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ARTHROGRAPHY
SECOND EDITION

&ULP
ii
ARTHROGRAPHY
SECOND EDITION

-XOLD5&ULP0'
Chief of Musculoskeletal Radiology
Professor of Radiology
University of Missouri at Columbia
Columbia, Missouri

iii
 1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

SPECIALTY IMAGING: ARTHROGRAPHY, SECOND EDITION ISBN: 978-0-323-59489-9

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.QRZOHGJHDQGEHVWSUDFWLFHLQWKLVˋHOGDUHFRQVWDQWO\FKDQJLQJAs new research and

experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.

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the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine
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To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.

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Names: Crim, Julia R.

Title: Specialty imaging. Arthrography / [edited by] Julia R. Crim.
Other titles: Arthrography.
Description: Second edition. | Salt Lake City, UT : Elsevier, Inc., [2018] | Includes
bibliographical references and index.
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Subjects: LCSH: Joints--Radiography--Handbooks, manuals, etc. | MESH: Arthrography--methods--Atlases. |
Joints--injuries--Atlases. | Joint Diseases--diagnostic imaging--Atlases. | Radiography--Atlases.
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DEDICATION

To Lester, my partner
and best friend.

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CONTRIBUTING AUTHORS

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Assistant Professor
Musculoskeletal Radiology
University of Utah
Salt Lake City, Utah

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viii
 PREFACE
It is with great pleasure that I present the second edition of Specialty Imaging: Arthrography.
,ZURWHWKHƬUVWHGLWLRQDGHFDGHDJREHFDXVHDWWKDWWLPHWKHUHZDVQRWH[WERRNDYDLODEOH
that addressed how to perform and interpret arthrography in conjunction with CT and MR.
,ZDVSOHDVHGZLWKWKHVXFFHVVRIP\WH[W,WZDVUHSULQWHGVHYHUDOWLPHVEXWXOWLPDWHO\LW
went out of print.

&KDQJHVIURPWKHƬUVWWRWKHVHFRQGHGLWLRQUHƮHFWERWKFKDQJHVLQKRZ,WHDFKDQGDGYDQFHV
in musculoskeletal (MSK) imaging. The technique chapters of the book have been completely
UHZULWWHQWRUHƮHFWP\DQDO\VLVRIWKHGLƯFXOWLHVWKDWWUDLQHHVHQFRXQWHUDVWKH\OHDUQWR
perform MSK injections. I have also studied interpretation errors. Every trainee encounters
WKHVDPHSLWIDOOVDQGPDNHVPDQ\RIWKHVDPHHUURUVRQWKHURDGWRDFKLHYLQJSURƬFLHQF\
LQWKHLQWHUSUHWDWLRQRI05DQG&7DUWKURJUDPV,KDYHDGGHGFDVHVDQGWH[WGHVLJQHGWR
make the learning curve easier. I have also added chapters called “Systematic Evaluation” for
each joint. These chapters are designed to help radiologists evaluate studies in an organized
DQGFRKHUHQWIDVKLRQ(DFKFKDSWHURƪHUVDQDSSURDFKWRVWXG\LQWHUSUHWDWLRQIRFXVLQJRQ
the clinical issues applicable to the joint in question. The “Systematic Evaluation” chapters
DOVRSURYLGHDEULHIJXLGHWRLPSRUWDQWƬQGLQJV DQGSLWIDOOV WKDWPD\EHYLVXDOL]HGRQ05
arthrograms but are not directly related to the arthrogram itself.

06.LPDJLQJKDVDGYDQFHGWUHPHQGRXVO\LQWKHSDVWGHFDGH0DQ\FKDQJHVUHƮHFWDGYDQFHV
in technology. MR and CT have become ever more sophisticated, and ultrasound has become
an increasingly important part of MSK imaging. Even more important than the technological
DGYDQFHVDUHWKHPDQ\VLJQLƬFDQWFRQFHSWXDODGYDQFHVLQRXUXQGHUVWDQGLQJRIDUWLFXODUDQG
WHQGRQGLVRUGHUV,WKDVEHHQDMR\WRSDUWLFLSDWHLQWKHDGYDQFHVLQP\ƬHOGWRJHWKHUZLWK
my wonderful colleagues in radiology and orthopedics.

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WKHƬUVW,KRSHWKDW\RXZLOOƬQGLWWREHDXVHIXODGGLWLRQWR\RXUSUDFWLFH

I’d like to thank my outstanding team at Elsevier, especially Nina Bennett, for their help and
patience through my many iterations of each chapter.

-XOLD5&ULP0'
Chief of Musculoskeletal Radiology
Professor of Radiology
University of Missouri at Columbia
Columbia, Missouri

ix
x
ACKNOWLEDGMENTS
/HDG(GLWRU
Nina I. Bennett, BA

7H[W(GLWRUV
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Terry W. Ferrell, MS
Lisa A. Gervais, BS
Matt W. Hoecherl, BS
Megg Morin, BA

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5LFKDUG&RRPEV06
Lane R. Bennion, MS
Laura C. Wissler, MA

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7RP02OVRQ%$

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Angela M. G. Terry, BA
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xi
xii
 SECTIONS
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xiii
 TABLE OF CONTENTS

