiologie
Clinique Des Lilas–CEPIM

Les Lilas, France
Chapter 3
Editor
Donald Resnick
Department of Diagnostic Radiology
University of California, San Diego
Department of Veterans Affairs
Medical Center
San Diego, California, U.S.A.
email:
Chapter 7
Stephane Romano
Institut Français de Chirurgie de la Main
Clinique du Trocadero
Paris, France
Chapter 3
Philippe Saffar
Institut Français de Chirurgie de la Main
Clinique du Trocadero
Paris, France
Chapter 3
Laurent Sarazin
Groupe Hospitalier Cochin
Service re Radiologie B
Paris, France
email:
Chapter 4
Jim Sloan
McGill University
Department of Anaesthesia

The Royal Victoria Hospital
Montreal, Quebec, Canada
Chapter 11
C. Sokolow
Institut Français de Chirurgie de la Main
Clinique du Trocadero
Paris, France
Chapter 3
Philippe Valenti
Clinique Jouvenet
c/o Clinique du Trocadero
Paris, France
Chapter 3
Foreword
In times of overburdened daily practice, we are all looking for concise,
practical books; books that are easy to consult and in which we rapidly find
clear answers to specific problems or suddenly arising queries. Musculoskeletal
Procedures: Diagnostic and Therapeutic belongs to this category of books.
With the valuable collaboration of a select group of young dedicated
musculoskeletal radiologists, the editor has revisited all of the chapters of her
previous book, Musculoskeletal Imaging: Diagnostic and Therapeutic Procedures,
with the fixed purpose of assisting residents in radiology, orthopaedics, and
neurosurgery in their diagnostic and therapeutic procedures. In addition,
this book offers the general radiologist a gamut of practical step-by-step
techniques now currently in demand. This is a true vademecum book.
Maryse Guerin, M.D.
Assistant Professor of Neuroradiology
Montreal General Hospital
Montreal, Quebec, Canada
CHAPTER 1

CHAPTER 1
Musculoskeletal Procedures: Diagnostic and Therapeutic, edited by
Jacqueline C. Hodge. ©2003 Landes Bioscience.
Shoulder Arthrography
Wilfred C.G. Peh and Jacqueline C. Hodge
Introduction
Arthrography is a long-established technique for evaluating internal structures
of the shoulder joint not otherwise visualized by conventional radiographic and
computed tomography (CT) techniques. Shoulder abnormalities such as rotator
cuff tear, damage from previous dislocation, articular disease, capsular abnormality
and long head of biceps tendon lesions can be demonstrated arthrographically.
Although arthrographic findings are considered reliable, the introduction of newer
diagnostic methods, such as magnetic resonance (MR) imaging,
1-5
arthroscopy
6-8
and ultrasound,
9-13
have led to modifications of previous indications for arthrography.
As with arthrography of other joints, successful shoulder arthrography depends on
precise needle placement under fluoroscopy, high quality radiography supplemented
by advanced imaging techniques, and accurate interpretation of arthrographic
findings.
Patient Preparation
No special preparation is required for shoulder arthrography. Like other needling
procedures, informed consent and careful questioning for possible allergic history
should be obtained. For adults, shoulder arthrography is usually performed as an
outpatient procedure, while for children, sedation or even general anesthetic may be
required. As the patient may experience discomfort following the procedure, it may
be advisable to ask the patient to be accompanied on departure from the radiology

department, particularly if bilateral shoulder arthrography is performed.
Indications
•Rotator cuff tear
•Recurrent or previous dislocation
•Synovitis
•Adhesive capsulitis
• Loose bodies
• Long head of biceps tendon abnormality
•Evaluation of painful shoulder
Contraindications
• Local sepsis
•General contraindications to MR imaging
2
Musculoskeletal Procedures: Diagnostic and Therapeutic
1
Equipment
• Radiographic unit, ideally with a small focal spot
•Fluoroscopic unit, ideally with an overcouch X-ray tube
•Sterile trolley
• 22-gauge short-bevelled 9 cm lumbar puncture needle
•Syringes (1-10 ml) and needles (18- to 23-gauge) of various sizes
•Short plastic connecting tube
•Sterile drapes
•Skin cleansing solutions
• Local anesthetic (1% lidocaine hydrochloride)
• 1:1000 adrenalin
•Nonionic contrast medium
•Gadopentetate dimeglumine (for MR arthrography)
•Normal saline (for MR arthrography)
Preliminary Radiographs

