Arthrogram injection techniques

Contrast for arthrogram:

10 cc omnipaque 300

10 cc normal saline

0.1 cc omnihance

For knee, double the quantities.

Joints:

Shoulder:

22 ga spinal needle.  Inject 10-14 cc

Place the patient supine with shoulder in external rotation, as tolerated by the patient.  Immobilize with a sandbag or lead glove.

1) (Subscapularis) Mark a position at the inferomedial margin (bottom half) of the humeral head, just lateral to the glenohumeral joint.  Prep and drape.  With the bevel pointing medially, advance the needle directly AP until it hits the humeral head.

2) (rotator interval): Mark a position over the superomedial  of the humeral head, about the level of the glenoid rim.  Prep and drape. With the bevel pointing medially, advance the needle directly AP until it hits the humeral head.

I prefer the rotator interval unless the patient is unable to externally rotate at least to neutral position.

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Elbow:

25 ga ¾” needle.  Inject 6-8 cc

Place the patient supine with the elbow supported by a rolled towel.  Palpate and mark the radiocapitellar joint laterally.  Prep and drape.  Advance the needle medially directly into the radiocapitellar joint.

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Wrist:

25 ga ¾” needle (I prefer a butterfly.)  Inject 4-5 cc.

Place the wrist prone on a clean towel.  Place a mark over the proximal scaphoid waist.  Prep and drape.  Advance the needle directly AP until it hits the scaphoid.

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Hip:

22 ga spinal needle.  Inject 10-14 cc.

Place the patient supine with the leg internally rotated, as tolerated, and stabilize the foot with a sandbag.  Palpate and mark the femoral artery.  Mark a spot at the greater trochanter.  Prep and drape.  Aim the needle from the marked spot posteriorly and parallel to the femoral neck toward the head-neck junction at the spot where a circle around the femoral head would intersect a line along the center of the neck. Advance the needle until it hits bone.

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Knee:

22 ga spinal needle.  Inject 25-30 cc.

Place the patient supine and place pillows under the knees to support the knees at about 90 degrees flexion.  The triangle foam cushion supplemented with a regular pillow works well.  Mark a spot at the anterolateral corner of the tibial plateau.  Prep and drape.  Confirm position by placing your thumb over the anterolateral tibia.  Place the needle above your thumb to avoid passing through the meniscus.  Angling parallel to the femur, advance the needle until it hits the femoral condyle.

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Ankle:

25 ga 1-1/2” needle.  Inject 5-7 cc.

Place the patient supine with the ankle relaxed, supported by a towel or flat pillow.  Palpate and mark the dorsalis pedis artery.  Palpate the tibialis anterior tendon, and mark a spot over the talar dome just medial to the tendon, about 1 cm below the tibiotalar joint line.  Prep and drape.  With the bevel caudad, advance the needle directly AP until it hits the talar dome

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