102 Elbow Anatomy

SECTION 1: GENERAL PRINCIPLES Julia R. Crim, MD
4 MR Imaging vs. MR and CT Arthrography 112 Systematic Evaluation of Elbow
Julia R. Crim, MD Julia R. Crim, MD
6 Fluoroscopic-Guided Joint Injections 114 Ulnar Collateral Ligament Injury
Julia R. Crim, MD and William B. Morrison, MD Julia R. Crim, MD
12 Tendon Sheath Injections 116 Radial Collateral Ligament Injury
Julia R. Crim, MD Julia R. Crim, MD
18 Ultrasound-Guided Joint and Bursa Injections 118 Chondral and Osteochondral Injury, Elbow
Julia R. Crim, MD and William B. Morrison, MD Julia R. Crim, MD
22 Aspiration for Fluid Analysis
Julia R. Crim, MD SECTION 4: WRIST
26 Therapeutic Injections 122 Wrist Procedures
Julia R. Crim, MD and Amy Powell, MD Julia R. Crim, MD and William B. Morrison, MD
30 Arthrographic Appearance of Arthritides 124 Wrist Anatomy
Julia R. Crim, MD Julia R. Crim, MD and William B. Morrison, MD
136 Systematic Evaluation of Wrist
SECTION 2: SHOULDER Julia R. Crim, MD
36 Shoulder Procedures 138 Triangular Fibrocartilage Complex Injury
Julia R. Crim, MD Julia R. Crim, MD and William B. Morrison, MD
42 Shoulder Anatomy 142 Scapholunate Ligament Injury
Julia R. Crim, MD Julia R. Crim, MD and Sarah Stilwill, MD
58 ABER Positioning 146 Lunototriquetral Ligament Injury
Catherine C. Roberts, MD Julia R. Crim, MD and Sarah Stilwill, MD
62 Systematic Evaluation of Shoulder 148 Extrinsic Ligament Injury, Wrist
Julia R. Crim, MD Sarah Stilwill, MD
64 Bankart Lesion and Its Variants 150 Chondral and Osteochondral Injury, Wrist
Julia R. Crim, MD Julia R. Crim, MD and William B. Morrison, MD
70 Posterior Labral Injuries 152 Postoperative Findings, Wrist
Julia R. Crim, MD Julia R. Crim, MD and William B. Morrison, MD
76 SLAP and Rotator Interval Tears
Julia R. Crim, MD SECTION 5: HIP
80 Chondral and Osteochondral Injury, Shoulder 156 Hip Procedures
Julia R. Crim, MD Julia R. Crim, MD
82 HAGL, PHAGL, and MGHL Tear 162 Hip Anatomy
Julia R. Crim, MD Julia R. Crim, MD
86 Capsular Laxity and Adhesive Capsulitis 178 Systematic Evaluation of Hip
Julia R. Crim, MD Julia R. Crim, MD
88 Postoperative Findings After Shoulder Instability 180 Femoroacetabular Impingement
Surgery Julia R. Crim, MD
Julia R. Crim, MD 186 Labral Tear, Hip
92 Rotator Cuff Tear Julia R. Crim, MD
Julia R. Crim, MD 190 Chondral and Osteochondral Injury, Hip
96 Postoperative Findings After Rotator Cuff Surgery Julia R. Crim, MD
Julia R. Crim, MD 192 Iliopsoas Impingement
Julia R. Crim, MD
SECTION 3: ELBOW 194 Capsular Ligament Injury, Hip
100 Elbow Procedures Julia R. Crim, MD
Julia R. Crim, MD 196 Ligamentum Teres Abnormality
Julia R. Crim, MD

xiv
 TABLE OF CONTENTS
198 Developmental Dysplasia
Julia R. Crim, MD
200 Perthes Disease
Julia R. Crim, MD
204 Postoperative Findings, Hip
Julia R. Crim, MD

SECTION 6: SACROILIAC JOINT AND

PUBIC SYMPHYSIS
212 Sacroiliac Joint and Pubic Symphysis Procedures
Julia R. Crim, MD
214 Sacroiliac Joint and Pubic Symphysis Anatomy
Julia R. Crim, MD

SECTION 7: KNEE
220 Knee Procedures
Julia R. Crim, MD and William B. Morrison, MD
222 Knee Anatomy
Julia R. Crim, MD and William B. Morrison, MD
234 Systematic Evaluation of Knee
Julia R. Crim, MD
236 Meniscal Injury
Julia R. Crim, MD
238 Chondral and Osteochondral Injury, Knee
Julia R. Crim, MD
240 Postoperative Findings, Knee
Julia R. Crim, MD and William B. Morrison, MD

SECTION 8: ANKLE
248 Ankle Procedures
Julia R. Crim, MD
250 Ankle Anatomy
Julia R. Crim, MD
260 Systematic Evaluation of Ankle
Julia R. Crim, MD
262 Lateral Ligament Injury, Ankle
Julia R. Crim, MD
268 Medial Ligament Injury, Ankle
Julia R. Crim, MD
272 Impingement Syndromes, Ankle
Julia R. Crim, MD
276 Chondral and Osteochondral Injury, Ankle
Julia R. Crim, MD
280 Postoperative Findings, Ankle
Julia R. Crim, MD

SECTION 9: FOOT
284 Foot Procedures
Julia R. Crim, MD
290 Foot Anatomy
Julia R. Crim, MD
302 Ligament Injury, MTP Joints
Julia R. Crim, MD
306 Chondral and Osteochondral Injury, Foot
Julia R. Crim, MD

xv
Thispageintentionallyleftblank
ARTHROGRAPHY
SECOND EDITION

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 6(&7,21

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MR Imaging vs. MR and CT Arthrography 

