arthrography of shoulder.pdf

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1962;44:1321-1359.J Bone Joint Surg Am.Julius S. Neviaser Capsulitis of the ShoulderArthrography of the Shoulder Joint: Study of the Findings in Adhesive

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www.jbjs.org20 Pickering Street, Needham, MA 02492-3157The Journal of Bone and Joint Surgery
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A rth rog raphy o f the S hou lde r Jo in tSq-u-Dy OF Th11 FIND Ix (;s IN AD IIESIV I C .up sv uis O F T IlE Smmo ITIDF :R

BY JU L IUS S . N EV IASER , M .D ., \iASH INGTON , D .C .

This mel)o lt is 1)ased om i the stu dy of a la rge g ro up of a r th rog raph ic l)m o (edu ie spem fom nied on the sho u lde r jo in t in w hich th e find ing s b y a rth rog ram w ere o r-re la ted u iith th e an a tom ica l am id pa tho lo g ical fin d im ig s seen a t ope ratio n and a tpo st m ortem exam inatiom i. The c lin ical se rie s inc lud es 26 1 shou lde r les ions. Thecon tra st m ed ium used uyas d iod ra st. S ix ty -fou r shou lde rs u i-crc sub sequem itly cx -p osed by op era tion am id eig h ty -seven uve re sub jec ted to c losed m an ipu la tion orred uc tion . In th e rem a in in g 1 10 sho u lde rs , th e re w as e ithe r no abnorm a lity tha tivou ld requ ire su rg ery o r m an ipu la tion or th e p a tien ts , in a feuv in stam ices, refusedthe ind ica ted th erapy . S ix ty -e igh t au to psy stu d ie s w ere a lso m ade iii wh ichd iod ra st u i-as in j ec ted in tracapsu la r ly in to cadave ra fo llow ed by ro en tgeno gram sof the sho u lde r m ade in the n ecessa ry pos itions and by d issec tions o f these sam eshou lde r jo im its . T h ese pos t m ortem stu d ie s uv ere m ad e uv ith in tu ven ty -fo u r hou rsafte r death . T hey affo rded a m o re de ta iled com parisom i of the roem itgen ograph icf ind ings and the am ia tom y th an is u sua lly po ssib le at o pe ra tiom i. I t. is the purpo seo f th is ar ticle to desc rib e th e an atom ical an d p ath o log ica l fin d ing s in adhesive(apsu l i t is (If the shou lde r a s d em onstra ted by a rth ro g rap hy am id to sho uv th e v alueof th is p ro ced ure as a d iagno stic an d th erapeu tic a id .

Codmau i , in 1934 , m em itiom ied th e pos sib ility o f im ijectin g an opaq ue flu id in tothe sho u lde r jo in t to con firm th e d iagm io sis o f an incom ple te rup tu re o f th e su pra-sp ina tus tend om i bu t d id n o t try th is p rocedu re . L im idbo lm and P a lm er used a rth ro g -raphy to de tec t com ple te o r in com ple te tears in th e m uscubo tem id im iou s cu ff andru p tu re s o f the tendon of the lon g head o f the b iceps. O b erho lze r u sed arth rog ram sof the sh ou ld e r to stud y th e le sions caused b y d isboca tiou is . A xen d iscus sed theva lue o f a r th rog raphy in th e d iagm io sis o f cu ff rup tu re s am id a lso descr ibed thefin d ing s in ru p tu re s o f the lon g h ead of the b icep s, a s w e ll as in d isloca tions . In h isrepo rt, a s in m ost o f th e pub lished artic les , t.he illu stra tions o f the fin d ing s w ereSpa rse am id o f p oor qu ality . P ettc rsson , in an exce llen t m onograp h on ru p tu re so f the m uscubo tend in ou s cu ff as soc ia ted w ith an te ro -in fe rio r d isloca tion s o f thesh ou ld er , repo rted the qu ite freq uen t use o f a rth ro g rap hy to te st fo r cu ff ru p tu re s,pa rticu la r ly in pa tien ts w ho w ere ov er th irty y ears o f age . H e a lso used th is p ro -ced ure to dem on stra te the p ro gress o f hea ling of the to rn capsu le a t th e an te ro -in fer ior p art of the jo in t.

