738
March 1975
TECHNICAL NOTES
Device for Lower Extremity Phlebography 1 Josh J. Porte, R.T.L.X.T. and Gerald R. Holzwasser, M.D. A simp le device Is described for lower extremity phlebography. With the patient standing or recumbent , simultaneous injection of contrast material can easily be achieved by one person. Venography , apparatus and equipment
INDEX TERMS:
Radiology 114:738, March 1975
In performhig lower extremity phlebography, it is not unusual to be forced to use a #21 or #23 needle to puncture a small vein in the dorsum of the foot. Because of the small aperture of the needle, it is difficult to inject the somewhat viscous contrast material. On bilateral studies, two persons are necessary to do the injecting and a simultaneous injection may not be achieved.
Fig. 1. Fig. 2. Fig. 3.
The device pictured here (Fig. 3) solves both problems . The metal syringe holder (Fig. 1) fits over the board (Fig. 2) on which the patient stands. A 50-ml center lumen syringe is then inserted into the holder (Fig. 1) and an extension tubing (approximately 50 cm [20 in.] long) is connected to the syringe. The tubing is connected directly to the needle and by utilizing a three-way stopcock, a drip infusion can also be maintained. Pressure is then applied to the syringe inside the metal holder and the weight of the body is sufficient to produce a slow injection without any undue strain. The result is a simultaneous injection achieved by one person . We have performed this study multiple times using this simple device and are always impressed with how easily the study can be done compared to our previous experience.
1 From the Department of Radiology, Genesee Hospital, 224 Alexander St., Rochester, N. Y. 14607. Address reprint requests to Dr. Holzwasser. Accepted for publication in September 1974. vb
The metal syringe holder wlttl syringe. The wooden board with metal syringes in place has notches for alternative positions for unilateral injections. Technique of injection with patient standing on boards.
•
A SlmpDfied Injection Technique for Shoulder Arthrography 1 Robert Schneider, M.D., Bernard Ghelman, M.D., and Jeremy J. Kaye, M.D.
An easy and reliable technique to Inject the shoulder joint for arthrography Is described . The technique utilizes a straight anteroposterior position of the patient and a directly vertical placement of the needle with the aid of fluoroscopy. IINDEX TERMS:
Shoulder, arthrography
Radiology 114: 738--739, March 1975
Shoulder arthrography can be helpful in the evaluation of painful shoulder disability. It is most useful to diagnose or ex-
elude complete and partial rotator cuff tears, adhesive capsulitis (frozen shoulder) and the capsular deformities due to previous anterior dislocation (1,2,3). In the past several years. we have modified the technique for the intra-articular injection of contrast material for shoulder arthrography. These modifications make the injection procedure much simpler. TECHNIQUE After preliminary films are obtained and reviewed , the patient is placed on a fluoroscopic table in the supine position with the shoulder flat against the table. The glenoid process, in this position, is tilted slightly anteriorly. This will allow the needle to enter the glenohumeral space without passing through the cartilaginous glenoid labrum. This position also makes it impossible to pass the needle completely through the joint. We no longer place the patient in an oblique posi-
TECHNICAL NOTES
Vol. 114
739
tion, as we did previously (1). The shoulder is placed in a neutral rotation or in mild external rotation . This serves to rotate the tendon of the long head of the biceps laterally, away from the projected needle path. The patient is cautioned not to move the shoulder or arm until the injection has been completed and the needle removed. The potential risk of needle breakage due to movement is therefore minimized. Using an image-amplified fluoroscope, a lead marker is moved into position over the junction of the middle and lower third of the glenohumeral joint space (Fig. 1). This point is marked on the skin with a felt-tipped marker containing indelible ink. As with any joint aspiration injection , strict adherence to aseptic technique is essential. After skin preparation and draping, the skin beneath the mark is infiltrated with local anesthetic. A 22-gauge 3.5-inch (B.9-cm) disposable needle, used for the joint puncture, is then inserted and directed absolutely vertically towards the glenohumeral joint space with the aid of image-intensified fluoroscopy. With this perfectly vertical approach, it is relatively simple to hit the glenohumeral space . Fluoroscopy then assures the correct medial-to-Iateral orientat ion of the needle, although it does