Fluoroscopic Guided Glenohumeral Joint Injection – Technique and Overview

Name of Procedure

  • Shoulder glenohumeral joint injection (with or without steroid)

Sample Opnote

Goal

To inject a medication into the glenohumeral joint

Indications

Depending on what’s injected, usually it is to treat pain from arthritis

Contraindications

Anatomy

For the purposes of a glenohumeral injection, anatomy is straightforward. From an anterior perspective the joint is just near the tip of the shoulder. Since this is fluoroscopically guided you’ll use the bone as your landmark under fluoro to get an exact location.

Source: https://en.wikipedia.org/wiki/Subacromial_bursitis#/media/File:Shoulder_joint.svg

Equipment/Skills

  1. C-Arm
  2. Bed for C-Arm
  3. 25g x 1.5″ hypodermic needle
  4. Contrast
  5. 1 or 2 3cc syringes (may not need as noted below)
  6. Desired injectate:
    1. bupivacaine/lidocaine
    2. supartz/synvisc/orthovisc
    3. steroid (dexamethasone/triamcinalone)
  7. prep solution
  8. drape to keep injection site clean

Landmarks and Patient Positioning

  1. Position the patient in a basic supine position so that the bottom of the c-arm can go under the table below the shoulder.
  2. Extend the arm on the ipsilateral side to open up the joints as much as possible.

Technique

  1. Position the C-arm in an AP orientation.
    1. Playing with the angle will allow you to see which angle is best.
  2. Use a pointer to find a spot directly over the superior border of the humerus.
  3. Insert a 25g x 3.5 inch needle in a mostly AP direction aiming for roughly the superior border of the humerus.
  4. Inject a small amount of contrast to confirm spread in the joint
  5. From here inject the desired medication based on the specific procedure that you’re doing.

Tips

  1. Usually a 25g x 1.5″ hypodermic needle is sufficient to enter any space in the shoulder. With this approach no second/larger needle is needed, and usually it can be done without local anesthetic since it’s the same needle that would be used to administer local anesthetic anyway.
    1. If it turns out that the hypodermic needle is not long enough, just inject lidocaine through the it while pulling out.
    1. Then use a longer needle such as a bent quincke needle to reach the joint space.