JULY, 1968

SHOULDER ARTHROGRAPHY*
By PAUL J. KILLORAN, M.D.,t RALPH C. MARCOVE, M.D.,
and ROBERT H. FREIBERGER, M.D.
NEW YORK, NEW YORK

P OSITIVE contrast arthrography of the jeopardize

patients with
results.’1”4
persistent
However,
disability,
in those
an ac-
shoulder graphically demonstrates the
integrity, shape and capacity of the gleno- curate roentgenographic method of diag-
humeral joint. It is used to show ruptures nosis is useful if operative repair is con-
of the musculotendinous rotator cuff, ad- templated, since the physical signs and
hesive capsulitis (“frozen shoulder”) and symptoms can be misleading.5’9”5 Distinc-
the degree of soft tissue damage in patients tion between muscle spasm, tendinitis and
with recurrent shoulder dislocation. The rupture of the rotator cuff may be difficult
method has also been advocated in diagnos- when conventional roentgenograms are
ing lesions of the bicipital tendon, but its negative. It is possible that the present
accuracy in this respect is less clearly uncertainty and confusion in treating
established. shoulder disorders is partially related to
American Journal of Roentgenology 1968.103:658-668.

Shoulder arthrography was first used in inaccurate clinical diagnosis. For this
1933 by Oberholzer’6 in a study of capsular reason, we believe that interest in the study
distortion due to shoulder dislocation. In of the shoulder by arthrography is increas-
1934, Codman3 suggested that contrast ing. With modern contrast agents, the pro-
material injected into the glenohumeral cedure is almost painless and can be per-
joint would demonstrate ruptures of the formed on out-patients without interfering
rotator cuff, but he did not have an oppor- with ordinary activity.
tunity to attempt this procedure. In 1939, It is the purpose of this report to bring
Lindblom and Palmer9”#{176} found arthrog- the technique to the attention of radio-
raphy accurate in diagnosing lesions of the logists and to illustrate the normal and ab-
rotator cuff in a substantial number of normal arthrogram based on our experi-
patients and their findings have been con- ence with 200 arthrographies.
firmed by others.2’7”3”8
TECHNIQUE
Although arthrography is safe and rela-
tively simple to perform, it does not ap- Internal and external rotation roentgen-
pear to be in widespread use today despite ograms and axillary and bicipital groove
the common clinical problem of shoulder roentgenograms are obtained and inspected
disability. The lack of interest may be before the injection. Injection of the shoul-
partially related to disagreement among der via an anterior approach is greatly
orthopedic surgeons on the necessity for facilitated by using an image intensified
operative repair of rotator cuff rupture. fluoroscope; in our institution the injection
While a discussion of treatment is beyond is performed by the radiologist.
the scope of this report, it does appear well With the patient supine, it is helpful to
established that some patients with rupture elevate the opposite shoulder with a
of the rotator cuff recover without surgery pillow in order to rotate the offending
and that a trial of conservative treatment shoulder into a mild posterior oblique posi-
is advisable since delay in repair does not tion so that the glenohumeral space is seen

* Presented at the Sixty-eighth Annual Meeting of the American Roentgen Ray Society, Washington, D. C., September a6-29, 1967.
From The Hospital for Special Surgery, affiliated with The New York Hospital-Cornell University Medical College, New York,
New York.
t Assistant Director, Department of Radiology, The Hospital for Special Surgery.
Associate Attending Orthopedic Surgeon, The Hospital for Special Surgery.
§ Director, Department of Radiology, The Hospital for Special Surgery.

68
 VOL. 103, No. Shoulder Arthrography 659

in profile. The arm is placed in neutral or

mild internal rotation where the anterior
joint capsule will be lax. Under aseptic
technique, the skin is infiltrated anteriorl
with I per cent lidocaine HC1 (Xylocaine)
about one finger breadth below and lateral
to the coracoid process. A 3 inch No. 20

gauge spinal needle is inserted and di-

rected vertically toward the glenohumeral
space with the aid of the image intensified
fluoroscope. When the needle enters the
joint, a difference will usually be felt in the
ease with which Xylocaine can be injected. Fic. I . Fluoroscopic spot roentgenogram during
Correct needle position is confirmed by injection of contrast medium. The needle is in-
fluoroscopically observing the location of a serted one finger breadth below and lateral to the
coracoid process and directed vertically toward
small amount of injected renografin 6o.
the glenohumeral space. When the needle is
The contrast material within the joint within thejoint, contrast material flows away from
immediately flows away from the needle
American Journal of Roentgenology 1968.103:658-668.