• Antero-posterior (AP) supine in internal rotation (bone exposure)
• AP supine in external rotation (bone exposure)
• AP erect with 20º caudal tilt (subacromial view) (soft tissue exposure)
Technique
The patient lies supine, with the arm and hand of the shoulder of interest placed
next to the body. The patient’s palm should be in contact with the upper thigh. The
skin over the shoulder region is cleansed and draped using strictly aseptic technique.
The shoulder of interest is briefly screened fluoroscopically and positioned such that
the field-of-view is centered over the intended puncture site, which is the gleno-
humeral joint at the junction of the superior 2/3 and inferior 1/3 of the glenoid
labrum (Fig. 1.1A). Maximum collimation is applied to minimize radiation and
the area of interest is magnified. Fluoroscopic positioning up to this point can be
performed by an assistant or alternatively by the radiologist prior to the start of the
procedure. Subsequent fluoroscopic screening should ideally be controlled by
the radiologist, using a footswitch. The articular surface of the glenoid should face
slightly forwards. If not, that is if the glenohumeral articulation is in profile, the
needle may damage the anterior cartilaginous labrum during its insertion. Slight
adjustments to shoulder position may be made by placing of pads under the shoulder
to ensure appropriate orientation of the glenoid (Figs. 1.1A and B).
Under screening, the needle tip of the syringe containing the local anesthetic is
placed over the intended puncture site. The syringe is held at a shallow angle in
relation to the skin surface such that the radiologist’s hand is outside the radiation
field. When the ideal position is located, the skin and subcutaneous tissue overlying
the intended puncture site is anesthetized. At the end of the local anesthetic injection,
my practice is to unscrew the syringe from the 23-gauge needle, leaving the needle
embedded in the subcutaneous tissue/muscle. A quick fluoroscopic screening is then
performed to check the position of the needle. Ideally, it should be seen end-on, that
is vertically orientated, directly over the intended joint space target site (Fig. 1.1A).
3
Shoulder Arthrography

1
Keeping a mental picture of the orientation of the 23-gauge needle, this needle is
quickly withdrawn and replaced, using the same puncture point, with a 22-gauge
lumbar puncture needle. If the skin puncture site does not overlie the glenohumeral
joint space, I would recommend choosing a more ideal skin puncture site, even if it
means re-infiltrating local anesthetic. The needle should be advanced vertically, under
intermittent screening to ensure that it does not deviate from its proper path, until
mild resistance is felt. If it is in the glenohumeral joint, the tip of the needle may be
seen to curve slightly, conforming to the joint articulation. The patient may experience
slight discomfort at this point.
The needle should be withdrawn, using a gentle rotating action, by about 1 mm
to free its tip. My practice is then to inject a few drops of local anesthetic, using very
gentle pressure, through the lumbar puncture needle. If there is no resistance to the
flow of local anesthetic, it is very likely that the needle is within the joint space (Fig.
1.1B). If there is much resistance, the needle tip may still be embedded in the articu-
lar cartilage and I would then withdraw the needle a further 1 mm and repeat the
injection of local anesthetic. If resistance persists, then it may be worthwhile
rescreening the joint before further injection of the contrast medium. Another
advantage of injecting a small (0.5-1 ml) amount of local anesthetic is that it provides
the patient with some relief from any discomfort associated with the procedure or
pre-existing shoulder pain.
The syringe containing the contrast medium is attached to the lumbar puncture
needle using a short connecting tube. The contrast medium is then injected slowly
under continuous screening to verify that the needle tip is within the joint. The
contrast medium should flow away from the needle tip, outlining the humeral head
articular surface or typically collecting at the subscapularis recess or the axillary pouch
Fig. 1.1. A) Shoulder arthrography puncture technique. The position of the needle
entry point (cross) is marked over the glenohumeral joint on the frontal view. B)
Needle pathway is illustrated on the cross-sectional image.
4