Fluoroscopic-Guided Joint Injections 
Tendon Sheath Injections 
Ultrasound-Guided Joint and Bursa Injections 
Aspiration for Fluid Analysis 
Therapeutic Injections 
Arthrographic Appearance of Arthritides 
 MR Imaging vs. MR and CT Arthrography
General Principles
Introduction
MR without arthrography is the standard for imaging of soft
tissue abnormalities of the musculoskeletal system.
Arthrography adds to the cost of an MR and also carries
associated risks of pain and (rarely) infection. For these
reasons, it is best to limit the use of MR arthrography to cases
where it provides significant added value. In many cases,
arthrography is not needed for diagnosis. For the correct
indications, arthrography provides valuable additional
information.
There is a large and somewhat contradictory body of
literature investigating the relative accuracy of MR and MR
arthrography. The preponderance of the evidence in the
literature supports increased accuracy of MR arthrography
over MR for certain indications. Some of the best and most
current articles on both sides of the issue are cited in the
relevant chapters of this book. It is important to remember
that studies of relative accuracy of different imaging methods
may suffer from observer bias, interpretational expertise, and
prevalence of the abnormality in the study population. For
instance, hip labral tears are sufficiently common after age 40
that researchers erring on the side of calling tears based on
minimal imaging findings on MR without arthrography would
tend to achieve a high accuracy.
CT arthrography is usually employed when MR is not possible.
It allows similar visualization of torn ligaments and cartilage
but gives inferior soft tissue detail when compared to MR.
Choosing MR vs. MR Arthrography
The author has utilized MR without arthrography as well as
with arthrography over a period of 30 years. Her experience
agrees with the preponderance of the literature:
Arthrography increases sensitivity and specificity in the
evaluation of ligament, articular cartilage, fibrocartilage, and
capsular injuries.
MR arthrography is not generally needed in the acute setting.
This is because acute joint injuries usually cause a
hemarthrosis, producing an arthrographic effect on MR. The
hemarthrosis outlines the joint structures for about the first 2
weeks following an injury.
MR evaluation of the knee rarely requires arthrography to
demonstrate abnormalities. CT arthrography is sometimes
employed when the patient cannot undergo MR. Some
radiologists utilize MR arthrography in the postoperative
setting because it improves specificity of diagnosis of
recurrent meniscal tear. Others, including the author, accept
that in the postoperative setting, a nondisplaced recurrent
meniscal tear may be missed without arthrography.
Performing MR vs. MR arthrography is a choice made after
consultation with the referring surgeon. In the author's
practice, the surgeon is unlikely to perform repeat
arthroscopy for meniscal tear unless the tear occurs in a new
location, or is displaced, and therefore MR without
arthrography will detect operable abnormalities. Every
radiologist should work with their referring surgeons to
establish guidelines that suit their practice.
MR evaluation of the shoulder benefits from arthrography in
characterizing labral and ligamentous injuries. Arthrography is
not generally needed for detection of rotator cuff disease.
Some radiologists argue that it may improve characterization
of minor partial-thickness tears. It has never been shown that
this improved characterization alters surgical management.
4
MR evaluation of the hip benefits from arthrography in order
to demonstrate articular cartilage and labral abnormalities.
MR of small joints often benefits from arthrography. It can be
difficult to diagnose nondisplaced ligament tears without it,
even at 3T.
Indirect Arthrography
Gadolinium contrast agents administered intravenously are
excreted by synovium. Over time, the contrast agent diffuses
throughout the joint, outlining cartilage and ligaments. This
phenomenon is utilized to create an "indirect arthrogram."
In the early phases after intravenous contrast administration,
the contrast remains adjacent to the synovium. This puddling
of contrast creates apparent synovial thickening. In order to
achieve uniform distribution of contrast in the joint, imaging is
delayed 20-30 minutes after contrast is injected intravenously,
and the joint is exercised prior to placing the patient in the
scanner.
Synovium lines tendon sheaths and bursae as well as joints.
Since the intravenous contrast is excreted by all synovium,
bursae and tendon sheaths, as well as joints, will show
contrast excretion. This may create difficulty in distinguishing,
for example, between a small rotator cuff tear resulting in
contrast extravasation into the subacromial/subdeltoid bursa
and a case of tendinosis and bursitis with opacification of both
the bursa and the joint.
Indirect arthrography is not indicated in the wrist, because all
wrist compartments will opacify. This negates the usual
diagnostic criterion of contrast extravasation into a different
wrist compartment. It is not useful in tight joints such as the
hip where there is rarely enough joint fluid to outline
abnormalities.
Pitfalls of Arthrography
Incorrect needle placement: Needle placement outside of the
joint is easily recognized because contrast either puddles at
the tip of the needle or flows into a space that does not
correspond to the anatomical joint cavity. It can be more
difficult to recognize an injection that is partly intraarticular
but partly into the substance of the joint capsule or a
ligament. Examples of both types of misplacement are seen in
the chapters regarding techniques of joint injection for each
joint. Partly extraarticular injections occur because the
operator has failed to consider the length of the needle bevel;
the tip of the needle may be intraarticular, but the proximal
portion of the bevel may be extraarticular. This is especially
common where the joint capsule is tightly apposed to bone. If
the needle enters the joint at a slight obliquity to the articular
surface, this will increase the distance available for the bevel
to lie within the joint cavity.
Excessive joint distention: If a joint is overly distended by
injectate, contrast tends to leak out of the joint through
microperforations. This can be distinguished on MR from a
true joint capsule or ligament rupture, which creates a focal,
larger, better defined area of abnormality.
MR Imaging vs. MR and CT Arthrography

General Principles
(Left) Axial T1 C+ FS MR of the
knee shows normal
appearance of synovial
excretion of intravenous
gadolinium, forming a thin,
enhancing rim ſt. (Right)
Sagittal T1 C+ FS MR with a
longer delay after injection
than the previous image
shows that the synovium
appears smoothly thickened
ſt. This reflects diffusion of
contrast away from the
synovium and should not be
mistaken for synovitis. To
obtain an indirect arthrogram,
joint must be exercised to
promote uniform contrast
dispersion in joint.

(Left) Coronal T1 FS MR
arthrogram shows contrast
opacifying the radiocarpal
joint and outlining the normal
radiocarpal ſt,
lunatotriquetral ﬇, and
triangular fibrocartilage st.
This is the most accurate
method of confirming
ligament integrity. (Right)
Coronal T1 FS MR indirect
arthrogram after intravenous
contrast administration shows
the ligaments outlined by
contrast on both the proximal
and distal surfaces. Contrast is
present in all compartments,
which limits the ability to
detect ligament defects.

(Left) Coronal T1 FS MR
arthrogram shows a full-
thickness tear of the
supraspinatus tendon ſt. This
patient had severe pain for 2
weeks after arthrogram and
returned for MR without and
with intravenous contrast.
(Right) Coronal T1 C+ FS MR in
the same patient shows
nodular thickening ſt of
synovium, consistent with
severe synovitis. Percutaneous
and open fluid samples
showed no infection. CRP was
elevated, with normal ESR.
Final diagnosis was sterile
synovitis related to
arthrogram injection.