the tip into the subscapularis and axillary recesses

tip, usually into the axillary and subscapu_ (arrows).
laris recesses (Fig. i). If the needle is not
within the joint, the soft tissues immedi- nically more difficult to perform because
ately around its tip will be infiltrated b\r an the svnovial recesses are obliterated, the
irregular deposit of opaque medium. When joint capacity is restricted and the sensa-
correct needle placement has been estab- tion of injecting into a joint is usually less
lished, usually 10-15 cc. ofrenografin 6o is distinct. Proper needle position is deter-
introduced and the needle is withdrawn. mined injecting very small quantities
The shoulder is exercised briefly to (us- of contrast material until the intra-articu-
tribute the contrast medium and roent- lar location is observed. In these patients,
genograms are made in internal and ex- it is usually not possible to inject more
ternal rotation using the Bucky technique. than 5-10 cc. of fluid and even with this
Axillary and tangenti al roen tgenograms small amount, reflux will be observed when
of the bicipital groove are then obtained pressure on the syringe plunger is released.
with screen technique. While the roentgen- The limited capacity of the joint is a
ograms are being processed, the patient is characteristic feature of the “frozen shoul-
instructed to continue shoulder exercises. der” syndrome, although the same sign
If the initial series of roentgenograms has also been reported recently in some
shows no abnormality or questionable leak- patients with rheumatoid arthritis.5 The
age of contrast material into the subacrom- normal shoulder will accept more than the
ial bursa, delayed roentgenograms are Ia-I cc. of renografin 6o but larger
made in internal and external rotation. In amounts may obscure intra-articular struc-
several cases, the leakage into the bursa tu res.
was barely perceptible or not visible on the Methylglucamine diatrizoate (renografin
initial roentgenograms, but was obvious 6o) has been employed as the contrast
on the delayed roentgenograms. If move- agent instead of the sodium salt, because
ment of the shoulder is restricted or pain- an inadvertent injection or extravasation
ful, the rotational roentgenograms are ob- of the former into extra-articular soft
tained by turning the entire patient rather tissues is usually not painful, whereas the
than just the shoulder.8 latter may cause severe pain. Roentgen-
In patients with “frozen shoulder,” ography must be performed within 30 to
satisfactory arthrography may be tech- 40 minutes after injection of renografin 6o
 66o P. j. Killoran, R. C. Marcove and R. H. Freiberger JULY, 1968

to obtain an arthrogram of good quality; mately fused with the major portion of the
the contrast material is no longer visible glenohumeral joi nt capsule.
in roentgenograms made 90 minutes after The long tendon of the biceps lies in the
injection. In a few patients in whom most intertubercular groove between the attach-
of the contrast medium was inadvertently ments of the supraspinatus and subscap-
injected into the extra-articular tissues, a ularis and passes through the joint from a
satisfactory arthrogram with an intra- synovial sheath in the bicipital groove to
articular injection could be obtained a few the superior margin of the glenoid rim.
hours later. Of major importance in interpreting the
Mild discomfort in the shoulder for 24 arthrogram is the anatomy of the sub-
to 48 hours following injection is common, acromial and subcoracoid bursae. The sub-
but rarely interferes with normal activity. acromial bursa superiorly and the sub-
No serious complications have been re- coracoid bursa anteriorly are often com-
ported in the literature and none occurred bined into a single large bursa. This is
in this series of 200 shoulder arthrographies. separated from the glenohumeral joint
capsule by the thick musculotendinous ro-
ANATOMY
tator cuff (Fig. 2A). The bursa, in turn,
The musculotendinous rotator cuff origi- separates the cuff from the deltoid muscle
American Journal of Roentgenology 1968.103:658-668.

nates from the scapula and inserts onto and the coraco-acromial arch.
the tuberosities of the humerus, almost Most ruptures occur in the supraspinatus
completel’ enveloping its head. The four portion of the rotator cuff at a “critical
components are: the supraspinatus supe_ area” just proximal to its insertion onto the
riorl’; the subscapularis anteriorly; and greater tuberosity. A tear through the
the infraspinatus and teres minor poste- complete thickness of the rotator cuff pro_
riorly. The tendons from these four muscles duces an abnormal communication be-
form a broad aponeurosis which is inti- tween the glenohumeral joint and the bursa

tic. 2. Cross section of the glenohumeral joint. (A) Normal. The thick rotator cuff separates the subacromial
bursa (arrow) from the joint. (B) Rupture of the rotator cuff. An abnormal communication (arrow) is
present between the joint and the bursa.
 VOL. 103, No. 3 Shoulder Arthrography 66i

