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

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Arthrography
Sq-u-Dy
OF Th11 BY FINDIx(;s
JULIUS S.

of the
IN
ADIIESIVI NEVIASER, M.D.,

Shoulder
C.upsvuiis OF TIlE \iASHINGTON, D.C.

Joint
SmmoITIDF:R

This

mel)olt

is

1)ased

omi

the

study

of a large the

group findings findimigs

of arthrographic by arthrogram seen at operation

l)mo(eduies were orand at

pemfomnied on the shoulder related uiith the anatomical

post

joint in which amid pathological

mortem examinatiomi. The clinical series includes 261 shoulder lesions. The contrast medium used uyas diodrast. Sixty-four shoulders ui-crc subsequemitly cxposed by operation amid eighty-seven uvere subjected to closed manipulation or reduction. In the remaining 1 10 shoulders, there was either no abnormality that ivould require surgery or manipulation or the patients, in a feuv instamices, refused

the indicated therapy. diodrast ui-as inj ected of the shoulder made shoulder joimits. These
after death. They

Sixty-eight intracapsularly in the necessary post mortem

a more

autopsy studies were also made iii which into cadavera followed by roentgenograms positions and by dissections of these same studies uvere made uvithin tuventy-four hours
detailed comparisomi of the roemitgenographic

afforded

findings of this (apsulitis

and article
(If

the to the

amiatomy describe shoulder

than the

is usually anatomical

possible and
by

at operatiomi. pathological amid

to

It. is the findings

shouv in

purpose
adhesive the value

as demonstrated

arthrography

of this procedure as a diagnostic and therapeutic aid. Codmaui, in 1934, memitiomied the possibility of imijecting the shoulder joint to confirm the diagmiosis of an incomplete spinatus tendomi but did not try this procedure. Limidbolm and raphy ruptures
of

an opaque fluid into rupture of the supraPalmer used arthrogcuff and

to detect of the

complete tendon study

in

or incomplete of the the the long head

tears of the by cuff

in

the

muscubotemidimious

biceps.

Oberholzer

used

arthrograms discussed described the the In his were ruptures of the ruptures, this proantero-

the shoulder to value of arthrography findings report, in ruptures as in most amid of poor

lesions caused diagmiosis of of the articles, in

disbocatiouis. Axen ruptures amid also

of the long head of the published quality. Pettcrsson,

biceps, as well t.he illustrations an excellent with antero-inferior of arthrography

as in dislocations. of the findings monograph on dislocations to test for cuff He also used at the capsule

Sparse of the shoulder, particularly cedure

inferior

muscubotendinous reported the in patients to demonstrate part of the joint.

cuff associated quite frequent use who the were progress over

thirty

years of the

of age. torn

of healing

TECHNIQUE

During
varying amounts

the

development
of

of the

technique

of arthrography

to

be

described not the the as

dye were injected into the shoulders of fresh cadavera, only to judge how much solution should be used to give the best detail on roentgenograms but also to determine the capacity of the joint. In adults, capacity varied from twenty-eight to thirty-five cubic centimeters. Strange
it may seem, some shoulders in women took more solution than comparable

shoulders from the nounced tendency

VOL.
44-A,

in men. In more than one instance, the left by as much as five cubic centimeters; in cadavera over sixty years of age. of the
NO.7,

right

shoulder differed in capacity this difference was more proThis may be explained by the which is least used habitually.
1321

capsule
1962

to contract

in the

shoulder

OCTOBER

1322

J.

5.

Ni:\1AsEm(

liu. Iig. t(riorly.

Fig.

I
)l r )(llt
4r(.(

lmu.
glLtt1 sitouving sitouvilig

2 after au
i

1:

:ltttl

I ssteti
l()(l1t

11(0(110 pl:ued

ill

aXi

llary

slIa(( through

ns(rt

ing

it

au

2 : xillary

gclngralii

n((dl(

in t lie joint

autterior

alll)roa(h.

1i. lig.

3-A 1Ite
vieuu
rotat

Fiu. 3-14
1 ills sInai It is not visible uuit Ii I Ito arm i It exterind ion. but t he sIll )s:tp(ll:Lris rotation.

3-; : ;rt ltograni of a ttornial sitoulder. 1tmrsa is uvell out liuted itt t itis amiteroj)( tsterior Fig. 3-14 : lit t his V1(tV t lie arni is iii imiternal

I mma n( umiimmI j
t i(Iii

)I u m

it uu:Ls foul

1(1 1 limit

misc

)f 1(1)0th!

six!