5
 Fluoroscopic-Guided Joint Injections

KEY FACTS
General Principles

PREPROCEDURE • Inject small quantity of nonionic iodinated contrast to verify

• Must not place needle through surrounding/overlying soft
tissue infection
PROCEDURE
• Position patient for patient comfort and easy joint access
• Choose site based on easy access, avoidance of
neurovascular structures, and joint morphology
• Localize injection site with radiopaque marker (BB, paper
clips, or hemostat work well)
• Pass arthrogram needle toward joint
• Signs of intraarticular position
○ Needle tip on bone (or metal prosthesis)
○ Sensing firm resistance related to passage through
capsule
○ Curving of needle within joint along contour of bone
surface
○ Injection of small amount of anesthetic meets low
resistance
articular positioning
○ Contrast should immediately flow away from needle tip
○ "Puddling" of contrast at needle tip indicates needle not
within joint capsule
• Amount of contrast to inject depends on joint
○ Observe under fluoroscopy and inject until there is mild
distention of recesses
○ Do not overly distend joint; overdistention may cause
contrast extravasation, mimicking injury
• If sudden increase in pain, stop injection
OUTCOMES
• Some patients may have prolonged pain after procedure
○ Cause unknown, and reported prevalence varies widely
○ Resolves spontaneously in 1-3 days

Arthrogram Tray Correct Needle Placement

(Left) Clinical photograph
shows the contents of a
typical arthrogram tray.
(Right) A variety of approaches
can be used for arthrography,
based on operator preference.
Whatever location is used,
consider neurovascular
structures, and utilize
fluoroscopy during injection to
confirm that contrast flows
freely away from the needle
ſt and outlines the joint.
Knowledge of normal
anatomy is key to success.

Variant Needle Placement Incorrect Needle Placement

(Left) In large patients, needle
entry ﬈ at the
intertrochanteric region and
an oblique course of the
needle may be useful to avoid
pannus ﬊. Contrast flows
away from needle tip and into
joint recesses st with any
successful needle approach.
(Right) In this oblique
approach, the operator failed
to recognize that the injection
was extraarticular, resulting in
contrast in the iliofemoral
ligament ﬈ and pericapsular
space ﬊.