TECHNIQUED uring the deve lopm en t o f th e techn iq ue of a r th rog raphy to be desc rib ed

va ry ing am ounts o f dye w ere in jected in to th e shou lde rs o f fresh cadave ra , no ton ly to jud ge how m uch so lu tion shou ld be used to g ive the b est de ta il on th ero ent g enog rams bu t a lso to de term in e the cap ac ity o f the jo in t. In ad u lts , thecap ac ity va ried from tw en ty -e igh t to th irty -f ive cub ic cen tim ete rs . S trange asit m ay seem , som e sh ou lders in w om en to ok m o re so lu tio n th an com parab lesho u lde rs in m en . In m ore th an one instance , the r igh t shou lde r d iffe red in capac ityfrom the lef t by as m uch as f ive cu b ic cen tim e ters; th is d iffe ren ce w as m ore p ro -nou nced in cadave ra o ve r six ty y ea rs o f ag e. Th is m ay be exp la ined by th etenden cy of the cap su le to con tract in the sho u lde r w h ich is leas t used hab itu a lly .VOL . 4 4 -A , NO .7 , O C TOBER 19 62 1321


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liu . I l m u. 2

1 i. 3-A F iu . 3 -1 4

1322 J. 5 . N i: \ As Em (

THE JOURNA L OF BON E AND J(IIN T SU RGERY

Iig . 1 : : t t t l I ssteti )l r )( llt 4r ( . glL tt1 s itouv ilig 11(0(110 ill aX i llary slIa(( afte r i ns( rt in g it aut(riorly.

F ig . 2 : x i l lary l()(l1 t gclngralii s itou ving n((d l( p l :u ed in t lie jo in t th ro ugh au au tter io r alll )ro a(h .

lg . 3 -; : ; t l tog ran i of a t to rn ia l s ito u ld er. 1 Ite 1 ills sInai It is n o t v isib le b u t t he s I l l ) s : t p (l l : Lr i s1 mrsa is u ve ll ou t liu ted itt t i tis am itero j)( ts te rio r v ieuu uuit I i I I to arm i I t e xte rin d ro ta t ion .F ig . 3 -14 : l it t h is V1( tV t l ie arn i is iii im itern a l ro ta t ion .

I m ma n( um iim mI j )I um it uu :L s fou l 1 (1 1 l im it m isc ( ) f 1 (1 )0 th ! six ! ( ( ii (III Il cc ii t i m i i( t (IS (Ii 5(11(1-t i(Iii m es ul t ( ( 1 i m oe m tt g e m mo g m a m ii s uv ith t l ie h )es t ( le t n il ( l ig s . 3 - . I h r(Iugh 3 -i ) . \V h emim iiom e t In n m s ix ! ((Ii ( tm l lie (C ii t i m ii et e rs uv eme use(1, I he shadouv of t he ((lilt m -ast m e -(hum w as S(I de imse tha t the ou t l ines of the jo im it w ere obscured .

Ano th e r f ind in g of im ite re st in th ree cadau-e ra h )etw eem i the ages o f s ix ty -f iv ean d sevem ity years u i-as a c(Ilumumiicatiomi b etw een th e jo in t p rope r am id th e su b-de lto id bu rsa uv ith ou t the 1 -agg e(I and irreg u la r edges charac te ristic o f a defin iterupture of the c im if. A sim ila r find in g w as m em itio ned by Gasser in 1902 . I t is knowmith at a con in iummica t io n be t uveen the sh ou lder jo im it and th e su bde lt(I id b ursa m aydeve lo p afte r a spontaneous rup tu re w ith ou t any h isto ry of trauma. This occursi io t im i fr eq ue it tl y itt pa tien ts p as t the age o f six ty ye ars as th e resu lt (If degemiera -tiv e chang es, as repo rted b y Iros tad an d other au thors D issec tion o f the threeshou lders w ith a comm uni(a tiom i be tw een the joint amid the bursa iii th is stud yfailed to es tab lish d efin ite ly the cause o f th is con in iw iica tiom i. T hem e uv as 11 0 eu- i -(lem ice o f a tear although in each in stan ce th e poste rio r 0 .11(1 sup em -i( Im (apsu le w asfo um id to b e ra the r th im i, p resum ably du e to attritiom ia l am id degem leratiu -e changes .In cid en ta lly , th is com m un ica tion u i-a s m io t dem onstra ted u n til the jo im it had b eem i