(Fig. 2B), so that contrast material in- cartilaginous glenoid rim are visible as
jected into the joint will flow into the bursa radiolucent triangular filling defects within
where it is easily recognized in the roent- the synovial recesses. A linear filling defect
genograms (Fig. 4, A, B and C). representing the long tendon of the biceps
is frequently visible anteriorly as it extends
THE NORMAL ARTHROGRAM
into its opaque filled sheath in the bicipital
A thin “halo” of contrast medium covers groove. The moderately large subscapularis
the superior aspect of the humeral head, recess is visible anterior to the glenoid.
separated from the bony margin by radio- The tangential view of the bicipital
lucent articular cartilage. In the external groove (Fig. 3D) shows the biceps tendon
rotation view (Fig. 3A), the “halo” of con- in cross section as an oval filling defect
trast material ends abruptly laterad at the within the contrast filled sleeve so that the
anatomic neck, and the soft tissues above location of the tendon, with regard to the
and lateral to the greater tuberosity should groove, can be established.
be free of opaque medium.
ABNORMAL ARTHROGRAMS
The long tendon of the biceps is fre-
COMPLETE RUPTURE OF THE ROTATOR CUFF
quently visible as a radiolucent filling de-
fect within the opaque filled recess at the Rupture of the rotator cuff , prodiices
American Journal of Roentgenology 1968.103:658-668.

superior aspect of the glenohumeral joint. an abnormal communication between the

It is sometimes possible to follow the glenohumeral joint and the subacromial .

course of the tendon through the , joint bursa, if the tear extends through the coth-
from the superior rim of the glenoid into plete thickness of the musculotendinois
its contrast filled synovial sheath within cuff.. Renografin injected into the joint will
the bicipital groove. flow into the bursa where it is easily recog-
The tongue-shaped subscapularis recess nized in the roentgenograms as a large
extends medially from the glenohumeral collection of contrast medium above and
space underneath the coracoid process and lateral to the greater tuberosity (Fig. 4, A,
deep to the subscapularis muscle. It com- B and C). In the normal shoulder, this
municates with the joint through a normal area is completely free of contrast sub-
opening in the anterior glenoid labrum. In stance. In the axillary view, the bursa ap-
the internal rotation view (Fig. 3B), the pears to hang across the surgical neck of the
recess will be a prominent landmark, but humerus like a saddlebag (Fig. 4C).
in external rotation it is usually less con- Usually the bursa is separated from the
spicuous because the taut overlying sub- joint capsule by a radiolucent zone oc-
scapularis muscle expresses the fluid. A cupied by the thick musculotendinous rota-
redundant capsule at the inferior margin tor cuff; this is more clearly visible in the
of the glenohumeral space forms the axil- internal rotation roentgenogram (Fig. 4B).
lary fold or recess, which will be obliterated Occasionally, there is no clearly defined
when the arm is in abduction. A distinct demarcation between the bursa and the
indentation is present between the sub- joint capsule (Fig. ), presumably because
scapularis recess and the axillary fold. In of atrophy of the cuff or virtual obliteration
cineroentgenography, opaque medium can of the superior aspect of the cuff by a large
be observed flowing from the subscapularis tear.
recess into the axillary fold when the arm The bursa is always in close relationship
is moved from internal to external rotation. to the undersurface of the acromion process
In the axillary view (Fig. 3C), a thin superiorly, but it extends downward beside
layer of contrast medium is seen in the the humeral head to a variable degree. The
glenohumeral space separated from the size and configuration of the bursa in the
bony margins by the articular cartilages. roentgenograms does not correlate with the
The anterior and posterior margins of the severity of the lesion in the rotator cuff,
 662 P. J. Killoran, R. C. Marcove and R. H. Freiberger JULY, 1968
American Journal of Roentgenology 1968.103:658-668.

