0:00

Okay, so here's the same shoulder

0:01

we saw on the last vignette.

0:03

Because some of these findings were subtle,

0:04

we weren't quite sure what was happening.

0:07

So we decided to get an MRI, as I

0:09

mentioned, but people in our department and

0:12

orthopedics felt that we couldn't really

0:14

rule out a labral injury also, or other

0:17

rotator cuff problems that may happen.

0:19

So we decided to get an MR arthrogram.

0:22

You sort of see the images up here

0:23

a little bit on the thumbnails.

0:25

But I wanted to show you exactly what

0:27

our approach is in getting arthrograms.

0:29

We do everything under ultrasound guidance.

0:31

And I think this may be a little

0:32

different, uh, than what you do.

0:34

Probably most people do it

0:35

under fluoroscopic guidance.

0:37

But because we're dealing with children, we

0:38

want to limit the radiation as much as possible.

0:41

And we've switched over to ultrasound guidance.

0:43

So, just for your education, I want to show

0:45

you how I would approach this under ultrasound.

0:48

I have brought the image here now.

0:50

I am going to first draw in where I think

0:55

the ultrasound probe is best placed.

0:57

What I first do under ultrasound,

0:59

imagine this is the transducer.

1:01

I have the transducer oriented in a plane that

1:05

is perpendicular to the shaft of the humerus.

1:09

So I put that transducer

1:11

right over here, like so.

1:16

This is sort of a top-down view, if you will.

1:19

Uh, the cord would be over here, it would

1:22

sort of dangle out down this way, okay?

1:26

And I always find this structure.

1:29

Again, that's my best friend.

1:32

That is the coracoid process.

1:34

Once I find the coracoid process, I know that

1:37

I'm about at the level of the subscapularis.

1:41

And then when we find the subscapularis

1:43

tendon, then I just go slightly above.

1:46

So the transducer is translated slightly

1:48

this way until I find the rotator interval.

1:52

And I'm going to show you all this on

1:53

the ultrasound, but at least this gets

1:55

you an idea of what my approach is.

1:58

On the plain film surface.

2:00

And where does the needle come in?

2:02

The needle comes in lateral to medial.

2:04

So it's going to come in like this.

2:07

Okay?

2:08

I'm going to hit the articular

2:09

surface, inject the needle.

2:11

I can actually see the

2:12

contrast filling the joint.

2:14

I can put a little bit of color, uh, to see the

2:16

motion of the fluid, and it's very, very simple.

2:20

So with that in mind, I want to show

2:22

you what the ultrasound of this looks

2:24

like as we inject the joint contrast.