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Fm( ; . 3-( F tc .. 3 - 1 )

Fm ; . 3 - i

A R T H R O G R A PH Y O F T IlE SH O U L D E R JO IN T 1323

VO L 44-A . N O ) 7, 0(T O B E It m 962

F ig . :4 -( : In th is v ie - th e arm is in a1)(luc-t ion . N ote obliteration of the axillary fold;also , 5011W dye is now seen in th e b icep ssheath .

F ig . :4 - I): A x illa ry v iew . N ote re( lum i(lancyof th e ( al)s Lm l( at the pos te rio r part o f thejo it it. T he sitl iscap it laris b ursa is we ll filleda lit.e rio r to the n eck of th e scapula .

F ig . 3 -E : B icil) it.a I g roo ve v iew . Tlio bicepsshea th is vell ou t lin ed its the h ic ijli ta l g roo ve.

fu lly d ist em i(1 (. (l u i- it I i m iso re t h an I u vin ty -eig h t (U IIi( - cen t in icte rs o f so lu tio n . (Ju lyth i( . ii d li( l tin sim bd e lto id bursa I )econ ie filled . It is p ossil) le tha t th ese op em iim igscou ld hau-e beem s uerv sm all s if l( e the bursa d id no t. f ill un til the jo im it. u i-as undertemision .

O ur te (h iiii( lU e u-am -ie (I, ( le en (h iiig on th e case. \V e used I lie su item ium app roa(hfor mos t s ho u l d e u - s e x ( - e p t t ho s e s us pe c t e d of hau iim g adhes iu -e capsu litis o r frozensh ou lder. Im i these the po stem io r approach u i-as fou nd to ) be m iso re sa tis facto ry .A ltho ugh th e po ls te rio lr techm ia iim e m ig h t l)e used im i a ll cases, its o ne d isadu-amitageis tha t the need le somet imes is ben t u i-hem s the pa tiem it is tu rn ed from the proneto th e sup ine pos ition to obtain ax illary \- ieu vs; th is h as no t cau sed d ifficu lty . B o thprocedu res a re ca rrie(1 ou t in th e x-ray d ep artm e nt uv ith i the pa tien t (I a c om bin edro en tgeno grap h ic and f luo roscop ic t a b l e .

In the a nt e r i o m a pp l - o a ( h , th e pa t iem it is p l a c e d iii I h e sup ine pos itio n wi t hh is a rm u by h i s s i d e a n d i n imi tem-t ia l 1-oltation . r fhe sk i i i iii th e area (If injection isp repared w ith I he usua l ste rile t ech iim aue . Th e la lt(lm iiau k fo u- in jec t 1(111 is a poim itju s t b elow - tu e tip o f the coraco io l pm m ess am id ve iy sligh tly m ed ial to it. T he siteo f im ijec tio ti i s in filtrated uv ith i I per (em it procaine, in (hm(h ing th e deep t i ssues( lown t(I t h e ume c k (If t h e scap u la c lose to the g lem io id . A 20-g au ge need le , t wo am ida ha lf om th ree inches lom ig , is th em i im ssem ted aiid d irected to uva rd the g lem so id . W hem tthe bone is reached the m ieed le is backed off sl igh t ly and them i u-ed irec ted a little


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Fm o. 6

1 324 J . S . NEV IASER

iill JOUItNAL 0)1 I OUNE AND JOiNT SURGERY

Fm ; . 4 Fm ;. ,5l ig . 4 : . t Itt )g t:t lii ( f a u t , )rtn al lio tm lde t. F lu I liccps slie :tt Ii is o im tli m le (l b itt tin su a-

s(alnmlauis hii t sa i s m :t t he t st i ia l l .lg . S : l ost ( .1. , )-0 t1 I ( lit It t( (Itt go tto g t:L ts i ( )f. fl r igh t s lit ) t th lc t lio v it ig ttc elk i t ls(t t(d I )ost .o r io r lv

iltt() tlit l m l) l) ( t I )t t t of the jitittt

m to ttIto r artliro gra mii of a t to rn ial sh ou lder m u ade its tIn 1 )os tero -:L ttto ri p ro j( (t io n . F lie b ic epsshea th is W Oll om tt lin e(l.

