SpringerLink
Log in

Fluoroscopy-guided injections of the upper extremity: pearls and pitfalls

  • Review Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

Fluoroscopy guidance is commonly utilized for injections in the upper extremity, with increased accuracy for injection placement compared to blind injection. Injection of the glenohumeral joint is the most commonly performed upper extremity procedure. However, there are a number of other sites which can be easily injected under fluoroscopy including the acromioclavicular joint, subacromial subdeltoid bursa, biceps tendon sheath, scapulothoracic bursa, elbow, wrist, first CMC joint, and pisotriquetral joint. Fluoroscopy can be used to guide injections into the glenohumeral, elbow, or wrist joints preceding MR arthrography. While there are technique similarities when injecting any of these sites, some particular approaches and pitfalls are unique to each anatomic site.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15

Similar content being viewed by others

References

  1. Rastogi AK, Davis KW, Ross A, Rosas HG. Fundamentals of joint injection. Am J Roentgenol. 2016;207:484–94.

    Article  Google Scholar 

  2. Raythatha M, Spitz D, Tang JY. Fluoroscopically-guided joint and bursa injection techniques: a comprehensive primer. Semin Roentgenol. 2019;54:124–48.

    Article  PubMed  Google Scholar 

  3. Cushman DM, Christiansen J, Clements ND, Cunningham S, Teramoto M, McCormick ZL. Infections after large joint or bursa injection: a survey of 554 sports medicine physicians. Am J Phys Med Rehabil. 2019;98:1106–9.

    Article  PubMed  Google Scholar 

  4. Hodler J. Technical errors in MR arthrography. Skeletal Radiol. 2008;37:9–18.

    Article  PubMed  Google Scholar 

  5. Foremny GB, Pretell-Mazzini J, Jose J, Subhawong TK. Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature. Skeletal Radiol. 2015;44:619–27.

    Article  PubMed  Google Scholar 

  6. Ali AH, Said HG, Abo elhamd E, Mahmoud MK, Qenawy OK. Shoulder MR arthrography: comparative evaluation of three different contrast injection techniques using an anterior approach. J Magn Reson Imaging. 2021;53:481–90.

    Article  PubMed  Google Scholar 

  7. Lungu E, Moser TP. A practical guide for performing arthrography under fluoroscopic or ultrasound guidance. Insights Imaging. 2015;6:601–10.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Jacobson JA, Lin J, Jamadar DA, Hayes CW. Aids to successful shoulder arthrography performed with a fluoroscopically guided anterior approach. Radiographics. 2003;23:373–8.

    Article  PubMed  Google Scholar 

  9. Schraner A, Major N. MR Imaging of the Subcoracoid Bursa. Am J Roentgenol. 1999;172:1567–71.

    Article  CAS  Google Scholar 

  10. Grainger AJ, Tirman PFJ, Elliott JM, Kingzett-Taylor A, Steinbach LS, Genant HK. MR anatomy of the subcoracoid bursa and the association of subcoracoid effusion with tears of the anterior rotator cuff and the rotator interval. Am J Roentgenol. 2000;174:1377–80.

    Article  CAS  Google Scholar 

  11. Goh CK, Peh WCG. Pictorial essay: pitfalls in magnetic resonance imaging of the shoulder. Can Assoc Radiol J. 2012;63:247–59.

    Article  PubMed  Google Scholar 

  12. Kresse ME, Perry MT, Nacey NC. Inadvertent intraosseous injection during fluoroscopyguided joint injection of two adult patients. Clin Imaging. 2021;76:109–15.

    Article  PubMed  Google Scholar 

  13. Dépelteau H, Bureau NJ, Cardinal E, Aubin B, Brassard P. Arthrography of the shoulder: a simple fluoroscopically guidedapproach for targeting the rotator cuff interval. Am J Roentgenol. 2004;182:329–32.

    Article  Google Scholar 

  14. Yau T, Ranzenberger L, Capannolo L, Rodriguez A, Snyder T. Shoulder MR arthrography complication – direct injection of the biceps tendon: a case report. J Med Imaging Case Reports. 2019;3:30–3.

