1. Shoulder Arthrography (肩關節攝影)

2. Outline Anatomy Arthrogram Introduction Indications Contraindications
Procedure
Risks
Other tests
Case

3. Anatomy The shoulder is a ball-and-socket joint
Tendons are tough cords of tissue that attach the shoulder muscles to bone and assist the muscles in moving the shoulder. The rotator cuff is a structure composed of tendons that work along with associated muscles to hold the ball at the top of the arm (humerus) in the shoulder socket; it provides mobility and strength to the shoulder joint.
Muscles are bundles of specialized tissue that attach to, and move bones via their tendons.

4. Anatomy

5. Anatomy

6. arthrogram
An arthrogram may be more useful than a regular X-ray because it shows the surface of soft tissues lining the joint as well as the joint bones. A regular X-ray only shows the bones of the joint. This test can be done on your hip, knee, ankle, shoulder, elbow, wrist, or jaw (temporomandibular joint).
An arthrogram is a test using X-rays to obtain a series of pictures of a joint after a contrast material (such as a dye, water, air, or a combination of these) has been injected into the joint. The radiologist may discuss the initial results with you after he or she reviews all the pictures. A detailed report will be available to your doctor in a few days.

7. Introduction
Shoulder arthrography is a procedure for demonstration of tendon injury, joint surfaces, and capsular structures.
This allows your doctor to see the soft tissue structures of your joint, such as tendons, ligaments, muscles, cartilage, and your joint capsule.

8. An arthrogram is used to:
Find problems in your joint capsule, ligaments, cartilage (including tears, degeneration, or disease), and the bones in the joint. In your shoulder, it may be used to help find rotator cuff tears or a frozen shoulder.
Find abnormal growths or fluid-filled cysts.

9. Indications
1. Assessment of persistent shoulder pain and limitation of movement, and tendon injury.
2. To assess the glenoid labrum in patients of recurrent dislocations:
3. In the evaluation of frozen shoulder.
4. for diagnosis of glenoid labrum tear
5. for diagnosis of adhesive capsulitis

10. Contraindications 1. Local infection.
2. Contrast allergy/iodine allergy
3. allergy to local anaesthetic agent
4. non-consent

11. Preparation
Patient Identification (3 C's- correct patient, correct side, correct procedure)
NPO4hr.
pregnant?
Does the patient have a history of contrast/iodine allergy?
Is the patient intending to drive home after the procedure?

12. Procedure Scout view AP external rotation
1. The patient is cleaned and draped in supine position.
2. Injection site localized and local anesthetic infiltrated.
3. Puncture needle is then inserted into the joint space, contrast medium is then injected via a connecting tube.
@15 mm of mixture of contrast fluid and lidocaine (ratio 3:1)
4. This is followed with 8-10 ml air (double-contrast arthrogram). The shoulder is moved passively in all directions to distribute the contrast medium.
5. A special type of X-ray, called fluoroscopy, is used to take pictures of the joint.
@AP shoulder preliminary image. The patient/tube should be angled to profile the acromion. This will afford maximum visualisation of the subacromial space.

13. Procedure-Needle Insertion and Contrast Injection
@15 mm of mixture of contrast fluid and lidocaine (ratio 3:1)
The needle is commonly inserted using an anterior approach. The needle is directed towards the junction of the middle and inferior third of the glenohumeral joint. Single or double contrast studies may be undertaken. Care must be taken to ensure that air is not introduced into the joint if undertaking a single-contrast study. It is good practice with all needle insertion procedures to position the needle in the centre of the fluoroscopic image to eliminate parallax error. When the needle is visualised at the centre of the needle hub on the fluoroscopic image and the needle is in the middle of the image, the radiologist can be confident of the exact needle position.