Fic. 3. Normal arthrogram. (A) External rotation view. Note the absence of contrast medium above and
lateral to the greater tuberosity. (B) Internal rotation view. (C) Axillary view. (D) Tangential yew of the
bicipital groove. Key: i = Long tendon of the:biceps within its synovial sheath. 2=Axillary recess. 3=Sub-
scapularis recess.

but is a function of normal anatomic varia- nosis of complete rupture of the rotator
tion. In Case i (Fig. 4, A, B and C), for cuff is quite simple because of the distinc-
example, a large combined subacromial- tive appearance and location of the con-
subcoracoid bursa is opacified, while in trast filled subacromial bursa. However, it
Case III (Fig. 6) onl’ a small subacromial is important to recognize three potential
bursa is visible. errors:
In most cases, the arthrographic diag- (A) Inadequate distribution of the
 VOL. 103, No. 3 Shoulder Arthrography 663
American Journal of Roentgenology 1968.103:658-668.

I’ .. . (ae 1. (mjletc riqttirc t the

r( tat( cuf}. .1 l’’.tern;iI t( )tlt( 11 A
Titeiflal T’( )tatl( fl; Ifli ((.‘) a\111Irv Vie\
I trc (‘(11)1)1 fled sfl he’ 111 al-su I)C( rI-
CII ursa is uj)aC1C1 Irru\ S.

clear iuc f r;LII(Iuceucv leteeii the

hursa tul rli hut capsulr s uccujhel he
tile r(tlr(r Clift.

opaque medium within the joint. As pre- sheath, identified by its location within the
viously mentioned, we have occasionally bicipital groove, moves into medial posi-
observed filling of the bursa only on de- tion in the internal rotation view. The
layed roentgenograms after the shoulder subacromial bursa is larger and it remains
was exercised. in the lateral position in both views.
(B) In the external rotation view, the (C) Inadvertent injection of the bursa
contrast filled sheath of the biceps tendon instead of the joint. In one patient, an un-
may project slightly lateral to the greater usu ally large com hi ned su bacrom i al-sub-
tuberosity and this should not be mistaken coracoid bursa was injected directly. In
for opacification of the subacromial bursa the frontal projection, the bursa covered
due to rupture of the cuff. The tendon the entire joint (Fig. 7) so that renografin
 664 P. J. Killoran, R. C. Marcove and R. H. Freiberger JULY, 1968

I’ u -. llIrsoralli. Fiie aiSefice ut clutrast illeilIltit

Ill tile IefllitlzuieraI SJilCe Ifli sllilsclptllaris

rrcess I lrr(\\ ) ‘Stli)liSheS tills 15 1 illlrsllLraln

rltil’r tilIlfi 1 true artilrlLtrlll with huh mill

American Journal of Roentgenology 1968.103:658-668.

plcitlcatiu tue hursIl.

f #{149}\ lhhistlke fl ii, utitv

could arise because o the large size of the com-

lic. c. Case ii. Complete rupture of the rotator cuff. bined subacromial-subcoracoid bursa in this case.
The absence of a radiolucent zone between the
bursa and the joint capsule suggests marked atro-
phy of the rotator cuff or obliteration by a large appeared to be flowing into the joint at
tear. fluoroscopy. On initial inspection of the
roentgenograms, the cuff was thought to
be ruptured but on closer inspection, it
was apparent that a simple bursogram had
been obtained instead of an arthrogram,

lic. 6. Case iii. Complete rupture of the rotator

cuff. Only a small subacromial bursa is opacified
(arrows) in comparison with the large bursa found
in Case i. The difference in size is a function of Fic. 8. Partial rupture of the rotator cuff. An ulcer-
normal anatomic variation and does not indicate like collection of contrast medium is visible within
the severity of the rupture. the tear (arrows). The bursa is not opacified.
 VOL. 103, No. 3 Shoulder Arthrography 665
American Journal of Roentgenology 1968.103:658-668.

Fic. . Frozen shoulder. (A) External rotation. (B) Internal rotation. The joint capacity is restricted and
the synovial recesses are small or absent.

since contrast material was not present in neck (Fig. 8). Incomplete tears deep within
the glenohumeral space or in the sub- the substance of the tendon probably es-
scapularis recess. At a later date a true cape detection by arthrography; however,
arthrogram in this patient showed an intact most orthopedic surgeons feel that partial
rotator cuff without opacification of the tears do not require operative ‘ , 12,14

bursa. Thus it is necessary to see contrast

ADHESIVE OR RETRACTILE CAISULI’FIS
medwm in both the glenohumeral joint
(“FRozEN SHOULDER”)
and in the bursa to establish the presence
of an abnormal communication. The usual Nioderate pressure is required to inject
site of needle puncture below the coracoid the relatively small amount of fluid (_

process misses the subcoracoid portion of 10 cc.) that the joint will accept. The joint
the bursa in most instances. We agree with not only feels “tight” on injection, it also