    Article  Google Scholar 

  15. Farmer KD, Hughes PM. MR arthrography of the shoulder: fluoroscopically guided technique using a posterior approach. Am J Roentgenol. 2002;178:433–4.

    Article  CAS  Google Scholar 

  16. Shortt CP, Morrison WB, Roberts CC, Deely DM, Gopez AG, Zoga AC. Shoulder, hip, and knee arthrography needle placement using fluoroscopic guidance: practice patterns of musculoskeletal radiologists in North America. Skeletal Radiol. 2009;38:377–85.

    Article  PubMed  Google Scholar 

  17. Rutten MJCM, Collins JMP, Maresch BJ, Smeets JHJM, Janssen CMM, Kiemeney LALM, et al. Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography. Eur Radiol. 2009;19:722–30.

    Article  PubMed  Google Scholar 

  18. Javed S, Sadozai Z, Javed A, Din A, Schmitgen G. Should all acromioclavicular joint injections be performed under image guidance? J Orthop Surg. 2017;25:1–4.

    Article  Google Scholar 

  19. Petscavage-Thomas J, Gustas C. Comparison of ultrasound-guided to fluoroscopy-guided biceps tendon sheath therapeutic injection. J Ultrasound Med. 2016;35:2217–21.

    Article  PubMed  Google Scholar 

  20. Slevin J, Joyce M, Galvin JW, Mahlon MA, Grant MD, Eichinger JK, et al. Ultrasound-guided bicepstendon sheath injections frequently extravasate into the glenohumeral joint. Arthroscopy. 2021;37:1711–6.

    Article  PubMed  Google Scholar 

  21. Osias W, Matcuk GR, Skalski MR, Patel DB, Schein AJ, Hatch GFR, et al. Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management. Skeletal Radiol Skeletal Radiology. 2018;47:161–71.

    Article  PubMed  Google Scholar 

  22. Hodler J, Gilula LA, Ditsios KT, Yamaguchi K. Fluoroscopically guided scapulothoracic injections. Am J Roentgenol. 2003;181:1232–4.

    Article  Google Scholar 

  23. Lohman M, Borrero C, Casagranda B, Rafiee B, Towers J. The posterior transtriceps approach for elbow arthrography: a forgotten technique? Skeletal Radiol. 2009;38:513–6.

    Article  CAS  PubMed  Google Scholar 

  24. Swindells MG, Logan AJ, Armstrong DJ, Chan P, Burke FD, Lindau TR. The benefit of radiologically-guided steroid injections for trapeziometacarpal Osteoarthritis. Ann R Coll Surg Engl. 2010;92:680–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Erpelding JM, Shnayderman D, Mickschl D, Daley RA, Grindel SI. The “Thumbs-up” sign and trapeziometacarpal joint injection: a useful clinical indicator. Hand. 2015;10:362–5.

    Article  PubMed  Google Scholar 

  26. Pessis E, Drapé JL, Bach F, Feydy A, Guerini H, Chevrot A. Direct arthrography of the pisotriquetral joint. Am J Roentgenol. 2006;186:800–4.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Radiology and Medical Imaging, University of Virginia, 1st Floor 1215 Lee St Charlottesville, Charlottesville, VA, 22903, USA

    Maxine E. Kresse, Michael T. Perry & Nicholas C. Nacey

Authors
  1. Maxine E. Kresse
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael T. Perry
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nicholas C. Nacey
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicholas C. Nacey.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Key points 

• Contrast can be utilized to confirm injection location when performing fluoroscopy-guided injections in the upper extremity. Intra-articular contrast should flow away from the needle tip and throughout the joint.

• Each targeted site has an expected intra-articular contrast filling pattern. Knowledge of these expected appearances is critical to avoiding non-target injection.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kresse, M.E., Perry, M.T. & Nacey, N.C. Fluoroscopy-guided injections of the upper extremity: pearls and pitfalls. Skeletal Radiol 52, 843–854 (2023). https://doi.org/10.1007/s00256-022-04129-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-022-04129-y

Keywords

Search

Navigation