Musculoskeletal Procedures: Diagnostic and Therapeutic
1
(Fig. 1.2). If the contrast medium collects in a patch around the needle tip, its
position is extra-articular. If this patch becomes increasingly dense or if parallel streaks
indicating intramuscular injection are seen, the contrast injection should be
terminated immediately. It is important to fluoroscopically view the contrast flow
continuously during injection, especially if a rotator cuff tear is suspected clinically
(Fig. 1.3).
In my institution, a nonionic contrast medium (Omnipaque 300) is routinely
used. The amount of the contrast medium to be injected depends on whether a
single or double-contrast arthrogram is required and whether the examination is to
be followed by a CT or MR scan. Almost all the shoulder arthrograms currently
performed in my institution are MR arthrograms, with the exception of the occasional
CT arthrogram. 1:1000 adrenalin is usually pre-mixed with the contrast medium
prior to injection with the advantages of: (1) decreased resorption of contrast; (2)
decreased development of intra-articular effusion; (3) maintenance of longer coating
and local contact of contrast with articular cartilage.
14
In many institutions the
fluoroscopic screening room is remote from the CT and MR suites, hence there is
usually a delay between contrast injection and start of scanning. With adrenalin
mixed with contrast, a good quality CT or MR arthrogram should still be achievable
even after a 45-60 minute delay. I use a 1 ml tuberculin syringe for drawing precise
amounts of adrenalin, a rule-of-thumb is to add 0.1 ml of 1:1000 adrenalin for each
ml of the nonionic contrast medium to be injected.
14
Contrast Agents
Single Contrast Shoulder Arthrography
12-15 ml of nonionic contrast medium is injected. In adhesive capsulitis, pain
development during injection may limit the total volume of contrast medium being

introduced. Addition of a small amount of local anesthetic may allow more
comfortable postprocedural manipulation. The single contrast technique is seldom
used nowadays except for distention arthrography in patients with the frozen shoulder.
In such cases, a painful shoulder may sometime be effectively treated using this
technique.
14-16
Double Contrast Shoulder Arthrography
Two 4 ml volumes of nonionic contrast medium is injected, followed by 8-12 ml
of air. The amount of air, which provides the negative contrast, to be introduced into
the joint depends on the size of the patient. In modern practice, the double contrast
study is usually part of the CT arthrographic examination.
16-18
MR Shoulder Arthrography
Up to 2 ml of nonionic contrast medium, containing up to 0.3 ml of 1:1000
adrenalin, is injected for the purpose of delineating the shoulder joint. This is
followed by a 9 ml mixture of a 2 mmol/L solution of gadopentetate dimeglumine
(Magnevist) diluted in normal saline. This solution is prepared prior to the whole
procedure and although 9 ml is routinely injected in my institution, the total amount
(up to 25 ml) to be injected depends on the joint capacity and body size of the
patient. At present, the use of intra-articular gadolinium is yet to be approved by the
5
Shoulder Arthrography
1
Food and Drug Administration (FDA) or the Health Protection Branch (HPB) and
institutional review board permission is required. An alternative contrast agent is
normal saline, but it suffers from the disadvantage of being indistinguishable from
bursal fluid on MR imaging. Intravenous MR arthrography, though avoiding shoul-
der joint puncture, produces inferior quality images compared with intra-articular
arthrography and fails to distend the joint capsule adequately.
Post-Puncture Protocol

Following needle removal for each of the above-mentioned types of shoulder
arthrography, the joint is gently manipulated to distribute the contrast medium evenly
within the capsule. If a rotator cuff tear is strongly suspected clinically, more vigorous
shoulder exercise may be employed to demonstrate the site of tear, especially if a
small one is present.
Single Contrast Shoulder Arthrography
Radiographs
• AP supine in internal rotation (bone exposure)
• AP supine in external rotation (bone exposure)
• AP erect (subacromial view) (soft tissue exposure)
Fig. 1.2. Double contrast
shoulder arthrogram. Extra-
vasation of contrast and air
(white arrowheads) from the
subscapularis recess (S),
occurring during injection. The
joint capacity is small, consistent
with adhesive capsulitis.
Smooth humeral head articular
cartilage is outlined by the
contrast medium (black arrow-
heads). (B = biceps tendon
sheath, A = axillary pouch).
Fig. 1.3. Double contrast
shoulder arthrogram showing
rotator cuff tear. Leakage of
contrast through a gap in the
rotator cuff (white arrows) is
demonstrated during contrast
injection. (S = subscapularis