not give an indication of its depth . The tip of the needle should always overlie the glenohumeral space . If it deviates either medially or laterally, it should be withdrawn slightly and reinserted until the proper position is achieved (Fig. 2). If the patient experiences pain as the needle is advanced slowly vertically, additional local anesthetic can be injected through the spinal needle. When the needle meets resistance, it should be withdrawn a millimeter or two . It should then be located within the shoulder joint. Aspiration of the joint should be attempted; however, fluid is seldom obtained. One or two milliliters of local anesthetic is then injected using a 2-ml syringe. If the needle is in the joint space , the local anesthetic will flow freely and easily. To confirm that the needle position is correct, approximately 0.5 ml of meglumine diatrizoate is injected. If the needle position is correct, the contrast material will flow away from the needle tip, outlining the joint space and/or its recesses (Fig. 3). If the needle is not in the joint, the contrast material will pool around the tip of the needle. When correct needle position has been established , 10-12 ml of meglumine diatrizoate is Injected and the needle removed . The filming is then done in the manner previously described (1). CONCLUSION The injection of contrast material into the shoulder joint for arthrography is greatly facilitated by a technique which utilizes a straight anteroposterior position of the patient and a directly vertical joint puncture . REFERENCES 1. Killoran PJ,MarcoveRG, Freiberger RH: Shoulder arthrography. Am J RoentgenoI103:658-668, Jul 1968 2. Nelson CL, Razzano CD: Arthrography of the shoulder: a review. J. Trauma 13:136-141 , Feb 1973 3. Samilson RL, Raphael RL, Post L, et al: Arthrography of the shoulder joint. ClinOrthop 20:21-32, 1961
1 From the Department of Radiology, the Hospital for Special Surgery, affiliated with the New York Hospital-Cornell University Medical College, New York, N. Y. 10021 . Accepted for publication in October 1974. vb
Fig. 1. The shoulder is in a neutral to slightly externally rotated position. The glenoid is seen obliquely. A lead marker has been placed over the junction of the middle and distal third of the glenohumeral [oint. Fig. 2. The needle is in an exactlyvertical position, directly over the glenohumeral joint. Fig. 3. A small amount of contrast material has been injected and has flowed away from the needle into the glenohumeral joint and its recesses, confirming the intra-articular position of the needle.
Technical Notes
March 1975
TECHNICAL NOTES
Device for Lower Extremity Phlebography 1 Josh J. Porte, R.T.L.X.T. and Gerald R. Holzwasser, M.D. A simp le device Is described for lower extremity phlebography. With the patient standing or recumbent , simultaneous injection of contrast material can easily be achieved by one person. Venography , apparatus and equipment
INDEX TERMS:
Radiology 114:738, March 1975
In performhig lower extremity phlebography, it is not unusual to be forced to use a #21 or #23 needle to puncture a small vein in the dorsum of the foot. Because of the small aperture of the needle, it is difficult to inject the somewhat viscous contrast material. On bilateral studies, two persons are necessary to do the injecting and a simultaneous injection may not be achieved.
Fig. 1. Fig. 2. Fig. 3.
The device pictured here (Fig. 3) solves both problems . The metal syringe holder (Fig. 1) fits over the board (Fig. 2) on which the patient stands. A 50-ml center lumen syringe is then inserted into the holder (Fig. 1) and an extension tubing (approximately 50 cm [20 in.] long) is connected to the syringe. The tubing is connected directly to the needle and by utilizing a three-way stopcock, a drip infusion can also be maintained. Pressure is then applied to the syringe inside the metal holder and the weight of the body is sufficient to produce a slow injection without any undue strain. The result is a simultaneous injection achieved by one person . We have performed this study multiple times using this simple device and are always impressed with how easily the study can be done compared to our previous experience.
1 From the Department of Radiology, Genesee Hospital, 224 Alexander St., Rochester, N. Y. 14607. Address reprint requests to Dr. Holzwasser. Accepted for publication in September 1974. vb
The metal syringe holder wlttl syringe. The wooden board with metal syringes in place has notches for alternative positions for unilateral injections. Technique of injection with patient standing on boards.
•
A SlmpDfied Injection Technique for Shoulder Arthrography 1 Robert Schneider, M.D., Bernard Ghelman, M.D., and Jeremy J. Kaye, M.D.