((ii

(III

Il

ccii

t imii(t

(IS

(Ii

5(11(1-

mesult ((1 ii moemtt gemmogmamiis uvith t lie h)est (let nil ( ligs. 3-\. I hr(Iugh miiome t Inn m six! ((Ii (tml lie (Cii t i miiet ers uveme use(1, I he shadouv of t he (hum was S(I deimse that the outlines of the joimit were obscured. Another finding of imiterest in three cadau-era h)etweemi the ages
and sevemity years

3-i
((lilt

) . \Vhemi
m-ast me-

of sixty-five amid
of

ui-as a c(Ilumumiicatiomi
and was

between memitioned
joimit

the
edges and history
years authors

joint

proper
in of

the

subknowmi

deltoid
rupture

bursa of the
after

uvithout the 1-agge(I cimif. A similar finding

ion

irregular

characteristic

a definite

by Gasser the
as

1902.

It is bursa
This
(If

that
develop

a coniniummicat imifrequeittly changes,

with

iiot tive failed

(lemice

bet uveen the shoulder a spontaneous rupture without itt patients past the age of by Irostad the
in each presumably

subdelt(Iid
trauma. result bursa Theme the

may
occurs
three

any
sixty

degemiera-

as reported

and
between

other the

Dissection amid the

iii

of the

shoulders of

a communi(atiomi

joint

this
uvas (apsule
110

study
eu-iwas

to establish to be
rather

definitely
thimi,

cause instance
due

of this
the to

coniniwiicatiomi. posterior attritiomial amid

a tear although

0.11(1 supem-i(Im degemleratiu-e

foumid

changes. had

Incidentally,

this

communication

ui-as miot demonstrated

THE JOURNAL

until
OF BONE

the
AND

joimit
J(IINT

beemi

SURGERY

ARTHROGRAPHY

OF

TIlE

SHOULDER

JOINT

1323

Fm(;.

3-(

Ftc..

3-1)

Fig.

tion.

:4-(: Note

also, 5011W sheath. Fig. :4-I):

of

In this vieiobliteration dye is now Axillary view.

the arm is in of the axillary seen in the

Note bursa
is

a1)(luc-

fold; biceps

re(lumi(lancy

the

(al)sLml( at
The
to the neck

the
of

posterior the
scapula.

part
well

of the
filled

joitit.
alit.erior

sitliscapitlaris

Fig. sheath

3-E: Bicil)it.aI is vell outlined

groove view. Tlio biceps its the hicijlital groove.

Fm;.

3-i

fully thi(.ii could

dist emi(1(.(l ui-it Ii misore t han I uvinty-eight (UIIi(cent inicters of solution. (July dli(l tin simbdeltoid bursa I)econie filled. It is possil)le that these opemiimigs hau-e beems uerv small sifl(e the bursa did not. fill until the joimit. ui-as under te(hiiii(lUe
shouldeu-s Imi the these polsteriolr position are the by carrie(1

temision. Our
for

u-am-ie(I, (le)en(hiiig
ex(-ept the sometimes
to
obtain

on the
approach might l)e

case.
ui-as used

\Ve found imi all

used adhesiu-e to)

cases,

I lie

suitemium capsulitis misore

one

approa(h or
frozen

most

those

suspected

of hauiimg

shoulder. Although

postemior techmiaiime

be
its

satisfactory. disadu-amitage

is that
to

the
supine

needle

the

is bent ui-hems the patiemit axillary \-ieuvs; this has

the
x-ray department

is turned not caused

the I he
iii

procedures

out

in

uvithi

patient supine
area

from the prone difficulty. Both (I a combined

position
(If
1(111

roentgenographic
In his armu

and
anteriom

fluoroscopic appl-oa(h, the in imitem-tial sterile coracoiol uvithi the scapula lomig, the
m962

table.

pat iemit
1-oltation.

is placed
rfhe The

iii

with
is poimit

his side and I he

skiii lalt(lmiiauk

the

injection is a

prepared

with

just
of

belowimijectioti
t(I

tue
is

tip
umeck inches

usual of the

t echiimaue.

fou- inject

pmmess I
per (emit

amid veiy
procaine,

infiltrated
(If

slightly medial to it. in(hm(hing the deep

The site tissues

(lown
a half the
VOL

the

om three bone
44-A. NO)

is

themi

close to the glemioid. imssemted aiid directed

off

A 20-gauge needle, two amid touvard the glemsoid. Whemt

and themi u-edirected a little

is reached
7, 0(TOBEIt

mieedle

is backed

slightly

1324

J.

S.

NEVIASER

Fm;.
lig. 4 : .tt

Fm;.