6
 Fluoroscopic-Guided Joint Injections
PREPROCEDURE
Indications
• Performed to evaluate for injury to articular and
fibrocartilage, ligaments, capsule; prosthesis loosening
• Usually performed in conjunction with CT or MR
Contraindications
• Surrounding/overlying soft tissue infection
○ Passing through infected tissue to access joint may infect
joint
Getting Started
• Things to check
○ Consent for risks
– Infection (rare; 1:20,000)
– Bleeding (uncommon, even in patients on
anticoagulants)
– Allergic reaction (uncommon in joint)
– Numbness, tingling, transient muscle weakness from
lidocaine injection
– Pain after arthrogram, occasionally severe
○ "Time out" verification of name and site
○ Medical history: Bleeding risk, allergies, medication list
○ Location of regional arteries
• Medications
○ 1% lidocaine HCl
○ Sodium bicarbonate (NaHCO₃) for mixing 1:9 with
lidocaine
– Optional, but diminishes "sting"
○ Nonionic iodinated contrast, e.g., iopamidol (Isovue 200)
○ Gadolinium contrast (for MR arthrography)
○ Optional: Epinephrine 1:1,000
– 0.1 cc, slows capsular resorption of contrast
○ Optional: Long-acting anesthetic (for diagnostic exam) or
steroid
– Can use anesthetic as diluent for arthrogram
– Decreases patient motion during exam
– Useful to determine if cause of pain is intraarticular
– Steroid can be added after contrast injected without
compromising diagnostic exam
• Equipment list
○ Wedges/pillows for positioning; localizer (BB/alternate);
skin marker; procedure tray
○ Procedure tray
– Sterile fenestrated drape
– Povidone-iodine (Betadine) skin cleanser or substitute
– Gauze; Band-Aid
– Arthrogram needle (gauge/length depends on joint,
preference)
– 25-g 1.5" needle for anesthesia
– Syringes: 1 cc (for gadolinium and epinephrine); 5 cc
(for iodinated contrast); 10 cc (for lidocaine); 10-20 cc
(for contrast)
– 20- to 25-g spinal needle for injection into joint
– 18-g needle for drawing up medications, contrast
• Contrast material
○ Nonionic contrast utilized; ionic contrast more painful
○ CT arthrography
– Iodinated contrast diluted 1:2 or 1:3 with saline or
bupivacaine
General Principles
○ Direct MR arthrography
– Dilute gadolinium contrast 1:200 to create 2.5 mM
concentration
– Diluent 25-50% nonionic contrast, remainder saline or
anesthetic
– e.g., in 20-cc syringe, draw up 0.1 cc gadolinium, 5 cc
nonionic contrast, 8 cc bupivacaine 0.25%, 7 cc
lidocaine 1%, 0.1 cc epinephrine
– May aspirate effusion before injecting contrast
– MR should be completed < 1 hour after contrast
injection
– If patient unable to tolerate MR, can perform CT
arthrogram
PROCEDURE
Patient Position/Location
• Position patient (see separate chapters) for patient comfort
and easy joint access
Equipment Preparation
• Needle size/length selection
○ 20- to 25-g needle can be used
– Larger gauge allows for better "feel": Lower
resistance felt when injecting into joint
– Larger gauge needles also easier to guide
– Smaller gauge more comfortable for patient
– For small joints (e.g., wrist), 25-g recommended
○ Plan needle length based on joint, patient size
– Wrist: 0.5-1.5"
– Elbow: 1.5"
– Shoulder: 3.5" (styletted needle)
– Hip: 3.5-5" (styletted needle)
Procedure Steps
• Choose site based on easy access, avoidance of
neurovascular structures, and joint morphology
• Notes for bariatric patients
○ Tape can be used to retract pannus; lift pannus and place
strong cloth tape across patient over lifted pannus,
attaching tape to both sides of table
○ Avoid areas of candida on skin
○ Stabilize skin with one hand while advancing needle with
other
– Avoids migration of needle as it traverses highly
mobile subcutaneous adipose tissue
• Localize injection site with radiopaque marker (BB, paper
clips, or hemostat work well)
• Mark skin at injection site with indelible marker
• Needle bevel length must be considered; need to access
joint in location where not only needle tip but entire bevel
can be intraarticular
○ Can be problem in nondistended joints
○ Avoid placing needle against joint surface perpendicular
to needle
○ Choose location where bone/joint curving away from
skin, allowing depth for bevel placement
• Cleanse skin with povidone-iodine (Betadine) or equivalent;
place sterile fenestrated drape
• Inject SQ lidocaine with 25-g needle, making small
subdermal wheal, and then inject more deeply
7
 Fluoroscopic-Guided Joint Injections
General Principles
• Since lidocaine not instantaneous, this is good time to draw
up joint injectate and allow anesthetic to take effect
• Pass arthrogram needle toward joint
○ Check position periodically using guidance modality
○ Use bevel at needle tip to help direct needle
• Signs of intraarticular position
○ Reaching bone
○ Sensing firm resistance related to passage through
capsule
○ Curving of needle within joint along contour of bone
surface
○ Multiple views showing intraarticular location of needle
tip
○ Injection of small amount of anesthetic meets low
resistance
• Inject small quantity of nonionic iodinated contrast (if
guidance modality fluoroscopy or CT) to verify articular
positioning
○ Contrast should immediately flow away from needle tip
○ "Puddling" of contrast at needle tip indicates needle not
within joint capsule
• High resistance to injection may be due to 1 of several
problems
○ Needle tip may be against cartilage; try turning needle
○ Needle may be in capsule or outside joint; try advancing
further
○ Needle may be plugged; try replacing stylet to push out
tissue plug
○ May need to try different area of joint; pull back beyond
fascia and reposition
• Aspirate joint effusion if present
• Inject contrast (avoid injecting air if MR to follow)
○ Add epinephrine as above if long wait before imaging
anticipated
• Amount of contrast to inject depends on joint
○ Inject until joint recesses are mildly distended
○ Ligament or tendon tear may increase apparent joint
capacity
○ If sudden increase in pain, stop injection
• Do not overly distend joint
○ Painful, has risk of extravasation of contrast
○ Iatrogenic extravasation may be mistaken for articular
abnormality
• Obtain spot radiographs to document position, articular
abnormalities
• Pitfalls
○ Firm capsule or postoperative scar may feel like bone to
inexperienced examiner
○ Inject small amount of lidocaine to confirm low-
resistance injection
– Inject small amount of contrast; should flow away
from needle tip
Findings and Reporting
• Diagnostic arthrogram
○ Abnormal communication of joint with other
compartments/collections
○ Synovitis (irregular capsular margins on plain
arthrographic images)
○ Loose bodies, cartilage abnormalities
8
POST PROCEDURE
Things to Do
• Pain relief should be monitored by patient if long-acting
anesthetic injected
○ Information used to determine if source of pain in joint
OUTCOMES
Problems
• Patient unable to tolerate MR: Can change to CT imaging
• Extraarticular injection: Contrast fills space other than joint
○ Move needle and verify intraarticular position prior to full
injection
• Partly extraarticular injection: Contrast may fill joint but also
puddle in adjacent soft tissues
• Extravasation of contrast: Overdistention of joint may cause
contrast to extravasate in absence of true capsule/ligament
injury
• Intravascular injection: Contrast fills branching vessels,
quickly clears
• Abnormal concentration of gadolinium: High concentration
will lengthen T1, cause fluid to appear black
Complications
• Most feared complication(s)
○ Septic arthritis
– Use careful sterile technique; never pass needle into
joint through suspected soft tissue infection
• Other complications
○ Injury to adjacent structures: Use of standard approaches
improves safety
○ Contrast reaction: If significant allergy history,
premedication recommended
○ Temporary numbness or weakness due to anesthetic
superficial to joint
○ Some patients may have prolonged pain after procedure
– Cause unknown, and reported prevalence varies
widely
– May be due to chemical irritation of joint related to
iodinated contrast
– Resolves spontaneously in 1-3 days
– Success in treating with Benadryl on hypothesis that it
is variant allergic reaction, but no scientific data to
back this practice
SELECTED REFERENCES
1. Fox MG et al: Shoulder MR arthrography: intraarticular anesthetic reduces
periprocedural pain and major motion artifacts but does not decrease
imaging time. Radiology. 262(2):576-83, 2012
2. Giaconi JC et al: Morbidity of direct MR arthrography. AJR Am J Roentgenol.
196(4):868-74, 2011
3. Andreisek G et al: Direct MR arthrography at 1.5 and 3.0 T: signal
dependence on gadolinium and iodine concentrations--phantom study.
Radiology. 247(3):706-16, 2008
4. Elentuck D et al: Direct magnetic resonance arthrography. Eur Radiol.
14(11):1956-67, 2004
5. Newberg AH et al: Complications of arthrography. Radiology. 155(3):605-6,
1985
 Fluoroscopic-Guided Joint Injections
Correct Needle Placement
Misplaced Injection
Air Bubbles on MR Arthrogram
General Principles
Misplaced Arthrographic Injection
(Left) Lateral fluoroscopic spot
radiograph of the knee during
arthrography documents
intraarticular needle
positioning. Note expected
appearance of contrast freely
flowing away from the needle
tip ﬊. (Right) Lateral
arthrogram of the knee shows
contrast pooling around the
needle tip st in Hoffa fat. In
general, there is increased
resistance to injection when
needle is extraarticular.
Misplaced Injection
(Left) Frontal fluoroscopic
spot radiograph of the
shoulder following injection
shows contrast overlying the
inferior joint ﬈. However,
note that the contrast is ill-
defined and does not extend
along the articular surfaces.
(Right) Axial T1 FS MR
arthrogram of the same
patient shows that the
contrast ſt is superficial to
the glenohumeral joint. The
physician should recognize the
appearance of extraarticular
injection under fluoroscopy to
prevent subsequent
nondiagnostic MR.
MR Delayed After Arthrogram
(Left) Sagittal T2 FSE FS MR
arthrogram shows bubbles ﬇
within the nondependent
aspect of the joint, which can
be mistaken for intraarticular
bodies. A characteristic high
signal intensity artifact st at
the margin of the air bubble is
useful for diagnosis. (Right)
Coronal oblique T1 FS MR
arthrogram shows suboptimal
contrast ﬇ within the
glenohumeral joint as a result
of resorption of contrast due
to excess delay in scanning.
9
 Fluoroscopic-Guided Joint Injections
General Principles

Effect of Gadolinium on T1 and T2 Signal Excessive Gadolinium Concentration

(Left) Graphic shows effect of
gadolinium concentration on
T1 and T2 signal. Peak signal
on T1-weighted images occurs
at a 2.5-millimolar
concentration (a 1:200
dilution of gadolinium in
saline). Note that T2 signal
progressively decreases with
increasing gadolinium
concentration. (Right) Coronal
scout GRE MR shows
consequence of operator using
1 cc rather than 0.1 cc of
gadolinium contrast agent in
20 cc of fluid. There is a
pronounced "blooming"
artifact ſt.

