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Shoulder Arthrography

- Discussion:
    - normally no communication exists between the shoulder joint and the subacromial bursae;
    - when radiopaque dye is injected into the shoulder and is subsequently demonstrated in the subacromial bursa, a rotator cuff tear is present;

- Indications:
    - for dx of complete rotator cuff tears, adhesive capsulitis, tear of the rotator interval, and disorders of the biceps tendon;
    - impingement syndrome unresponsive to non surgical rx for 12 wks in patients more than 40 years old;
    - rotator cuff tear:
           - dye which appears simultaneously in joint & bursa is diagnostic for a tear;
           - arthrography (for complete rotator cuff tears) has accuracy of > 90 - 95 %.
           - in the study by Gartsman et al, 19 out of 24 patients w/ RCT, had a positive arthrogram;
           - arthrography is of little value for detection of partial tears involving superior (bursal) surface of the rotator cuff or intra-tendinous tears;
    - adhesive capsulitis:
           - diminished joint capacity ( < 10 ml) & loss of axillary fold
    - rotator interval tears:
           - may mimic rotator cuff tears;
           - impingment signs may be present along w/ biceps tendon tenderness;
           - may allow extravasation of dye into subacromial space, as well as the subscapularis fossa (w/ dye seen anterior to the subscapularis);
                   - leakage into the subscapularis fossa may require shoulder movement;

- Technique:
    - posterior portal:
         - using the standard posterior portal position, insert 20 cc of saline into the joint thru a long spinal needle, and then remove the syringe, leaving the needle;
                - if fluid drips out of the needle, then the needle is definately in the joint;
    - anterior portal:
         - local anesthetic is infiltrated into the skin and subcutaneous tissue, down to and including the anterior shoulder capsule;
         - landmark is point just lateral to the tip of coracoid process;
         - 15 mm of mixture of contrast fluid and lidocaine (ratio 3:1)

The joint side tear of the rotator cuff. A followup study by arthrography.

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