n io re la tem all 5(1 th at it em ite rs the ,J(Iimit. space just a l)ou -e the ax illa ry fo ld (F ig s.1 am id 2). T he p(Isitio)iI of the n eed le can uiouv be ch eck ed by fluo ro sco py . A m u ix tu reof t u -e li-c (n ine cen t inietem-s of 35 per cemit d io drast an d foum cub ic c e ii t im i ie t er s o fpmocaimie is im ijec ted in to t he j oi mi t. At f i rs t m i ot .mo re th am i tu io cub ic cem itim e te rs isin jec ted . I f th is flouv s eas ily am id ou t hues t.he j o int . u i-eli on th e fluoroscopic screen ,then the m em iia im ide r (If the so lu tion is im ijec ted , th e need le is qu ick ly w ith drawm i,am id uoen t g em io gm -am sis ar e im nm ned ia te lv m ade uv ith the sho u lde i- in th e necessaryposi t ions. S ince the diodmast i s a bs or be d in abou t t went m niiiu tes it is necessa ryf om th e te (hm iic iam i to pro lo eed w ith a certain amoum i t (If speed .

A 20-g au ge need le uvas foun d to h e th e m ost sa tis facto ry size s in ce in th i(1)01s t moIm teni s tw .lies it u i-as (Ib sen-ed tha t t h eme uvas som ne leakage th rough th en eed le op en ing iii the c ap su le if au 1 8-gauge on 19-gaug e u teed le uvas emnp lo y ed .Lak:mge of dye ou t side the joiumt may iiiuke t lie i ii! em prel ;tt io u of n i t a rt h ir og ta iii(h ifh i(h i l t

A n iix tum e o f tw elv e ( 0100 cem itim eters o f 3 p em ((itt (h iodma.s t am id fon t oub io cen t imeters (If I pc i cem it p ro ca im ie eh im isiu ia tes am iy psum i w hen the mixture is iii-


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AR T H R O G R A PH Y O F TH E SH O UL DE R J O IN T 1325jected im ito the jo int. If the m ixture should no t be in the jo int, pain iv ihl occur,but it uv ill be less severe than the pain w hich results from the use o f 35 per centdiodrast w ithout procaine.

The appearance o f normal arthro gram s can be seem i in Figures 3 -A through3-E. It. should be no ted that in som e cases the subscapularis i)ursa ivan uv e ll out-lined (Fig . 3-A ) ; in o ther instances , it ui-as someivhat smaller and did no t show upuiehi (Fig . 4 ). This also ) applied to the bicipital sheath uvhich u vas o c ca si on al ly ivelhv isualized for some dis tam ice (Fig . 4 ), w hereas iii (Ither cases it. w as bare ly v isible.A im arthrog ram made uv ith the arm in internal ro tatiom i (Fig . 3 -B ) has a differem itappearance than one made w ith the arm in ex ternal ro tatioms (Fig . 3 -A ). W hen thea r m u v a s abducted, the normal ax illary fo ld uvas obliterated. This maneuver w asvery he lpful in outlining the biceps sheath (Fig . 3 -C). In many instances, thebiceps sheath w as not outlined w ell uv ith the arm at the side; hut uv ith the armabducted, the dy e w -as pushed superio rly by the tense re flec ted ax illary fo ldand the so lutio n ran into the synov ial sheath of the biceps w ithout difficulty .The ax illary u-ieuv (Fig . 3 -D ) shouved the outline o f the subscapuharis bursa an-tcriorly as uve ll as the 1 )iceps sheath rumining ouer the le sser tui)erosity . The po s t . e -n or c a p su le (I f the shoulder jo int w as foumid to be relaxed in all shoulders. Thisled me to speculate that this may 1)e the reasom i w hy posterio r dislocatio ns of theshoulder are infrequemit. S im ice the capsule is redumidamit, the humeral head mayhave muore space to m isove backuvard before it ac tually tears or stre t(hes the articu-lar capsule am id subluxates. A roeuitg enogram of the bicipital groov e (Fig . 3 -E) ismade by directing the central ray from the tube along the long ax is o f the shafto f the humerus ui- it.hi the film placed abov e the humeral head. This uiew oluthim iesthe sheath of the long head of the biceps tendom i by the contrast m edium filling theperitendim sous space (lig . 3 -E).