,5

Itt )gt:t lii ( f a ut, )rtnal s(alnmlauis hiitsa is m:tthet stiiall. lig. S : l ost (.1., )-0t1 I (lit It t( (Itt gotto iltt() tlit lml)l)(t I)ttt of the jitittt

liotmldet.
gt:Ltsi
(

Flu )f.
fl

I liccps
slit )t

slie:ttIi thlct

is liovitig

oimtli mle(l ttcelk

bitt

tin

sura-

right

i tls(tt(d

I )ost.oriorlv

mtottItor

artlirogramii

of a ttornial

shoulder

Fmo. 6 muade its

tIn

1)ostero-:Ltttorit

proj((t

ion.

Flie

biceps

sheath

is WOll omttline(l.

niore 1 amid of

latemall2). The (nine t u-eli-c

5(1

that

it emiters of the

the

,J(Iimit.

space
uiouv be

just
checked

al)ou-e
and

the
foum

axillary
cubic

fold

(Figs.

p(Isitio)iI

needle

can

by fluoroscopy. cubic

A muixture
ceiitimiieters of

cent

inietem-s of 35 per cemit diodrast

pmocaimie

injected.

is imijected into the joimit. At first miot. more thami tuio If this flouvs easily amid out hues t.he joint. ui-eli on the

fluoroscopic

cemitimeters is screen,
withdrawmi, the
necessary

then
amid
positions.

the
uoent

memiiaimider
gemiogm-amsis Since te(hmiiciami 20-gauge the to needle stw.lies
iii the

(If

the are

solution

is imijected,

the

needle

is quickly
in mniiiutes it

imnmnediatelv
is absorbed

made
in a certain to

uvith
about

the
t went
(If

shouldeispeed.

diodmast

is

necessary in thi(

fom the A
1)01st

proloeed
uvas

with found (Ibsen-ed

he
that

the

amoumit most

satisfactory

size

since

moImteni

it

ui-as
capsule

needle
Lak:mge

opening
of dye

if au

theme uvas somne leakage through the 18-gauge on 19-gauge uteedle uvas emnployed.
iiiuke t lie of 3
iii! emprel ;tt iou of nit

out

side the joiumt may (0100 cemitimeters

art hirogta font

iii

(hifhi(hilt A niixtume centimeters

(If

of twelve
I pci cemit

pem amiy

((itt

(hiodma.st when
0)1 IOUNE

amid

oubio
is
SURGERY

procaimie

ehimisiuiates

psumi

the
AND

mixture
JOiNT

iii-

iill JOUItNAL

ARTHROGRAPHY

OF

THE

SHOULDER

JOINT

1325 joint, pain ivihl occur, the use of 35 per cent 3-A through uvell
show

jected imito the joint. If the mixture should not be but it uvill be less severe than the pain which results diodrast The 3-E. lined uiehi without procaine. appearance of normal arthrograms can be

in

the from

seemi in Figures

It. should be noted that in some cases the subscapularis (Fig. 3-A) ; in other instances, it ui-as someivhat smaller (Fig. 4). This also) applied to the bicipital sheath uvhich
for some distamice (Fig. 4), whereas
iii

i)ursa ivan and did not

uvas occasionally

outup ivelh

visualized Aim arthrogram

made one

uvith

the

arm

in internal

(Ither rotatiomi

cases it. was (Fig. 3-B)

barely visible. has a differemit the was the

the arm

appearance
arm uvas

than abducted,
in was

made with the normal the

outlined

the arm axillary biceps

well uvith

in external rotatioms fold uvas obliterated. (Fig.

the arm

(Fig. 3-A). When This maneuver In

side;

very
biceps

helpful
sheath

outlining
not

sheath

3-C).
at the

many
hut

instances,
uvith

abducted, and The tcriorly

nor

the

dye

w-as

pushed

superiorly

by

the of

tense

reflected

axillary

fold

the solution ran into the synovial axillary u-ieuv (Fig. 3-D) shouved as uvell as the
capsule (If

sheath the outline ouer

to reasomi

the biceps without of the subscapuharis lesser relaxed

posterior the tears

difficulty. bursa anThe

post.e-

1)iceps
that this Simice

sheath joint
may the

rumining was foumid

1)e the capsule before from the

the
be why

tui)erosity.
in

the

shoulder

all

shoulders. head
the

This
of the

led have

me

to muore

speculate are infrequemit. to space

dislocations humeral or stret(hes

shoulder

is redumidamit, it actually

may
articu-

misove the

backuvard ray

lar

capsule

amid subluxates.
central

A roeuitgenogram film placed above the

of the
tube

bicipital
the

groove
long axis

(Fig.
of

3-E)

is

made by directing of the humerus

along

ui-it.hi the

humeral

head. contrast (-apsuhtis superiorly, the joint

This medium

the shaft uiew oluthimies filling the

the sheath of the long head of the biceps tendomi by the peritendimsous space (lig. 3-E). The posterior approaoh is usually used imi adhesive
der. In this
coiiditiomi

oIm. fmozemi

shoul-

inferiorly;

hence,

the dapsUic temi(ls to contract. it is difficult. to imiject the dhye int.o

anteriorly,
amiteniorly. Iii

amid
mny

earlier attempts grams of the this difficulty.

inserted
imiternal

at. arthrography this was the cause of failure shoulders with adhesive capsuhitis. The p(lstenior With some relaxatiomi of the capsule posteriorly,
relatiyc ease. The patient lies prone usith his armu

to obtain approa(h the needle

by his side

art.hrosolved cams be
amid in

with
rotation.