Nelso&3 that it is ver difficult to inject a looks “tight” in the roentgenograms: the
normal bursa because it is only a narrow subscapularis and axillarv recesses are ab-

potential space. In his case, the bursa max’ sent, or are ver’ small, and the biceps

have been abnormall’ large and distended tendon sheath fills poorl’ or not at all
with fluid. Direct injection of the bursa has (Fig. 9, A and B). Neviaser’5 observed that

occurred twice in this series of 200 arthrog_ patients with adhesive capsulitis were
raphies. sometimes relieved of their symptoms for
a few weeks following arthrography. Re-
PARTIAL RUP’I’URE OF ‘rHE ROTATOR CUFF
centl’, Andr#{233}n and Lundberg’ have advo-
In partial thickness or incomplete tears, cated distention arthrographv as a form
the joint does not communicate with the of therap’ for “frozen shoulder” with en-
bursa; therefore, the bursa will not opacif’ couraging preliminar’ results.
in the arthrogram. A tear in the under
RECURRENT AN’rERIOR D1sLocA’rIoN OF SHOULDER
surface of the tendon may be visible as an
ulcer-like collection of contrast medium A rthrograph y is performed preopera-
above the humeral head near the anatomic tively to show the location and severity of
 666 P. J. Killoran, R. C. Marcove and R. H. Frieberger JULY, 1968

norm al SU bscapularis recess. and

others described blunting of the anterior
glenoid labrum, but in many of our normal
arthrograms, this structure is partially oh-
scured or appears blunt because of over-
lapping contrast material in the subscapu-
laris recess. The axillary roentgenogram
may show an enlarged posterior synovial
recess indicating stretching and redun-
dancy in the posterior capsule.
In patients with recurrent dislocation,
arthrography is also performed to evaluate
the integrity of the rotator cuff. Among our
i i patients, one had a partial tear and 2

had complete ruptures of the rotator cuff.

In the arthrogram of i of these patients
(Fig. ii), opacification of the subacromial
bursa indicated a complete tear of the
American Journal of Roentgenology 1968.103:658-668.

cuff. However, the normal indentation be-

lic. 10. Recurrent anterior dislocation. Internal tween the subscapularis and the axillary
rotation view. The large anterior pouch (arrows), recesses was still present and there was no
between the subscapularis and axillary recesses, evidence of an anterior pouch. Presumably,
was produced by the dislocating humeral head.
the dislocating humeral head ruptured the
rotator cuff instead of detaching the cap-
soft tissue damage and to evaluate the
integrit’ of the rotator cuff. The dislocat-
ing humeral head may detach the joint
capsule from the glenoid rim and neck of
the scapula between the subscapularis re-
cess and the axillary fold to form an ante-
rior pouch of variable size. In the arthro-
gram (Fig. io), the pouch is visible in the
frontal view as a collection of opaque
medium extending from the subscapularis
recess to the axillarv fold, obliterating the
normal indentation or demarcation be-
tween these structures. The size of the
pouch, best appreciated on the internal
rotation roentgenogram when the anterior
muscles are relaxed, indicates the degree
of detachment of the capsule from the
glenoid and neck of the scapula; this may
be of assistance in planning an operative
repair.
In our limited experience of i i patients Fic. ii. Recurrent anterior dislocation with com-
with recurrent anterior dislocation, the plete rupture of the rotator cuff. Internal rotation
view. The subacromial bursa is opacified (arrows).
axillary view has not been very helpful in
An anterior pouch is not present, presumably be-
showing the degree of anterior capsular de- cause the dislocating humeral head ruptured the
tachment because the anterior pouch can cuff rather than detaching the capsule from the
not be clearly distinguished from the scapula.
 VOL. 103, No. Shoulder Arthrography 667

sule from the neck of the scapula. In this

patient, evidence of previous dislocation
was present in the conventional roentgeno-
grams with a “Hill-Sachs”6 compression
defect clearly visible in the posterolateral
aspect of the humeral head.