The pos terior approaoh is usually used im i adhesiv e (-apsuhtis o Im. fm oz em i shoul-der. In this co i idit iomi the dapsU ic tem i(ls to contract. superiorly , anteriorly , am idinferiorly ; hence , it is difficult. to im ijec t the dhye int.o the jo int am iteniorly . Iii mnyearlier attempts at. arthro graphy this w as the cause o f failure to obtain art.hro -g rams of the shoulders w ith adhesive capsuhitis . The p(ls tenior approa(h so lvedthis diff iculty . W ith some relaxatiom i of the capsule posterio rly , the needle cams beinserted w ith relatiyc ease. The patient lie s prone usith his armu by his s ide amid inim iternal rotatio n. A good landmark fo r injec tio n is the slight depressiom i fe lt justbe low the medial portion o f the acromion w here it jo im is the spine of the scapuladirec tly posterior to the tip o f the coraco id proces s. The 20 -g auge needle is im i se r t e dumider sterile precautions and direc ted slightly upuvard so that. the needle entersthe upper part o f the jo int (Fig . 5 ). The po sition (I f the needle is checked underfluoro scopic contro l, as is the dis tributioms of t.he contrast niedium after the injec-tiom i o f tuvo cubic cem it.imeters o f dy e. If the fluid is iii the jo int the remaim ider of thedye is injec ted into the jo im it, am id the desired roem itg em sograms are niade immedi-ately.

The appearance o f a m iormal arthrog ram made in the postero -antenior po sit 1 (111is s houvn in Figure 6 , w here the bic ipital sheath is w ell outlined.N orniahly , s ix teen cubic cemstim et.ers o f dy e so lution (tw elv e cubic centimetersof 35 per cent diodrast and four cubic centimeters o f I per cem it pro caim ic ) can heinjected uv ithout any res istance. If there is re sistance the im ijec tion should he dis-co iuliumued, since this may mean that the m icedle is no t placed correctly iii the jo iitt;or , if I lie needle is iii the j o in t , iu i j ec t iom i under lre ssure may cause the dye h I leakout o f the capsule aiouiid the needle opening . This is e spec ially true iii cases o fadhesiv e capsuhit.is in w -hich the capac ity o f the jo int is only f iv e to tem i cubiccentimeters.V O L . 44-A . NO . 7. OCTOBER 1962


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1326 J. S . N EV IA SE R

i i IE J (I1RX AT . O F 130)NE A N I) JO INT SU RG ERY

Fa; . 7 -A F . 7-14l ig . 7-A : A r t h ro gram of a case (P atieum t. M S . ) (If adhesive (al)sumlit.is.No te the (le(rease(I jo in t

( a Ia n it V a ut il t he a ltilos t ( t m p li t e o l Il ierat ion f t he axi Ilat f ld . T he s tm hl sc al nm la ri s I m tsa aum dI 0((J)S shoat 11 0 t)( )t 0 )1 1 t Iille(l.F ig . 7 -14 : lie truss is itt m ax in ium u abduct ion .

Fi;. 7 -C Fm e. 8 -AFig . 7- ( : Ax illa rv v iew . (C om pa re wi t I t t to r ni al s ho ti ld er in F ig . S -( -.F ig . 8 -A : A ppea ran ce of th e r ig ht s ho ul de r of MS . Th e ou t I tr g ra tl i is nomni:tlw it It t h e ax i Ilarv

1 1 )1 (1 ( l l O t it Ii tO ) 1 a nd t h( 1 sh eo t It (a s; lv see tt.A i)II1S IV I (P s1 1 1115

.r th im ogm am ns u vem e n iad o of h oth i sho uldem s (If fifly -th iu ee l)a t.ie iits uv ith adhesiveCaJ)stm litis o f on e sh i(Ilm lde l. F lie a rth im ogm -ap h ic find ings in th is ( on(h iti(In ( ( Imif im-nim isa lly ( If t he l) h i Il (Ig i(a l fi i id i uig s pm ev io lus ly rep It ! ed 20 , ,%i t I i m -o gran is a lsoden iom mst rate healing (I f th e ( apsu le a ft em - m au ti p im la ti om i under au testh iesia , as wellas the loca tion of th e team - a t. the m eflec ted fo ld of the jo im it.