A good portion to the of the

as

landmark tip

for

injection where process. slightly position

of t.he

is the

slight

depressiomi

felt

just

below directly umider the

fluoroscopic

the medial posterior sterile part

of the acromion of the coracoid and directed (Fig. 5).

distributioms

it joimis the spine of the scapula The 20-gauge needle is imiserted upuvard
(If

precautions joint
control,

so that. the needle

niedium the

the

needle
after the

enters under
injecof the

upper

The

is checked
remaimider

is the

contrast

tiomi of tuvo cubic cemit.imeters of dye. If the fluid is iii the joint dye is injected into the joimit, amid the desired roemitgemsograms
ately.

are

niade

immediposit
1(111

The

appearance

of a miormal

arthrogram

made sheath of dye

in the

postero-antenior outlined. (twelve cubic

is shouvn in Figure 6, where Norniahly, sixteen cubic of 35 per

the bicipital cemstimet.ers

is well solution

centimeters

cent diodrast and four cubic centimeters of I per cemit procaimic) can he injected uvithout any resistance. If there is resistance the imijection should he discoiuliumued, since this may mean that the micedle is not placed correctly iii the joiitt;
or, if I lie needle

is

iii

the in

joint,

iuijectiomi

under opening. of

lressure This the joint

may

cause five

the dye

hI

leak of
cubic

out

of the

capsule capsuhit.is

aiouiid w-hich

the

needle the

is especially is only

true to

iii

cases
temi

adhesive centimeters.
VOL.
44-A. NO.

capacity

7. OCTOBER

1962

1326

J.

S. NEVIASER

Fa;. lig. 7-A:

Art hrogram

7-A
of a case

F;. MS. ion ion.

7-14
joint
aumd

(Patieumt. (aIanit V autil t he altilost ( tmplite olIli terat I 0((J)S shoat 11 0 ( t)( )t 0)11 t Iille(l. Fig. 7-14: lie truss is itt maxiniumu abduct

) (If adhesive (al)sumlit.is. Note the (le(rease(I f t he axi Ilat f ld . The stmhlscalnmlaris Itmtsa

Fi;.

7-C

Fme. 8-A
axi Ilarv

Fig. 7-( : Axillarv view. (Compare wit It ttornial shotilder in Fig. S-( -. Fig. 8-A: Appearance of the right shoulder of MS. The out Itr gratli is nomni:tl wit It t he 11)1(1 (ll Ot it Ii tO) 1 and t h( 1 sheot It (as; lv seett.
A i)II1SIVI (Ps1 11115 (If

\.rthimogmamns CaJ)stmlitis
misally ( If

uveme niado shi(Ilmldel.

hi Il(Igi(al
(If

of

hothi

shouldems pmeviolusly
aftem-

fifly-thiuee in ed

l)at.ieiits this
20,

uvith

adhesive
((Imifim-ni

of
t he

one
l)t

Flie

arthimogm-aphic

findings rep fold

of
It!

(on(hiti(In
,%it

fi i id i uigs

Ii m-ogranis
as

also
well

deniommst

rate location

healing of the

the
at.

(apsule

mautipimlatiomi

under joimit. that

autesthiesia, take

as the so-called

team-

the

meflected rates

the

The

followiuig
fmozeit

(ase uepom-t demotist shioul(len:

thirty-nine proviously giveum hlt
of muotion

the

chiatiges

1)lace

imi the

MS.,
htat autd logical
and

a white womati, eight

uiiallil)Illat

\ears
ll(rsistont

old, was pain Bosuit mnakiutg

tlte shoulder.

first seen had

on of
t

1\Iav 31. 1957, whett in the left sliotmhler.

she imo

stated
llat 110-

about uiiihl

months The
limitation

developed
)rOgress, When soot

Ixercises at. utighit of

t Ite

i(flis had

no shte

relief. was
of

getsograms
no

lu

shoulder sIn (0011)1

internal

revealed tot sleep

((luRhit ion.