BICIPITAL LESIONS

In our experience, the intra-articular

segment of the long biceps tendon is visible
in only so per cent of all the arthrograms
as a relatively faint linear filling defect
from the glenoid rim to the bicipital groove.
Lack of visualization in the remaining
cases may have been caused by excess con-
trast material which obscured the tendon.
This question is being investigated.
In i I per cent of otherwise normal arth-
American Journal of Roentgenology 1968.103:658-668.

rograms in this series, the sleeve of the

biceps tendon did not opacify. While this
may indicate rupture of the biceps tendon,7
there are other possible explanations such
as insufficient contrast medium,4 adhesions,
and subluxation or dislocation of the ten-
don. In a few of our patients, the sleeve Fic. 12. Leakage of contrast material from the biceps
was visible only on delayed roentgenograms sleeve into the muscles of the upper arm (arrows).
after exercise, supporting the concept that
nonvisualization is sometimes related to centage of patients to have disruption of
inadequate distention. It is clear that with the transverse bicipital ligament. In many
the present method, a rupture of the ten- of their cases leakage was considered a
don cannot be assumed in cases of non- secondary phenomenon due to distention
visualization of the tendon or its sleeve. of the joint. Clinical evidence of a bicipital
We agree with Ennevaara5 that since the lesion was present in only i of our i i pa-
findings can be variously explained, they tients with this finding. We agree with
can hardly be accorded any direct diag- Ennevaara and de Seze that leakage from
nostic significance. the biceps sleeve probably lacks specificity
Leakage of contrast material from the and cannot be considered pathognomonic
biceps sleeve along the course of the tendon of a bicipital lesion.
into the muscles of the upper arm (Fig. 12) Tangential views of the bicipital groove
was observed in ii otherwise normal arth- have been obtained in only the 30 most re-
rograms in this series. This phenomenon cent arthrograms in this series. In all cases
has been noted by others in a few patients in which the sheath opacified, the tendon
with subluxation of the biceps tendon due was clearly visible within the groove. In
to disruption of the transverse bicipital patients with nonvisualization of the sleeve
ligament,7’8 and it has also been noted in the biceps tendon will, of course, not be
a patient with rupture of the biceps ten- visible in the tangential view of the groove.
don.9 Leakage from the biceps sleeve was
SUMMARY
found in I i per cent of Ennevaara’s5 and
13 per cent of de Seze’s4 patients. They Shoulder disability is a common and
thought it unlikely for such a high per- often perplexing clinical problem made
 668 P. J. Killoran, R. C. Marcove and R. H. Freiberger JULY, 1968

more difficult by uncertainty in diagnosis 7. KERNWEIN, G. A., ROSEBERG, B., and SNEED,

and management. An accurate, nonopera- W. R., JR. Arthrographic studies of shoulder

joint. :. Bone & 7oint Surg., 1957,394, 1267-
tive method of diagnosis is desirable, not
1279.
only for the individual patient but also as 8. LEWIS, R. W. Non-routine views in roentgen
an investigative procedure in evaluating examination of extremities. Surg., Gynec. &
various methods of treatment. Obst., 1938, 67, 38-45.
Shoulder arthrography is a useful aid in 9. LINDBLOM, K. Arthrography and roentgenog-
raphy in ruptures oftendons of shoulder joint.
the diagnosis of rupture of the rotator cuff,
Acta radiol., 1939, 20, 548-562.
adhesive capsulitis and in the preoperative 10. LINDBLOM, K., and PALMER, I. Ruptures of ten-
evaluation of recurrent shoulder disloca- don aponeurosis of shoulder joint; so-called
tion. Its accuracy in bicipital lesions has supraspinatus ruptures. Acta chir. scandinav.,
‘939, 82, 133-142.
not yet been established.
II. MCLAUGHLIN, H. L., and A5HERMAN, E. G.
The technique is reviewed and normal
Lesions of musculotendinous cuff of shoulder.
and abnormal arthrograms are described. IV. Some observations based upon results of
surgical repair. 7. Bone & 7oint Surg., 1951,
Paul J. Killoran, M.D. 33A, 76-86.
535 East 70th Street 12. MOSELEY, H. F. Shoulder Lesions. Second cdi-
New York, New York ioo2 tion. Paul B. Hoeber, Inc., New York, 1953.
American Journal of Roentgenology 1968.103:658-668.

13. NELSON, D. H. Arthrography of shoulder. Brit.

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5. ENNEvAARA, K. Painful shoulder joint in i8. SAMIL50N, R. L., RAPHAEL, R. L., POST, L.,
rheumatoid arthritis: clinical and radiologic NOONAN, C., SIRIS, E., and RANEY, F. L., JR.
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