The fo l lowiu ig ( a se u e po m- t d em ot is t ra tes the ch ia tiges tha t take 1)lace im i th eso -cal led f m oz ei t s hi ou l( le n:

MS., a white w om ati, th ir ty -n in e \ears old, was first seen on 1\Iav 31. 1957, whett she statedh tat abo ut eig h t m onths pro v io us ly ll(rsistont pain ha d developed in the l eft slio tm hle r. Ixe rcis es

au td u iiih l uiiallil)Illat i(flis had giveum no relief. B o su it g etso gram s of t lu sho uld er rev ealed im o lla t 110 -log ical ( (luR hit io n . T he P atien t h lt sh te w as m nakiu tg no rO g ress, soo t s In ( 00 11 )1 to t sleep a t. u tig h itand ha d (l(tillite lim ita tion of m uotio n o f tlte shou lder. W hen exaniitied a ct iv e a l d ti o tou ) of t IteshloIiId(r \V:L5 #{182}K)egrees :tti(I p ass ive ab du ctio u t w as 95 deg rees . U pout in terna l ro ta t ion , tlte lift.h au td j us t. ue:u hud t I m e l e ft l o it . t o( k. A r th r o gt an i .s w ere n i:u le o f I ot It s lu l lmhh r s (Ill ,June 1, 1957.The rig h it sh ioum lder ea sily to ok th e s ix te en cubic cetitimneters of so lu tion th at w as in je cte d and th etrt .h irogran is (F igs . S -A , 8-B , and 8-C ) w ere no rm al. T he lef t sh oum ld er took om ily t.e ti cu b ic cen tim ete rsL nd th t trth iro u rns I i 7 7 B (tIll 7 ( ) r( V( u lt d (10 h tiite d o r ( 9 .Se (l jo in t cp u tt v u t h u ln t o - t


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Fme . 8- B Fe;. 8 - C

ARTHROGRAPHY OF THE SHOULDER JOINT 1327

V O L . 44-A , N O . , O C T O B E R 1962

Fig . 8 -14 : fhn rightt shoulder in abduc tio n. l hie ax illary fo ld hots hs.c oune tense aum (I thte dy e iseasi ly see ti ill thie suhsoal)( tlaris bursa and Ilic ipital sheath.

Fig . 8 -C: The ax illary v iew o f the right shoulder reveals g ood ouuthitte of thie suliscapuularis hursat11(1 biceps shieat.hi :01(1 relaxat. io it o f t h te l)osto rio lr capsule .

FIG. 9-_& Fa;. 9 -BFig . 9 -A : A rt.htro gram n (If shmoum lder of M .5 . afte r mnalm ipulationi of the arun un(le r am iesthie sia. N (It.e

th e e s( ape of dye at the s ite of the tcar itt thie adheremtt ax il lary fo ld. The ulye extrav asate s into theax illarv 5 i)a(e an( l along the iuiner si(le (If the artis .

Fig . 9 -B : A rthirog rani niade after unanil)um latio ts w ith the ann mt ah.Iductiout.com plete obliteratio n of the ax illary fo ld. The subscapularis bursa, as w ell as the hicipital sheath,wa s not v isualized. In this instance , i t wo u l d appear that the inflammatory Process h ad o hh ite ra t, edbo th the subscapularis bursa and tendon sheath sinc e ev en wi t h a b d u c t i o n o f the shoulder the pic-ture di d not change. Comparison of the ax illary v iew s of the tw o shoulders (Fig s. 7 -C and 8-C) andof the anteroposterior v iew s (Figs . 7 -A , 7-B , 8 -A , an(I 8-B) emphasizes the exoe llemst outlitie o f thesubscapularis bursa and bic ipital sheath am id the loose (apsule of the normal shioulder as comparedw ith the decreased jo int capac ity and obliteration o f the axillary fo ld in the fro zen shoulder.