An easy and reliable technique to Inject the shoulder joint for arthrography Is described . The technique utilizes a straight anteroposterior position of the patient and a directly vertical placement of the needle with the aid of fluoroscopy. IINDEX TERMS:
Shoulder, arthrography
Radiology 114: 738--739, March 1975
Shoulder arthrography can be helpful in the evaluation of painful shoulder disability. It is most useful to diagnose or ex-
elude complete and partial rotator cuff tears, adhesive capsulitis (frozen shoulder) and the capsular deformities due to previous anterior dislocation (1,2,3). In the past several years. we have modified the technique for the intra-articular injection of contrast material for shoulder arthrography. These modifications make the injection procedure much simpler. TECHNIQUE After preliminary films are obtained and reviewed , the patient is placed on a fluoroscopic table in the supine position with the shoulder flat against the table. The glenoid process, in this position, is tilted slightly anteriorly. This will allow the needle to enter the glenohumeral space without passing through the cartilaginous glenoid labrum. This position also makes it impossible to pass the needle completely through the joint. We no longer place the patient in an oblique posi-
TECHNICAL NOTES
Vol. 114
739
tion, as we did previously (1). The shoulder is placed in a neutral rotation or in mild external rotation . This serves to rotate the tendon of the long head of the biceps laterally, away from the projected needle path. The patient is cautioned not to move the shoulder or arm until the injection has been completed and the needle removed. The potential risk of needle breakage due to movement is therefore minimized. Using an image-amplified fluoroscope, a lead marker is moved into position over the junction of the middle and lower third of the glenohumeral joint space (Fig. 1). This point is marked on the skin with a felt-tipped marker containing indelible ink. As with any joint aspiration injection , strict adherence to aseptic technique is essential. After skin preparation and draping, the skin beneath the mark is infiltrated with local anesthetic. A 22-gauge 3.5-inch (B.9-cm) disposable needle, used for the joint puncture, is then inserted and directed absolutely vertically towards the glenohumeral joint space with the aid of image-intensified fluoroscopy. With this perfectly vertical approach, it is relatively simple to hit the glenohumeral space . Fluoroscopy then assures the correct medial-to-Iateral orientat ion of the needle, although it does not give an indication of its depth . The tip of the needle should always overlie the glenohumeral space . If it deviates either medially or laterally, it should be withdrawn slightly and reinserted until the proper position is achieved (Fig. 2). If the patient experiences pain as the needle is advanced slowly vertically, additional local anesthetic can be injected through the spinal needle. When the needle meets resistance, it should be withdrawn a millimeter or two . It should then be located within the shoulder joint. Aspiration of the joint should be attempted; however, fluid is seldom obtained. One or two milliliters of local anesthetic is then injected using a 2-ml syringe. If the needle is in the joint space , the local anesthetic will flow freely and easily. To confirm that the needle position is correct, approximately 0.5 ml of meglumine diatrizoate is injected. If the needle position is correct, the contrast material will flow away from the needle tip, outlining the joint space and/or its recesses (Fig. 3). If the needle is not in the joint, the contrast material will pool around the tip of the needle. When correct needle position has been established , 10-12 ml of meglumine diatrizoate is Injected and the needle removed . The filming is then done in the manner previously described (1). CONCLUSION The injection of contrast material into the shoulder joint for arthrography is greatly facilitated by a technique which utilizes a straight anteroposterior position of the patient and a directly vertical joint puncture . REFERENCES 1. Killoran PJ,MarcoveRG, Freiberger RH: Shoulder arthrography. Am J RoentgenoI103:658-668, Jul 1968 2. Nelson CL, Razzano CD: Arthrography of the shoulder: a review. J. Trauma 13:136-141 , Feb 1973 3. Samilson RL, Raphael RL, Post L, et al: Arthrography of the shoulder joint. ClinOrthop 20:21-32, 1961
1 From the Department of Radiology, the Hospital for Special Surgery, affiliated with the New York Hospital-Cornell University Medical College, New York, N. Y. 10021 . Accepted for publication in October 1974. vb
Fig. 1. The shoulder is in a neutral to slightly externally rotated position. The glenoid is seen obliquely. A lead marker has been placed over the junction of the middle and distal third of the glenohumeral [oint. Fig. 2. The needle is in an exactlyvertical position, directly over the glenohumeral joint. Fig. 3. A small amount of contrast material has been injected and has flowed away from the needle into the glenohumeral joint and its recesses, confirming the intra-articular position of the needle.
Technical Notes