recess).
6
Musculoskeletal Procedures: Diagnostic and Therapeutic
1
Double Contrast Shoulder Arthrography
Radiographs
• AP supine in external rotation (bone exposure)
• AP supine in internal rotation (bone exposure)
• AP erect in neutral (soft tissue exposure)
• AP erect (subacromial views) (soft tissue exposure)
CT Shoulder Arthrography
• Radiographs as for double contrast shoulder arthrography
• CT technique
a) Patient is supine with arms in the neutral position (palms placed against
the side of the upper thighs).
b) 18 cm field-of-view (FOV), centered upon the glenohumeral joint.
c) 3 mm-thick contiguous axial scans from upper acromio-clavicular joint
to the inferior axillary pouch of the joint.
d) Prospectively-obtained scans using bone algorithm (Window level 300-
400 HU, window width 1500-2000 HU), with retrospectively
reconstructed scans using soft tissue algorithm (Window level
80-100 HU, window width 450-500 HU).
e) In spiral scanners, 1.0 mm or 1.5 mm overlapping bone images are
retrospectively reconstructed, followed by sagittal, coronal and oblique
reformatted images.
MR Shoulder Arthrography
• Radiographs as for single contrast shoulder arthrography
• MR technique
a) Ensure that there are no contraindications to MR examination.
b) Patient is supine, with palms placed against the sides of the upper

thighs.
c) The shoulder coil is positioned and secured around the shoulder of
interest.
d) Axial localizer (24 cm FOV; 5 mm thickness, 1 mm gap; 256 x 128
matrix; 0.75 number of excitations (NEX)
e) Oblique coronal images (parallel to the plane of the supraspinatus
muscle)
- spin-echo (SE) T1 (14 cm FOV; 3 mm, 0 mm gap; 256 x 192; 2
NEX)
- SE T1 fat saturation (sat) (14 cm FOV; 3 mm, 0 mm gap; 256 x
160; 1.5 NEX)
-Fast SE T2 fat sat (14 cm FOV; 3 mm, 0 mm gap; 256 x 224; 2
NEX)
f) Oblique sagittal images (perpendicular to the supraspinatus muscle
plane)
- SE T1 (14 cm FOV; 4 mm, 0.5 mm gap; 256 x 192; 2 NEX)
7
Shoulder Arthrography
1
- SE T1 fat sat (14 cm FOV; 4 mm, 0.5 mm gap; 256 x 160; 2 NEX)
g) Axial (from the acromio-clavicular joint to the inferior axillary pouch)
- SE T1 (14 cm FOV; 3 mm, 0.5 mm gap; 256 x 160; 2 NEX)
Complications
After the procedure, the patient should be warned to expect some joint discomfort
lasting up to one day. Complications are otherwise generally rare and are related to
either needle placement or contrast reaction. Faulty needle placement may result in
injection of contrast into the surrounding soft tissues, into the subacromial bursa or the
biceps tendon sheath. These inadvertent injections are preventable by meticulous
positioning of the needle tip.
19

A rare complication is painful swelling of the joint developing within hours
following the arthrogram due to irritation of the synovium by contrast medium. This
chemical synovitis usually subsides after 1-2 days and may be treated by the aspiration
of joint effusion. Infection is an extremely rare and a largely preventable complica-
tion.
20
Vasovagal syncope occurs infrequently. A minor allergic reaction in the form
of urticaria affects 1 per 1000 patients, while serious allergic reaction or death from
shoulder arthrography has yet to be reported.
19
Morbidity from this procedure can
be reduced by using nonionic contrast media and/or double contrast instead of single
contrast examinations.
21,22
Normal Arthrogram
Conventional Shoulder Arthrography
The glenohumeral space is initially visible as a curvilinear opacity between the
humeral head and the glenoid surface. The axillary pouch, adjacent to the humeral
neck, is best seen with the shoulder externally rotated while the subscapular recess,
overlying the glenoid and lateral subscapular region, is best appreciated on the internal
rotation view. The long head of biceps tendon is a tubular-shaped filling defect within
the contrast-filled biceps tendon sheath which extends into the bicipital groove in the
upper humeral metaphysis (Figs. 1.2 and 1.3). Sometimes, the biceps tendon can be
seen running across the superior aspect of the humeral head. Before CT arthrography
became commonly performed, axillary views were important in delineating the
glenoid labra and the articular surfaces of the glenohumeral joint.
15-17,19
CT Shoulder Arthrography
The pouches and recesses of the shoulder joint seen on conventional
arthrography are precisely delineated on CT. The relationship of the joint capsule to