Excessive Gadolinium Concentration Joint After Gadolinium Resorption

(Left) Coronal PD FS MR
arthrogram shows the injected
fluid is dark ſt due to high
gadolinium concentration. The
labrum st is difficult to see
adjacent to the dark fluid in
the joint. (Right) Coronal PD
FS MR in the same patient on
the following day shows that
the gadolinium has resorbed
and fluid is bright st.
However, the injected fluid
has imbibed into the joint
capsule, causing it to appear
amorphous ſt.

Low Signal of Injectate on STIR Gadolinium on T1 Without FS

(Left) Coronal STIR MR
arthrogram shows
characteristic low-signal
gadolinium contrast ﬇ in the
glenohumeral joint. Because
of this appearance, T2 FSE
sequences are preferred to
STIR in MR arthrography.
(Right) Coronal T1 MR
arthrogram of the same
patient shows recurrent
rotator cuff tear ﬊ and high
signal in subacromial-
subdeltoid bursa ſt. Fat and
contrast are difficult to
distinguish because fat
saturation was not used.

10
 Fluoroscopic-Guided Joint Injections
Extraarticular Needle Placement
Arthrogram of Arthroplasty
Overdistention of Shoulder Joint
General Principles
Extraarticular Needle Placement
(Left) AP fluoroscopic spot
radiograph shows needle ﬇
overlies joint. However,
contrast is outlining muscle
fibers in one area ﬈ and
pooling outside of the joint in
other areas st. This should be
recognized, and patient should
be rescheduled for a different
day. (Right) Axial CT in the
same patient confirms
contrast within deltoid fibers
ſt and no intraarticular
contrast. Exam should be
repeated at no additional
charge.
Inadvertent Intravenous Contrast
(Left) Frontal fluoroscopic
spot radiograph of a hip
arthroplasty shows needle
placement on prosthetic
femoral neck and normal
opacification outlining the
joint pseudocapsule ſt.
Arthrography of arthroplasty
follows the same guidelines as
for native joints; the prosthesis
metal has a distinctive feel
when reached by the needle
tip. (Right) AP arthrogram
shows intravenous injection
ſt of contrast. Intravenous
contrast clears rapidly and is
not of great concern; needle is
merely repositioned.
Overdistention of Shoulder Joint
(Left) AP fluoroscopic spot
radiograph shows severe
distention of joint with
apparent enlargement of
medial joint recess ſt and
axillary recess ﬇. Both areas
were normal at arthroscopy.
Aggressive distention may
cause extravasation of
contrast. (Right) Axial T1 FS
MR arthrogram shows medial
extravasation of contrast ſt
due to overdistention of joint.
There is no need to fill the
joint to this extent, and it can
cause extravasation mimicking
injury.
11
 Tendon Sheath Injections

KEY FACTS
General Principles

PREPROCEDURE ○ Hold transducer with nondominant hand, needle with

• Diagnostic: Evaluate for presence of tenosynovitis, aspirate
for infection
• Therapeutic: Corticosteroid, platelet-rich plasma (PRP), or
anesthetic injection for treatment of tenosynovitis
• Ultrasound or MR should be performed prior to injection to
confirm diagnosis
PROCEDURE
• May be performed under fluoroscopic or ultrasound
guidance
• Ultrasound guidance is generally easier once operator is
familiar with technique
• Ultrasound guidance for tendon sheath injection
○ Visualize tendon in cross section and plan trajectory to
enter tendon sheath
○ Plan trajectory to position needle as nearly parallel to
transducer as possible
dominant hand
○ Transducer must be perpendicular to skin
○ Inject therapeutic agents under direct ultrasound
guidance
○ Injectate should flow away from needle tip
• Fluoroscopic guidance for tendon sheath injection,
preferred method
○ Palpate tendon at expected landmark
○ Advance needle through tendon to underlying bone
○ Slowly withdraw needle while injecting lidocaine until
there is loss of resistance to injection
– At this point, needle should be within tendon sheath
POST PROCEDURE
• Corticosteroid not instantaneous, usually takes 2-5 days
• PRP pain relief may not occur until 3-4 weeks after injection

Medial Ankle Tendons Posterior Tibial Tendon Preinjection

(Left) Lateral graphic of the
medial side of the ankle shows
medial tendons. In the
hindfoot, the posterior tibial
﬈ is superior to the flexor
digitorum longus (FDL) st and
flexor hallucis longus (FHL)
ſt. (Right) Axial (short-axis)
ultrasound shows the
posterior tibial tendon ſt, the
most medial of the deep flexor
tendons, adjacent to the
posterior medial corner of the
tibia. Note loss of transducer
contact with the ankle st due
to the skin curvature. A
minimal amount of fluid is
present in the tendon sheath
﬇.

Posterior Tibial Tendon Sheath Injection Posterior Tibial Tendon Post Injection
(Left) Oblique ultrasound in
the same patient shows that
the needle ſt has been placed
through the posterior tibial
tendon into its sheath deep to
the tendon, and fluid is being
injected, filling the sheath ﬇.
(Right) Oblique ultrasound
below the medial malleolus
after injection shows the
injected fluid ﬇, which has
moved freely along the
sheath. Injected corticosteroid
is echogenic st. The posterior
tibial tendon ſt has a
heterogeneous architecture
due to tendinosis.

