Glenohumeral, Joint/Bursa/Tendon, Procedures, Upper Extremity - procedures

Glenohumeral Joint Injection With Fluoroscopy

Final image. After injection of the steroid and local anesthetic mixture. Note the intraarticular spread.

By Chris Faubel, M.D. —

Indications

  • Glenohumeral Joint (Shoulder) Osteoarthritis and Pain

    • ICD-9 code: 715.11 “Osteoarthrosis, localized, primary, shoulder region”
    • ICD-10 code: M19.01 (M19.011, M19.012) “Primary osteoarthritis, shoulder” (right & left, respectively)
  • Adhesive capsulitis (frozen shoulder)
    • ICD-9 code:  726.0 “Adhesive capsulitis of shoulder”
    • ICD-10 codes:  M75.0 (M75.01, M75.02) “Adhesive capsulitis” (right & left, respectively)
  • Shoulder Labral/Labrum Tear
    • ICD-9 code: 840.7 “Superior glenoid labrum tear”
    • ICD-10 code: S43.43 (S43.431, S43.432) “Superior glenoid labrum lesion” (right & left, respectively)

CPT codes:

  • 20610 “Arthrocentesis, aspiration and/or injection; major joint or bursa”
  • 77002 – Fluoroscopic guidance of a needle (non-spinal)
  • Remember to bill for the J-codes for the contrast and steroid as well.

Patient Position

  • Supine

Materials Needed

  • Gloves – sterile
  • ChloraPrep (3-ml)
  • Band-aid – small, round
  • Needles
    • 25-gauge 2″ needle
  • Syringes
    • 5-ml plastic syringe (for the steroid/local mixture)
    • 3-ml plastic syringe (for the Omnipaque contrast) – use with 6-inch micro-bore plastic tubing
  • Injectate mixture

    • 1-ml of 40mg/ml Depo-Medrol or Kenalog, or 7.2-mg of Celestone (6mg/ml)
    • 3-ml of 1% lidocaine or 0.5% bupivacaine
    • 1-ml of sterile normal saline
  • For skin numbing:  Will not need it if using the 25-gauge needle, but can use a tuberculin syringe with 2% lidocaine or ethyl chloride spray.

Tips

  • Curve the needle tip slightly away from the opening of the needle.  I feel this makes it easier to slip it under the shoulder joint capsule.
  • If the contrast blobs up at the needle tip, adjust the needle.
  • Do NOT try to enter the actual articulating surface of the humeral head and glenoid fossa.  Not only will you possibly damage the cartilage, but it may be difficult to enter as the overhanging osteophytes from the arthritic joint are not calcified enough to show up on the x-ray.
  • Add enough volume (5 or more milliliters) so the injectate will reach the articular surfaces.
  • Test the shoulder afterward:  Have the patient do Codman shoulder circles (bent-over shoulder movements without gravity) to spread the steroid/local mixture.  Then have them test the shoulder against gravity to give a nice “awww” effect from the happy patient.
  • Note:  This exact same glenohumeral joint injection technique is used for performing both therapeutic steroid injections AND diagnostic arthrograms of the shoulder.
  • Arthrograms:  When injecting the contrast, look for spread under the acromion which would mean a full thickness tear in the rotator cuff.

VIDEOCheck out these videos showing the contrast being injected.

LEFT intraarticular shoulder injection with fluoroscopy. Note the ideal target zone.

Before entering the skin, the 18-gauge needle used to draw up the meds is set on the skin to mark the target site on the humeral head.

The needle is driven down to the target site on the humeral head with the assistance of intermittent fluoroscopy.

Attach the extension tubing to the luer-lock needle after reaching the target site.

Contrast is injected to show true subcapsular spread. Note that the contrast does NOT pool up under the needle tip, which would mean the tip is still outside the joint capsule. If that happens, readjust or wiggle the tip under the capsule more.

Final image. After injection of the steroid and local anesthetic mixture. Note the intraarticular spread. Also note that no contrast is seen under the acromion process, which means there is not likely a full thickness rotator cuff tear.