the surrounding muscles and the capsular insertion sites are well demonstrated. Using
spiral CT, coronal and sagittal reformatted images are able to show the muscles of the
rotator cuff in relation to the adjacent contrast- and air-filled joint capsule and bony
structures.
The contour and outline of the cartilaginous glenoid labra are clearly demonstrated
on CT arthrography. The anterior labrum is usually triangular in shape compared to
the more rounded posterior labrum, although normal variations in appearances of
these structures exist (Fig. 1.4). Other intra-articular structures which may be depicted
are the three glenohumeral ligaments and the long head of biceps tendon. In my
8
Musculoskeletal Procedures: Diagnostic and Therapeutic
1
experience, the superior glenohumeral ligament, which arises from the superior
labrum and runs anteriorly and parallel to the coracoid process, is most constantly
seen as it is the thickest of the three ligaments. The origin of the middle gleno-
humeral ligament is from the superior labrum and it courses adjacent to the superior
subcapularis tendon, often merging with and strengthening the anterior capsule.
The inferior glenohumeral ligament consists of two bands—superoanterior and
inferoposterior—which attach the inferior half of the labrum to the humerus. The
middle and inferior glenohumeral ligaments are better seen on MR than on CT
arthrography.
18
The long head of the biceps tendon originates from the supraglenoid tubercle
and superior glenoid labrum, takes an intra-articular course over the humeral head,
and runs through the bicipital groove, before merging with the short head of the
biceps in the distal third of the arm and inserting into the proximal forearm bones.
On CT arthrography, this tendon is best appreciated in cross-section as a rounded
filling defect within its air and contrast-filled sheath in the bicipital groove of the
upper humerus (Fig. 1.4). Its origin from the superior glenoid can often be seen on
axial or coronal reformatted images. Its path over the humeral head is however

visualized with difficulty, due to partial volume averaging.
Besides intra-articular structures, the surrounding bones such as the
humeral head, bony glenoid, acromium, and the acromio-clavicular joint are nicely
demonstrated on CT. The shape of the acromial arch can be determined using
oblique sagittal reformatted images.
23
Fig. 1.4. Normal CT shoulder arthrogram at mid-glenoid level. The triangular-shaped
anterior glenoid labrum (straight arrow) and more rounded posterior labrum (curved
arrow) are seen. The long head of the biceps tendon (arrowheads) is present within
its tendon sheath in the bicipital groove. The anterior and posterior joint capsular
attachments are delineated by air and contrast.
9
Shoulder Arthrography
1
MR Shoulder Arthrography
MR arthrography combines the advantages of visualizing intra-articular structures,
made possible by capsule distention, with the inherent multiplanar capability of MR
and superior delineation of soft tissue structures. The rotator cuff and other muscles
and tendons are exquisitely demonstrated on T1-weighted images (WI). The bone
marrow, intra- and inter-muscular fat and subcutaneous fat are also well seen with
this sequence. T2-WI are useful for detection of soft tissue edema or other lesions,
bone edema, contusion or other lesions, and fluid in the subacromial bursa and
acromio-clavicular joint. Fat-suppression sequences improve visualization of fluid
on T2-WI and of the rotator cuff by nulling the adjacent bright subacromial-
subdeltoid peribursal fat on T1-WI.
24-32
Besides demonstrating intra-articular structures such as the glenoid labra, long
head of biceps tendon and loose bodies, the middle and inferior glenohumeral
ligaments are visualized, particularly on the oblique sagittal images. Extra-articular
structures forming the coracoacromial arch such as the coracoacromial ligament can

also be seen (Figs. 1.5 and 1.6).
24-32
The shape of the acromial arch, important in the
impingement syndrome and suspected rotator cuff lesions, is best appreciated on
oblique sagittal images.
33
Abnormal Arthrogram
Rotator Cuff Tears
Plain radiographic clues to impingement and rotator cuff disease include
narrowing of the acromio-humeral space, sclerosis of the greater tuberosity, inferior
acromio-clavicular joint osteophytes and subacromial soft tissue calcification (Fig. 1.7).
Fig. 1.5. Normal MR shoulder arthrogram—oblique coronal sections. A) Spin-echo
(SE) T1-weighted image (WI) shows the supraspinatus muscle (large arrowheads)
and tendon (small arrowheads), and normal marrow signal within the humeral head,
glenoid and distal end of the clavicle (*). The supraspinatus fossa is marked with a
star. B) Fat-saturated SE T1-WI shows the contrast-filled joint capsule, inferior gleno-
humeral ligament (white arrows), and the superior (black arrowheads) and inferior
(black arrows) glenoid labra more clearly. Normal sublabral sulcus is arrowed (small
white arrows).
10
Musculoskeletal Procedures: Diagnostic and Therapeutic
1
These radiographic signs are however unreliable, particularly for acute tears of the
rotator cuff, and double contrast shoulder arthrography has long been recognized as
the standard technique for diagnosis of full-thickness rotator cuff tears.
19
This type
of tear is demonstrated arthrographically as abnormal communication between the
glenohumeral joint space and the subacromial-subdeltoid bursa (Fig. 1.8). Partial
tears, especially superior surface tears, are difficult to diagnose arthrographically.