12
 Tendon Sheath Injections

General Principles
– If patient experiences sensation of
TERMINOLOGY fullness/discomfort from tendon sheath distention by
Synonyms corticosteroid, do not inject bupivacaine
• Tenography is misnomer because most injections – This method is more cumbersome than premixing
performed into tendon sheath, not into tendon medications in single syringe but ensures that patient
gets full dose of corticosteroid
PREPROCEDURE Procedure Steps
Indications • Ultrasound guidance for tendon sheath injection
• Diagnostic: Evaluate for presence of tenosynovitis, aspirate ○ Visualize tendon in cross section and plan trajectory to
for infection enter tendon sheath
• Therapeutic: Corticosteroid, platelet-rich plasma (PRP), or ○ Mark needle entry site and ultrasound probe site
anesthetic injection for treatment of tenosynovitis – Plan trajectory to position needle as close to parallel
to transducer as possible
Contraindications
– Needle becomes progressively more difficult to
• Tendon rupture visualize as it becomes more perpendicular to
Preprocedure Imaging transducer
– Superficial tendons: Needle entry adjacent to probe
• Ultrasound or MR should be performed prior to injection to
confirm diagnosis – Deep tendons: Needle entry sufficient distance from
probe to allow correct trajectory
Getting Started ○ Use standard sterile technique, including sterile
• Equipment list ultrasound probe cover
○ Marker to mark skin ○ Hold transducer with nondominant hand, needle with
○ Sterile aperture drape or sterile towels dominant hand
○ 1.5-inch, 25-gauge needle for anesthetic and access to ○ Transducer must be perpendicular to skin
superficial tendons – Even slight tilt from vertical will make it very difficult
○ 3.5- to 5-inch, 20-, 22- or 25-gauge needles for access to to track needle
deep tendons ○ For 1st centimeter of inserting needle, watch needle and
○ 1% lidocaine for anesthesia transducer, not ultrasound screen
○ Chosen agent for therapeutic injection: Corticosteroid, – This enables operator to match needle trajectory to
hyaluronic acid preparation, or PRP position of transducer
○ Bupivacaine 0.25% may also be placed in tendon sheath ○ Perform superficial anesthesia with 25-gauge, 1.5-inch
– Avoid for small spaces as overdistention of sheath can needle under ultrasound guidance
be painful – Confirm correct needle trajectory
○ Ultrasound: Sterile probe cover and gel – For superficial tendons, this needle can also be utilized
○ Fluoroscopy: Iodinated contrast for injection
– For deep tendons, change to longer needle
PROCEDURE □ Needles vary in visibility under ultrasound, not
necessarily correlated to needle gauge
Patient Position/Location ○ For superficial tendons, may wish to traverse tendon
• Best procedure approach with needle and inject on far side of tendon
○ May be performed under fluoroscopic or ultrasound – This stabilizes needle and prevents inadvertent needle
guidance displacement during injection
– Ultrasound guidance is generally easier once operator ○ Inject therapeutic agents under direct ultrasound
is familiar with technique guidance
○ Position patient so they are comfortable, and preferably, – Injectate should flow away from needle tip
will not see injection needle ○ If injection becomes painful, injectate is probably
○ Perform time-out to verify patient name, date of birth, overdistending tendon sheath
and procedure to perform, including on which side of ○ PRP injection
patient – Usually dose is 4-5 cc
○ Informed consent – Scarring and adhesions in tenosynovitis may preclude
– Bleeding, infection, corticosteroid-induced "flare" of placement of entire volume at 1 site in tendon sheath
pain all are rare □ Place in several locations within scarred tendon
– Onset of long-term pain relief is several days for sheath
corticosteroid, 1-3 weeks for PRP ○ Obtain ultrasound image after injection to confirm
○ Have all medications ready at hand before starting correct placement of injectate
procedure • Ultrasound guidance for intratendinous needle
○ Corticosteroid and anesthetic may be mixed in single placement
syringe or separate syringes ○ Primarily used for PRP injection
– Preferable to have separate syringes and inject
corticosteroid 1st