Patient

had

(l(tillite
\V:L5

exaniitied Upout

active al dtiot iou)

rotation,
(Ill

shloIiId(r

#{182}K) degrees

:tti(I passive

abductiout

was

95

degrees.

tlte

lift.

hautd just. ue:uhud The righit shioumlder trt.hirogranis (Figs.

trthiror

tIme left loit.to(k. Arthrogtani.s were ni:ule of I ot It slullmhhrs easily took the sixteen cubic cetitimneters of solution that was S-A,
urns

,June injected

1, 1957. and the

8-B, I
i,

and

8-C)

were

normal.
V(

The

left

shoumlder

took

omily t.eti cubic cp

ANI)

centimeters
v

Lnd tht

7 B

(tIll 7 ( ) r(

ult d (10 htiite

iiIE

d o r( 9.Se(l joint
OF 130)NE

tt

uth ulnto-t
SURGERY

J(I1RXAT.

JOINT

ARTHROGRAPHY

OF

THE

SHOULDER

JOINT

1327

Fme. 8-B
Fig. easily Fig.
t11(1

Fe;. in abduction. lhie bursa and Ilicipital of the right shoulder

of t hte l)ostoriolr

8-C
tense
thie

8-14 : fhn rightt shoulder seeti ill thie suhsoal)(tlaris 8-C: The axillary view
biceps shieat.hi :01(1 relaxat.ioit

axillary sheath. reveals

capsule.

fold good

hots hs.coune
ouuthitte
of

aum(I thte

dye
hursa

is

suliscapuularis

FIG. Fig.

9-_&
(If shmoumlder

Fa;.
of M .5. after mnalmipulationi tcar itt thie adheremtt axillary

9-B
into

the axillarv
Fig.
complete

9-A : Art.htrogramn es(ape of dye at the

site niade

of the after axillary instance, and

of the arun un(ler amiesthiesia. fold. The ulye extravasates

ann

N(It.e the

5i)a(e an(l
9-B:

along

the iuiner

si(le

(If

the artis.
with subscapularis
appear that the

Arthirograni

unanil)umlatiots fold. The sheath axillary

the

mt ah.Iductiout.
as well abduction shoulders the normal in patient t.orti at the anesthesia the was the got after the lost as the hicipital had sheath, ohhiterat,ed and 8-C)
Process

obliteration
not the visualized. subscapularis not change. bursa In

of the
this bursa Comparison

bursa,
inflammatory

was

it would

both ture

tendon
of the 7-A, sheath

since views 8-A, loose

even of the (apsule

with two

of the (Figs.

shoulder
7-C

did

of the with

anteroposterior
and

views

(Figs.

7-B,

an(I 8-B) of the

umider

emphasizes
of the fold petitot.hal while axillary

exoellemst
shioulder frozen on under

the picand outlitie of the

as compared

subscapularis

bicipital

amid the

the decreased This patients

was

joint capacity left shoulder

performed just

and
was

obliteration
manipulated to the showed usual

shoulder. July 9, 1957.

Arthrography

prior They

manipulation

The
fold merus and

findings with
regained Although she
NO.7,

were
after

the

same

as shown

in Figures
that
space

7-A,
the

7-B,

and

7-C.
had

Roentgenograms
adherent aspect along

anesthesia. were made

axillary

immediately (Figs.

manipulation.

capsule

escape
9-A 180 this started

of the dye into

amid 9-B). degrees patient to With

the axillarv
the and of pain

atid
abduction function

(IOWtiward
care about of the shoulder left which

along
the a month

t.he inner
patient

of the humquite short well period so that

postnianipulation

of active regained complain

1962

passive in the

manipulation. motion

satisfactory

shoulder gradually

in a very

of time,
VOL. 44-A,

right

OCTOBER

1328

J.

NEVIASER

Fmu.

10-A two
rnomtt

Fu;. his after complete with

10-B Fig. 8-A, now shows of the axillary

lig. 10-A: MS. Arthrograrn of thie right shoulder, tnade adhesive (allsumh;tis wit hi decreased j(Iiitt capacity and almost fold. Fig. 10-14: The arm is iti maximum abduction. (Compare

obliteration

Fig. 8-14.)

Fe;.

il-A

Fme.

il-B

FIG.