This patients le ft shoulder wa s manipulated umider pe tito t.hal ane sthesia on July 9 , 195 7 .A rthro graphy was perfo rmed just prio r to the manipulatio n w hile the patient w as under anesthesia.The finding s w ere the same as show n in Figures 7-A , 7 -B , and 7-C . Roentgenograms w ere madeimmediately afte r manipulatio n. They show ed that the capsule had t.o rti at the adherent ax illaryfo ld with escape o f the dye into the ax illarv s p a c e atid (IOW tiw ard along t.he inner aspect o f the hum-merus (Figs . 9 -A am id 9-B ). W ith the usual postnianipulation care the patient go t along quite w elland regained 180 degre es o f active and passiv e abduction about a month after the manipulation.

A lthough this patient regained satisfac tory function o f the le ft shoulder in a v ery short periodof time, she started to complain o f pain in the right shoulder w hich gradually lo st motion so that


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Fm u . 10-A F u;. 1 0-Blig . 10 -A : M S. A r thro grarn o f th ie rig h t sh ou lde r, tnade tw o rnomtt his afte r F ig . 8 -A , now show s

a d h e s i v e ( a l l s umh ; t i swi t hi d e c r e a s e d j(Iiitt capac ity and a lm ost com p lete obliteration of th e ax illa ryf o l d .

F i g . 1 0 - 1 4 : The arm i s iti max imum a b d uc t i o n . ( Co mp a r e wi t h F i g . 8 - 1 4 . )

Fe ; . i l - A Fme . i l - B

1328 J. S N E V IA S E R

FIG. 11-CF ig . 1 1 -A : A r thrograrn o f he ft shou lde r of M S. m ade tw o m ou ths a fter m an ipula tion un( ler

anes the sia . N o te the g ood axillary fo ld . (C om pare wi t h F ig s . 7-A and 7-B .)F ig . 1 1-14 : W ith the left a rm in abdu ction , the ax illa ry fo ld be com es te tise. N ote t h e (lye in the

b iceps shea th .F ig. 11-C : In the ax ilha ry v iew the b iceps shea th ap pears m iorm a l.

T H E JO U R N A L O F B O N E A N D JO IN T SU R G E R Y


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AR T H R O G R AP H Y O F T H E SH O U LD E R J O INT 1329

\(IL. 44-A. NO. 7, O(.TOBEit 1962

Fiu. 1 2-A FIG . 12-BFig . 12-A : A rthrog ram made immediate ly afte r manipulation of the right shoulder. The dy e is

escaping through the tear in the axil lary fo ld.Fig . 12-B : A rthrogram made w ith the arm in abduction after manipullati(Iti o f the rig ht s hio ulde r.The dy e is ex trav asating along the inner side of the arm .

O n S ep te ml) er 10 , 1957 , she could only abduc t to 1 20 deg ree s atid, on internal rotation, the righthand just to uched the right buttock. The le ft shoulder continued to have an exce llent range ofmotion w ithouut pain. On S eptember 1 :3 , 1 95 7 , a rth ro gra ms were repeated on both shoulders . N owonly s ix cubic c entime ters o f dye cotmld be injec ted into the right shoulder which tw o months or-v iouslv had easily taken s ix teen cubic centimeters (F ig . 8 -A ). T h e a r t h r ogr am o f t h is sh o u ld ershow ed def inite ev idence o f adhe siv e capsulitis w ith decreased jo int capac ity , obliteration of theaxillary fo ld, and alniost complete lack of f illing of the subscapularis bursa (Figs . 1 0-A and 10-B ).D uring abductio n of the armn the arthro granss show ed no significant change s. The left shoum lder,w hich had hieen manipulated a little ov er tw o months prev iously , a pcared almos t normal Ilyarthrograns w ith a good ax illary fo ld w hich tensed in abduction (Figs . 1 1-A atid 1 1-B ). The ax illaryv iew outhim ied the biceps sheath and show ed the no rmal re laxatio n of the po sterior capsule (Fig .1 1 - C ; coniare iv ith Fig . 7 -C ).