Undersurface tears are seen as small focal or linear areas of opacification, usually at
the musculotendinous junction, or critical zone, of the affected tendon.
19
Reformat-
ted coronal and sagittal CT images provide an improved display of the cuff tears
(Fig. 1.9).
18
Fig. 1.6. Normal MR shoulder arthro-
gram—Oblique sagittal T1-WI, at A) mid-
and B) medial humeral head levels, show
the muscles and tendons comprising the
rotator cuff, namely: subscapularis (small
white arrows), supraspinatus (black arrows),
infraspinatus (open arrows) and teres minor
(white arrowhead). The inferior gleno-
humeral (long black arrows) and cora
coacromial (black arrowheads) ligaments,
as well as the intra-capsular course of the
long head of biceps tendon (short black
thick arrows), are also seen. (A =
acromium, * = coracoid process). C) Axial
T1-WI at the level of the coracoid process
shows normal anterior (black
arrowheads) and posterior (black arrows)
glenoid labra, part of the middle gleno-
humeral ligament (white arrow), long head
of biceps tendon (white arrowhead) and
the deltoid muscles (short black thick
arrows). (* = coracoid process).
11

Shoulder Arthrography
1
The location and size of a full-thickness rotator cuff tear, the degree of retraction
and state of the remnant muscle can be demonstrated by conventional MR imaging,
particularly in the presence of pre-existing joint effusion. In partial tears however, as
tendon morphology is usually normal, the diagnosis relies heavily on changes in
tendon signal intensity. Normal variations in signal intensity of supraspinatus tendons
exist and hence may simulate lesions.
34,35
MR arthrography has been shown to be
superior to conventional MR imaging in depiction of partial tears, in distinguishing
between partial and small full-thickness tears, particularly if fat-suppression is
employed (Fig. 1.10).
36,37
Recently, the usefulness of MR arthrography in detection of
postero-superior glenoid impingement in throwing athletes,
38
and the effectiveness of
positioning the arm in abduction and external rotation (ABER position) during
MR arthrography,
39
have been described.
Labral-Ligamentous Complex Abnormalities
Although the bony Bankart and Hill-Sachs deformities may be visible radio-
graphically, and labral and capsular abnormalities may be seen following double
contrast shoulder arthrography,
17,19
CT arthrography has been the standard method
of evaluating the labral-ligamentous complex since the early 1980s. Besides showing
bony lesions, CT arthrography depicts tears of the cartilaginous labra and stripping

Fig. 1.7. Radiograph showing
calcification of the subacro-
mial soft tissue.
Fig. 1.8. Full- thickness rota-
tor cuff tear. Double contrast
arthrogram shows air and
contrast outlining the sub-
acromial-subdeltoid bursa
(arrowheads).
12
Musculoskeletal Procedures: Diagnostic and Therapeutic
1
of the joint capsule attachments, structures which have been accepted, in the past,
to contribute to shoulder instability (Figs. 1.11, 1.12, 1.13).
18,40-42
MR arthrography has been shown to be more sensitive than conventional MR
imaging and CT arthrography in detecting labral tears, and distinguishing between
labral detachment and degeneration (Figs. 1.14).
43
MR arthrography is particularly
useful in detecting abnormalities of the labral-ligamentous complex, particularly if
there is no joint effusion. The superior, middle and inferior glenohumeral ligaments
are nicely shown during MR arthrography. Together with the long head of the biceps
tendon, these three ligaments attach to the glenoid labrum. Hence labral tears may
result in ligamentous instability, especially of the inferior glenohumeral ligament.
29-
31
Palmer and Caslowitz, in their recent analysis of 121 MR arthrograms, concluded
that inferior labral-ligamentous instability was closely associated with anterior
glenohumeral instability and that capsular insertion sites had no role in the evaluation