11-C
after manipulation Note

Fig. 1 1-A: Arthrograrn anesthesia. Note the good Fig. 11-14: With the left

of heft shoulder of MS. made two mouths axillary fold. (Compare with Figs. 7-A and arm in abduction, the axillary fold becomes

un(ler in the

7-B.)
tetise.

the (lye

biceps
Fig.

sheath.
11-C: In

the

axilhary

view

the

biceps

sheath

appears
THE

miormal.
JOURNAL OF BONE AND JOINT SURGERY

ARTHROGRAPHY

OF

THE

SHOULDER

JOINT

1329

Fiu. Fig. escaping 12-A: Arthrogram through the

tear

12-A made immediately in the axillary after fold. manipulation after of the

FIG. right

12-B shoulder. of the The dye is

Fig.
The dye

12-B:

Arthrogram

made
along

with
the

the arm
inner side

in abduction
of the arm.

manipullati(Iti

right

shioulder.

is extravasating

On

Septeml)er

hand
motion

just

10, 1957, touched the

pain. On

she

could

only

abduct

to

120

degrees were the

atid,

on

right

buttock.

withouut

September of dye

The left shoulder 1:3, 1957, arthrograms

be injected with of the showed two months into (Fig.

continued
right 8-A).

internal rotation, to have an excellent

on arthrogram capacity, bursa changes. a)pcared (Figs. The almost both shoulders. two of 10-A left obliteration and which

the

right

range
months

of
Now or-

repeated shoulder The joint

only six cubic centimeters viouslv had easily taken

showed axillary During which
arthrograns

cotmld

sixteen
of adhesive complete

cubic
lack the a little

centimeters
capsulitis of filling over

this

shoulder of the 10-B). Ily

definite fold, had and hieen abduction

evidence alniost of the manipulated

decreased subscapularis no

armn

arthrogranss

significant

shoumlder, normal

previously,

with a good axillary view outhimied the biceps sheath 1 1-C ; coni)are ivith Fig. 7-C).
The righit
of

fold which tensed and showed the

under tearing along the range of the inner

in abduction (Figs. 1 1-A atid 1 1-B). The axillary normal relaxation of the posterior capsule (Fig.
pentothal atsesthesia
showed

shoulder
obtained

was
during

manipulated
the manipulative
-

oui September

26, fold 12-A aui(l

l)aili.

1957. and

The after (s(al)( In

art.hrograun.s nrunil)ullation of

procedure

the same
adherent humerus

changes axillary

observed 12-B).

the axillary

left patient

shoulder space had and

capsule side of

at the the in

dye

into months

the

(Figs. arm with

three

this

complete

of motion

the

right

no

Omic of the
differentiatiomi a stiff
to form

problems
betuveemi

in

the

treatment
ivith true

of a so-called
adhesiue

frozen
(apsuhitis motion iiifiequemit is

shoulder
and due those

is the
ui-it hi some pnimnarily are

patiemits due (an aid. In

and

paimiful
spasm.

shoulder
Limitation

imi which
t.(I

the
Inuscle

limitat.iomi
spasm not only fifty-three not

of

muscle the also

hy follows

of tratmma
same, as

or tendimsitis.
arthrographv

Simice
be

the
used our

clinical
series,

fimidimigs

of 1)0th

types ui-crc showed fold,

sseittool

t.iallv but.
signs

as a valuable

diagmiosti( seen that

bursa. in

a therapeutic

suggestive

of adhesive decreased
or sh

capsuhitis. joint
capacity, complete

However,
obliteratioms absence
ivere

patients art hrography

of the

with
only

forty-t.uvo quently

had

axilhary

ami(I freThe
appearei the 1

a complete

almost in
these

of
quite

the

suI)scapulal-is consistent

anthrolgraphic
am ice. The physical by

fimidings
eleu-cmi exercises
iii
Iii

shoulders
these
(If

their capsule

lokm-s
restore

without

by

thicmapy
to

on by

iiijectioiis
abduction

louved viously
\(IL. 44-A.

findings uvcre hiydrocortisone and external

to coufimmii there was the

treated
into

suooessful
t he

ly

joint

fohby pie(If

rotation.
pathological

The
amid

findings findimigs thickenimig

arthrographiy described
NO.

adhesive
in 1945
1962

capsuhitis
u#{149} In every

tend
case

comitracture

7, O(.TOBEit

1330 the capsule with resultant decrease reflected fold causing obliteration
stances the subscapularis bursa

J.

S.

NEVIASER

in of

the joint capacity and adherence the dependent axillary fold. In

and could not be visualized.

of the some inThe

was

obliterated

biceps that
cause.

sheath biceps Only

was tendinitis 18 per

outlined cent

in the

majority
with

of cases, results by

thus

confirming

the

concept

is one of the end of the shoulders of the biceps

of adhesive capsulitis and not its proved adhesive capsuhitis showed arthrogram.

failure

of visualization

sheath

CONCLUSIONS

1 . Arthrography
ill

of the

shoulder

demonstrates

the

gross

pathological

changes

adhesive capsulitis of the shoulder. In true adhesive capsuhitis, or der, arthrography shows a very definite decrease in joint capacity tion of the reflected axillary fold. In many instances the subscapularis decreased in size or not visualized at all but, as a rule, the bicipitai outlined. 2. This procedure can serve as a diagnostic aid to differentiate
capsulitis from stiff and painful shoulder due to other causes.

frozen shoulwith obliterabursa is sheath is well true adhesive amid to four use dejoint.