14. Procedure In internal rotation In neutral position
This is an AP image of the shoulder joint post contrast injection with the patient's arm in internal rotation. The patient's arm is not fully internally rotated. Further caudal angulation of the beam would improve visualisation of the sub-acromial space. The contrast injected is localised and not outlining the shoulder joint adequately
fig2:AP shoulder with the patient's arm in a neutral position. There is is adequate double-contrast outlining of the shoulder joint. The subacromial space is well demonstrated. The caudal angulation required to achieve visualisation of the subacromial space is variable from patient to patient. If the fluoroscopic image reveals the subacromial space to be inadequately demonstrated, change in beam angulation can be made prior to acquiring a DSI image.

15. Procedure In external rotation fully abducted
Fig1:This is an AP image of the shoulder joint post contrast injection with the patient's arm in external rotation. Further caudal angulation of the beam would improve visualisation of the sub-acromial space. The contrast injected is localised and not outlining the shoulder joint adequately
Fig2:The patient's arm is fully abducted in this image. This position produces maximum impingement of the subacromial soft tissue structures. The subacromial space is well demonstrated. There is inadequate double-contrast demonstration of the shoulder joint.

16. Procedure outlet position
This is a shoulder outlet position (Neers) with good demonstration of the subacromial space. There is good double-contrast outlining of the shoulder joint.

17. Procedure
You may be asked to move your joint around to help the dye or air spread inside your joint. Pictures from the fluoroscope show if the dye has filled your entire joint. Hold as still as possible while the X-rays are being taken unless your doctor tells you to move your joint through its entire range of motion. The X-rays need to be taken quickly, before the dye spreads to other tissues around your joint.

18. Risks Joint pain for more than 1 or 2 days.
An allergic reaction to the dye.
Damage to the structures inside your joint or bleeding in the joint. But this is very rare because the needle that is used is small.
Infection in the joint.

19. After the arthrogram: rest your joint for about 12 hours.
Do not do any strenuous activity for 1 to 2 days.
Use ice for any swelling and use pain medicine for any pain.
You may also hear a grating, clicking, or cracking sound when you move your joint. This is normal and goes away in about 24 hours.

20. Other tests
such as magnetic resonance imaging (MRI) and computed tomography (CT), give different information about a joint. They may be used with an arthrogram or when an arthrogram does not give a clear picture of the joint.

21. Arthrogram -normal appearance
Normal:The joint capsule, the sac containing joint fluid, is normal. The cartilage and other structures of the joint are normal. 
Arthrogram obtained with the shoulder positioned in external rotation shows a normal appearance, with the expected pattern of opacities in the axillary pouch (large arrows), subcoracoid recess (small arrows), and biceps tendon sheath (arrowheads).

22. Rotator cuff tear(arrow)
Abnormal:The cartilage is worn down (degeneration) or there is a tear in the cartilage cushion of the joint.
There is a tear in the ligaments or tendons of the joint. The tear may be partial or complete. If a rotator cuff tear in the shoulder is present, the dye leaks from the tear.
The joint capsule is enlarged or has ruptured. A joint cyst is present.
Abnormal material is present in the joint. This could be a tumor, extra growth of joint tissues, or pieces of bone or cartilage.
*CM extention from the glenohumeral joint into the subacromial/subdentoid bursa(arrowheads) through a large full-thickness rotator cuff tear(arrow)

23. Intraarticular Masses
 (a) Arthrogram of the right shoulder in a patient with calcific bursitis reveals a calcified nodule in the subdeltoid bursa (white arrowhead). Note the normal extension of contrast material into the axillary recess (black arrowhead), into the subscapular bursa (black arrow), and along the tendon sheath of the long head of the biceps brachii muscle (white arrow). (b) Anteroposterior radiograph of the right shoulder in a different patient with synovial osteochondromatosis shows the characteristic calcified nodules. Understanding of the normal joint anatomy is essential to realize that the calcified nodules are intraarticular in the axillary recess (arrowhead), in the subscapular bursa (black arrow), and extending along the biceps tendon sheath (white arrow).

24. adhesive capsulitis
Shoulder arthrogram showing a contracted and adherent joint capsule in adhesive capsulitis

25. 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

26. Thank you!!!