of shoulder instability.
44
Adhesive Capsulitis
45
Adhesive capsulitis may be both diagnosed and treated during single contrast
arthrography. Relatively high resistance to the injection of contrast, overall decreased
Fig. 1.9. CT arthrography showing
a full-thickness supraspinatus
tear. A) Axial section at level of
the coracoid process shows air
and contrast within the subdeltoid
bursa (arrowheads). B) Oblique
coronal reformatted image
depicts air and contrast in the
supraspinatus tear gap (arrow-
heads), and contrast media in the
subacromial bursa (white arrows;
* = acromial arch). C) Oblique
sagittal reformatted image also
demonstrates the full-thickness
supraspinatus tear (black arrow-
heads) and contrast media in the
subdeltoid bursa (white arrow-
heads; * = acromial arch).
13
Shoulder Arthrography
1
volume of contrast within the joint, and/or irregularity of the joint capsule all
suggest the presence of “frozen shoulder”. Patients are often referred with the diag-
nosis, in which case the radiologist requires only 1-2cc’s of contrast or air to confirm

that the needle is indeed intra-articular. Once this has been established Depomedrol
40 mg and 10 cc’s of 1% Bupivocaine are instilled into the joint capsule. The patient
is shown a series of stretching exercises that he/she must perform until his second
appointment.
46,47
In total the patient has three shoulder injections , as described above,
separated by a seven to ten day interval. This treatment regimen may be supple-
mented by physiotherapy.
Calcific Tendinitis
Calcific tendinitis is a relatively common condition in the soft tissues of the
shoulders and hips. Nonsteroidal anti-inflammatory agents constitute the first line
of treatment. In those patients who are unresponsive, extra-corporeal shock wave
therapy may be the next step.
48,49
Alternatively, blind injections of corticosteroids is
often attempted. A small group of patients will still have persistent symptoms,
either because the injection was not administered directly into the calcifications or
because of resistance to percutaneous and medical therapy.
50
In these cases, fluoro-
scopic, CT, or ultrasound-guided percutaneous corticosteroid administration, and/
or aspiration of soft tissue calcifications, is recommended.
51,52
Fig. 1.10. MR arthrography
showing a full-thickness su-
praspinatus tear. Fat-satu-
rated oblique coronal SE
T1-WI shows a large full-
thickness tear (arrows) pro-
viding communication be-

tween the glenohumeral
joint and the subacromial-
subdeltoid bursa (arrow-
heads). Note mild retrac-
tion of the supraspinatus
muscle.
Fig. 1.11. Anterior Bankart
lesion after anterior shoul-
der dislocation. CT arthro-
gram shows a mildly dis-
placed osteocartilaginous
glenoid fracture (arrow).
14
Musculoskeletal Procedures: Diagnostic and Therapeutic
1
For fluoroscopic or ultrasound guidance, you should localize the calcifications in
two planes that are essentially perpendicular to one another. Then proceed with
needle placement, using aseptic technique.
With CT, the calcifications are easily identified. Depending on the site of soft
tissue calcifications, and the adjacent neurovascular structures, the patient is placed
in the prone, supine, or decubitus position. Using aseptic technique, a 22g 3-1/2”
spinal needle is placed into the calcifications and corticosteroids are administered
(Fig. 1.15). If you are planning to aspirate the calcifications, an 18 or 20g 3-1/2”
spinal needle should be utilized for the procedure.
Fig. 1.12. Severe changes following recurrent anterior shoulder dislocation. CT
arthrogram at (a) mid- and (b) distal humeral head levels show a truncated anterior
bony glenoid (thick arrow), with the resulting detached osteocartilaginous fracture
fragment (arrows) located in the anterior axillary pouch. Note flattening of the
posterior humeral head (arrowheads) consistent with a Hill-Sachs deformity, as
well as a capacious anterior capsule.

Fig. 1.13. Moderate changes following recurrent anterior shoulder dislocation. CT
arthrogram at (a) coracoid process and (b) mid-glenoid levels show a Hill-Sachs
defect (black arrow), attenuation of the anterior cartilaginous labrum (white ar-
row), and medial stripping of the anterior joint capsular attachment (arrowhead).