3. cubic

A mixture centimeters

of twelve of 1 per

cubic cemit

centimeters procaine appears

of 35 to

per be

cent the

diodrast solution

ideal

for imijection tail, an(1 the

of shoulder joints. procaine prevents

This amount any pain ivhen

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I . Am E i.I.( I, ( . L. : Neuniolart rorra(ln)gratia (10(1 hionih )ro. lliv. ( )rtAlp. y Traunsat4 )l. , I 8 : I -8, 1948. 2. AXEN, P. : tJeh)(r dent \Vert, der Arthrographiie (les Scluultergeleuikes. Acta Radiol., 22: 268-276, 1941. 3. BATEMAN, J.E. : The Shoulder atid Environs. St. Louis, The CV. Moshly Co., 1955. 4. BRAUS, HERMANN: Anatomic des Ienschen. Bits 1elirhuichi f#{252}r Studiereuide urni Aerzte. Berlin, Julius Springer, 1921. ,15, CODMAN, E.A. : The Shoulder. Rupture of the Supraspinatus Teuidomi amid other I4esi(IIiS in or about the Subacromial Bursa. Boston, Privately Printed, 1934. 6. CODMAN, E.A., 8)1(1 AKERSON, I.B. : The Pathology Associated wit.hi Rupture of the Suprasl)inatuis Tendon. Ann. Sumrg., 93: 348-359, 1931. 7. Ei)EN, ItUD0II.F: Zur Operation der habituiellen Schulterluxation tinter tIitteilung eines neuen Verfahrens bei Abriss am itineren Pfauinienrauide. I)eumtsche Zeitschr. f. Chir., 144: 268-280, 1918. 8. FR0STAo, H. : Art.hrographische untersuchutuigen des Schultergelenks, mit spezieller Rficksicht fauif die Ruptuir (icr sehnen Desselben. Acta Itadiol., 23: 336-35:4, 1942. 9. GA.SSER, G. : Cited by E. Ktister In Ueber Bursitis sulmcromiahis (Periarthritis humeroscapularis). Arch. f. KIm. Chir., 67: 101:4-1021, 1902. 10. HYBBINETTE, S. : J)e la transplantations (lun fragment osseumx lXlt1 retn#{233}dier aux luxations r#{233}cidivatites (IC l#{233}paumle; constatations ct r#{233}sultats op#{233}ratoires. Acta Chir. Scandinavica, 71: 411-445, 1932. I 1. KERNWEIx, GA.; ROSEBERG, BERTmt; atid i-ixEEo, \V.lt. Art.hrographiic Studies (If the Shoul(Icr joimit. .1. Bone and Joint Surg., 39-A: 1267-1279, l)ec. 1957. 12. LAGo, HI)., and GtTARINONI, V.H. : Neumoartrorradiografia del honiihro. (Resuiltado de ha experimentation cadav#{233}rica.) 11ev. Ortop. y Traummatol., 18: 9-15, 1948. i:3. LmNIBonM, KNIIT: On Pathogenesis of Ruptures of the Tendomi Aponeurosis of the Shoulder Joint. Acta Radiol., 20: 563-577, 1939. 14. LINDBOLM, Kxtrr: Arthrography an(i Roentgenography in Ruptures of the Tendons of the Shoulder Joint. Acta Radiol., 20: 548-562, 1939. iS. LINDBOLM, KNLJT, and PALMER, IvAR: Ruptures of the Tendon Apotseurosis of the Shoulder Joint-the so-called Supraspinatus Ruptures. Acta Chir. Scandinavica, 82: 133-142, 1939.

16. 17.
18.

NEVIASER,

J.S.:

in Periarthritis
NEVIA.SER,

Adhesive Oapsulitis of the Shoulder. A Study of the of the Shoulder. J. Bone and Joint Surg., 27: 211-222,
An Operation Oct. 1948. for Old 1)islocation of the Shoulder.

Pathological
1945. and Joint

Findings
Surg., The

30-A:

19. 20.

J.S.: 997-1000, NEVIASER, .J.S.: Americaui Academy Edwards, 1949. NEVIASER, J.S.:
NEVIASER,

Apr. J. Bone

Adhesive
of
Ruptures

Capsulitis
Ort.hopaedic
of

of the
Surgeouis,

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In Instructional Course Lectures, Vol. (1, pp. 281-291. Aunt Arbor,

.J.W.

the

Hotatslr

J.S.:
J.:

Injuries
Academy

The

Americaut

in and allotmt of Orthopaedie

the

Cuff. Cliii. Shoulder

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()rthop.,
Joint.. 1956. bei In Vol.