The righit shoulder w as manipulated under pento thal atse sthe sia oui S eptember 26 , 195 7 . Theart.hrograun.s obtained during the manipulative procedure show ed the sam e change s observed afternrunil)ullation of the left shoulder - te aring of the capsule at the adherent ax illary fo ld and (s( al) (of dy e into the axil lary space and along the inner side o f the humerus (Figs. 12 -A aui(l 12-B). Inthre e months this patient had complete range of motio n in the right arm w ith no l)aili.

Om ic of the problem s in the treatment o f a so -called fro zen shoulder is thedifferentiatiom i betuveem i patiem its iv ith true adhes iue (apsuhitis and those ui-it hia s tiff and paim iful shoulder im i which the lim itat.iom i of motion is due pnimnarilyto muscle spasm . Lim itation due t.(I Inusc le spasm no t iiifiequemit hy fo llow s someform o f tratmma or tendimsitis . S im ice the clinical f im idim igs o f 1 )0 th types ar e ssei t-t.iallv the same, arthrographv (an be used no t only as a valuable diagm iosti( toolbut. also as a therapeutic aid. In our series , fif ty -three patients ui-crc seen w ithsigns suggestive of adhesiv e capsuhitis . How ever, art hrography show ed that onlyforty-t.uvo had decreased jo int capac ity , obliteratioms of the ax ilhary fo ld, am i(I fre -quently a complete or almo st complete absence of the suI)scapulal-is bursa. Th eanthro lg raphic fim iding s in these shoulders iv ere quite cons istent in the ir appear-am ice . The eleu-cm i sh Ii i lokm -s w ithout these findings uvcre treated suo o e ssful ly ei the 1by physical thicmapy on by iiijec tio iis (I f hiydrocortisone i n t o t he jo int capsule foh-louved by exerc ises to res tore abduction and ex ternal ro tation. The finding s byarthrographiy iii adhesiv e capsuhitis tend to coufim m ii the patho log ical findim igs pie-v io usly described in 1945 u#{ 149}n ev ery case there w as comitracture amid thickenim ig (I f


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1330 J. S . NEVIASERth e capsu le w ith re su ltan t decrease in the jo in t capac ity and adhe ren ce o f theref lected fo ld causing ob lite ratio n of th e depend en t ax illa ry fo ld . In som e in -s tances the sub scapu la ris bursa w as ob lite ra ted and co u ld no t be v isua lized . T heb icep s sh eath w as o u tlined in the m a jo rity o f case s, thu s confirm ing th e con cep ttha t b iceps tend in itis is on e of the en d re su lts o f adh es ive cap su litis and no t itscause. On ly 18 pe r cen t o f the sho u lde rs with prov ed adhesiv e cap suh itis sh ow edfa ilu re o f v isua lizatio n of the b iceps shea th b y a rth ro g ram .

CONCLUS IONS1 . A rth ro g rap hy of the sho u lde r d em ons tra tes the g ross p ath o log ica l ch an ges

ill ad hesive capsu litis o f the sh ou ld er . In tru e adh es ive capsu h itis , o r frozen sh ou l-de r, a rth rog raph y sh ow s a ve ry d e fin ite d ecrease in jo in t cap ac ity w ith o b lite ra -tion of th e ref lected ax illa ry fo ld . In m any in stances the sub scap u la ris b u rsa isdec reased in size o r no t v isua lized a t a ll bu t, a s a ru le , the b ic ip itai sheath is w e llou t l ined .

2 . Th is p roced ure can se rve as a d iagno stic aid to d iffe ren tiate true ad hesivecap su litis from stif f and pa in fu l shou ld er due to o ther causes .

3 . A m ix tu re o f tw e lve cub ic cen tim e ters o f 3 5 p e r cen t d iod ra st am id fou rcub ic cen tim e te rs o f 1 pe r cem it p ro ca ine app ears to b e the id ea l so lu tion to u sefo r im ijec tion o f sh ou ld er jo in ts . T h is am oun t g ives a rth rog ram s w ith excellen t d e -ta il, an (1 the p roca ine p reven ts any pa in ivhen th e sohu itiom i is iu ijec ted in to th e jo in t.

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go np rax i s , 5: 5 89 -5 90 , 1 9: 43 .(C ontinued on page 1359)

TH E JOURNAL OF BO NE AN I) JO INT SUR GER Y


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VO L . 44 -A . NO.7, OCTOIER 1962

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