3: 92-98,
Instruct.iotial 13, pp.

195:4.
Course Lectures, 187-216. Ann Arbor, Roust-

.J.W.
21.
gonpraxis,

Edwards,

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liabitueller Schumlterluxation.

UBERIIOLZER,

1)ie Arthropuieunioradiographie 5: 589-590, 19:43. (Continued on

page

1359)
JOURNAL

THE

OF

BONE

ANI)

JOINT

SURGERY

TROUBLESOME

LIPOMATA

OF

THE

UPPER

EXTREMITY

1359

REFERENCES 1. BIcK, E.M.: Lipoma of the Extremities. Ann. Surg., 104: 139-143 1936. 2. BOSCH, D.T., and BERNHARD, W.G. : Lipoma of the Hand. Am. .1. #{225}hin. Pathol., 20: 262, 1950. 3. BUTLER, ED.; HAMILL, J.P.; SEIPEL, ItS.; and DELORIMER, A.A.: Tumors of the Hand. A Ten-Year Survey and Report of 437 Cases. Am. J. Surg., 100: 293-302, 1960. 4. CAMPBELL, CS., and WULF, R.F. : Lipoma Producing a Lesion of the 1)eep Branch of the Radial Nerve. A Case Report. J. Neurosurg., 11 : 310, 1954. 5. EwING, JAMES: Neoplastic Diseases. A Treatise on Tumors. Ed. 4. Philadelphia, \V. B. Sautsders Co., 1940. 6. FOSHEE, J.C., and WILKES, J.B. : Nodular Symmetrical Lipomatosis. Review of the Literature and Report of a Case. J. Michigan State Med. Soc., 41: 1043-1046, 1942. 7. HUSTEAD, A.P. ; MULDER, 1).W. ; and MAcCARTHY, CS. : Nontraumatic, Progressive Paralysis of the Deep Radial (Posterior Interosseous) Nerve. Arch. Neurol. and Psychiat., 79: 269-274, 8. 9. 10.

New York, Hoeber-Harper, 1958. 1 1. POSCH, J.L. : Tumors of the Hand. J. Bone and Joint Surg., 38-A: 517-540, June 1956. 12. RICHMOND, D.A.: Lipoma Causing a Posterior Int.erosseoums Nerve Lesion. J. Bone and Joust. Surg., 35-B: 83, Feb. 1953. 13. SCHMITZ, R.L., and KEELEY, J.L.: Lipomas of the Hand. Surgery, 42: 6913-700, 1957. 14. STACK, H.G.: Tumors of the Hand. British Med. J., 1: 919-922, 1960. 15. STRAUS, F.H.: Deep Lipomas of the Hand. Ann. Surg., 94: 269-273, 1931. 16. SULLIVAN, C.R.; DAHLIN, D.C.; and BRYAN, R.S.: Lipoma of the Tendon Sheath. J. Bone anol Joint Surg., 38-A: 1275-1280, Dec. 1956. 17. WELLS, HG.: Adipose Tissue, A Neglected Subject. J. Am. Med. Assn., 114: 2177-2183: 2284-2289, 1940.

1958. LEWIS, DEAN, and GESCHICKTER, CF. : Diffuse Lipoma of the Right Upper Extremity. A and B Yielded by Bio-Assay of Fat. Ann. Surg., 102: 154-158, 1935. MASON M.L. : Tumors of the Hand. Surg., Gynec., and Obstet., 64: 129-148, 1937. PACK, #{243}.T., and ARIEL, I.M. : Tumors of the Soft Somatic Tissues. A Clinical Treatise.

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THE

SHOULDER page 1330)

JOINT

from

22.
23. 24. 25.

OBERHOLZER, OBERJTOLZER,

J.:

Die

Arthro-Pneumoradiographie. di contrasto
of the

Beitr. articolari

z. Klin.
Bircher).

Chir., Chir.
Shoulder

158:
J. Radiol.

113-156,

1933.

J.:
1936.

LArthro-pneumoradiographie

(m#{233}thode de

et

El#{233}ctrol.,

20:

18-23,

OEEItHOLZER,

22: 363-372,
PETTERSSON,

J.: I methodi 1936-37.

GUSTAF:

in radiografia.
of the

Organi
Joint

Movimento,
in Antero-

Inferior

Dislocation.

Rupture Acta Chir.

Tendon

Aponeurosis

Scandinvavica,

Supplementum

87,

1942.

VOL.

44-A.

NO.7,

OCTOIER

1962