13
 Tendon Sheath Injections
General Principles
○ Same process as that for tendon sheath injection, but
place needle tip in center of tendon or in areas of
tendinosis
○ May divide into 2-3 doses in adjacent areas of tendon
○ Studies have shown migration of injectate away from
site of injection
• Fluoroscopic guidance for tendon sheath injection,
preferred method
○ Palpate tendon at expected landmark
○ Advance needle through tendon to underlying bone
○ Slowly withdraw needle while injecting lidocaine until
there is loss of resistance to injection
– At this point, needle should be within tendon sheath
○ Inject small amount of iodinated contrast to confirm
location
○ Inject therapeutic agent(s)
○ Obtain postinjection image to evaluate for adhesions,
abnormal communications
○ Contrast should disperse along tendon sheath
• Fluoroscopic guidance for tendon sheath injection,
alternate method
○ Palpate tendon
○ Advance needle into tendon, which will feel firm
○ Have patient voluntarily contract tendon and then relax
– Needle will move with tendon if needle is
intratendinous
○ Withdraw needle slightly while injecting with lidocaine
1%
– When feel loss of resistance, needle is probably in
tendon sheath
– Inject small amount of iodinated contrast to confirm
position
• Landmarks for fluoroscopic guidance
○ Posterior tibial tendon: Posteromedial margin of medial
tibial plafond, or mid talar neck
○ Flexor hallucis longus tendon: Inferior margin of
sustentaculum tali
○ Peroneal tendon: Posterior groove of lateral malleolus or
along lateral margin of calcaneus
○ Biceps tendon: Bicipital groove of humerus
Findings and Reporting
• Pain relief
○ Utilize visual analogue scale 1 to 10
– Helpful to show scale to patient to reduce variation in
numerical score
○ Record preprocedure and postprocedure pain scores
• Stenosing tenosynovitis
○ Irregular, scarred tendon sheath
○ Blocked passage of contrast along tendon sheath
Alternative Procedures/Therapies
• Radiologic
○ Tendon sheath injections are usually easier under
ultrasound guidance if operator is practiced in that
technique
○ Fluoroscopic-guided injection/aspiration is usually also
good option
– Localization of tendon sheath is more difficult
because tendon is not visible, requires excellent
knowledge of anatomic landmarks
14
POST PROCEDURE
Expected Outcome
• Short-term pain relief due to anesthetic injection
• Corticosteroid not instantaneous
○ Pain relief begins in several days
• PRP pain relief may take 3-4 weeks
○ Patients may be sore for several days, treat with ice or
Tylenol, but not NSAIDs
Things To Do
• Counsel patients to avoid vigorous activity for several days
for corticosteroids, 2 weeks for PRP
• Counsel patients regarding time delay for onset of
corticosteroid and PRP efficacy
OUTCOMES
Problems
• If needle traverses nerve, patient will experience pain and
paresthesias along nerve distribution
○ Reassure patient and move needle; nerve is not
damaged
• Postinjection corticosteroid flare
○ Rare
○ Pain, redness, warmth generally < 24 hours after
injection
○ May last 2-3 days
○ Treat with ice, nonsteroidal antiinflammatory agents
• Elevated serum glucose in diabetic patients
○ Diabetic patients should be aware of this possibility and
monitor serum glucose
SELECTED REFERENCES
1. Park GY et al: Distribution of platelet-rich plasma after ultrasound-guided
injection for chronic elbow tendinopathies. J Sports Sci Med. 16(1):1-5, 2017
2. Peters SE et al: Ultrasound-guided steroid tendon sheath injections in
juvenile idiopathic arthritis: a 10-year single-center retrospective study.
Pediatr Rheumatol Online J. 15(1):22, 2017
3. Lee KS: Ultrasound-guided platelet-rich plasma treatment: application and
technique. Semin Musculoskelet Radiol. 20(5):422-431, 2016
4. Nwawka OK et al: Volume and movement affecting flow of injectate
between the biceps tendon sheath and glenohumeral Joint: a cadaveric
study. AJR Am J Roentgenol. 206(2):373-7, 2016
5. Petscavage-Thomas J et al: Comparison of ultrasound-guided to
fluoroscopy-guided biceps tendon sheath therapeutic injection. J
Ultrasound Med. 35(10):2217-21, 2016
6. Hashiuchi T et al: Accuracy of the biceps tendon sheath injection: ultrasound-
guided or unguided injection? A randomized controlled trial. J Shoulder
Elbow Surg. 20(7):1069-73, 2011
7. Schreibman KL: Ankle tenography: what, how, and why. Semin Roentgenol.
39(1):95-113, 2004
 Tendon Sheath Injections
Posterior Tibial Tendon Tenosynogram
Flexor Hallucis Longus Tenosynovitis
Lateral Ankle Tendons
General Principles
Flexor Hallucis Longus Tenosynogram
(Left) Lateral tenosynogram
shows contrast outlining the
posterior tibial tendon ſt
after needle placement st in
the tendon sheath. Note
proximity to the anterior
colliculus of the medial
malleolus ﬊, a key landmark.
(Right) Lateral tenosynogram
shows contrast filling the FHL
tendon sheath ſt, extending
anteriorly and posteriorly from
the injection site. The site of
entry is chosen using
sustentaculum tali as the
landmark. Only thin tram
tracks of contrast are visible
unless tenosynovitis is present.
Flexor Hallucis Longus Tenosynovitis
(Left) Lateral tenosynogram
shows an irregular, beaded
appearance of the FHL tendon
sheath st, reflecting
tenosynovitis. Slight contrast
extension into the FDL tendon
sheath ﬇ is seen distal to the
master knot of Henry where
the 2 tendons intersect. This is
a normal finding. (Right)
Oblique tenosynogram in the
same patient shows
irregularity of the FHL tendon
sheath st and slight filling of
the FDL tendon sheath ﬇.
Peroneal Tenosynogram
(Left) Lateral graphic of the
lateral side of the ankle shows
the peroneus longus ſt
located inferior to the brevis
st in the hindfoot. The brevis
attaches to the 5th metatarsal
base. The longus courses
beneath the cuboid and inserts
on multiple sites at the
plantar, medial aspect of the
midfoot. (Right) Lateral
tenosynogram shows the
needle in the peroneus longus
tendon sheath ſt with little
filling of the brevis sheath st
but good filling of the
common sheath ﬇.
15
 Tendon Sheath Injections
General Principles

MR Arthrogram of Peroneal Tenosynovitis Tenosynogram of Peroneal Tenosynovitis

(Left) Sagittal PD FS MR
arthrogram shows a wide,
irregular peroneal tendon
sheath ﬇ that filled during an
arthrogram due to a
calcaneofibular ligament tear.
The peroneus brevis tendon st
is thinned and the longus ſt is
thickened. (Right) Lateral
tenosynogram in the same
patient shows a normal distal
appearance of the peroneus
brevis st and longus ſt
tendons, but irregularity of the
proximal sheath ﬇, which
corresponds to scarring seen
on MR.

Injection of Peroneal Tendons Peroneal Tendons Post Injection

(Left) Oblique ultrasound
shows placement of the
needle ſt in a peroneal
tendon sheath and a stream of
high-echogenicity
corticosteroid st flowing
away from the needle tip.
Direct observation of injection
under ultrasound helps to
confirm correct needle
placement. (Right)
Postinjection coronal
ultrasound shows fluid has
extended around the tendons.
Echogenic corticosteroid ſt is
readily apparent.
Heterogeneous, decreased
echogenicity in the peroneus
longus ﬇ reflects tendinosis.

Peroneal Tendons Preinjection Peroneal Tendons Post Injection

(Left) Coronal (short-axis)
ultrasound of the peroneal
tendons ſt at the lateral
margin of the calcaneus shows
no appreciable fluid in the
sheath. Injection was
performed because of focal
tenderness and pain with
ankle eversion. (Right) Coronal
ultrasound of the peroneal
tendons ſt after therapeutic
injection of anesthetic and
corticosteroid shows fluid ﬇
in the tendon sheath.
Postinjection images are
useful to document correct
placement of injectate.

16
 Tendon Sheath Injections
Platelet-Rich Plasma Injection Into
Scarring After Peroneal Tendon Repair
Biceps Tenosynovitis on MRI
Biceps Tenosynovitis
General Principles
Peroneal Tendons
(Left) Coronal ultrasound in a
woman with pain and limited
motion after a peroneal
tendon repair shows matted,
irregular tendons ſt. Platelet-
rich plasma (PRP) injection
was performed to promote
healing and decrease
adhesions. (Right) Ultrasound
in the same patient shows the
needle ſt within the peroneus
longus tendon. To utilize the 5
cc of PRP, multiple small
injections were made along
the tendon and in the sheath.
The patient did well for a year,
then had recurrent symptoms
after injury and was again
treated successfully with PRP.
Biceps Tendon Sheath Injection
(Left) Axial PD FS MR shows
the biceps tendon st
surrounded by heterogeneous
fluid ſt. This patient had
focal, anterior shoulder pain,
and a biceps tendon sheath
injection was requested.
(Right) Axial ultrasound in the
same patient shows the
needle st placed posterior to
the biceps tendon within the
sheath ſt. Direct visualization
of the injectate confirmed the
correct position. This patient
had complete pain relief after
the injection.
Biceps Tendon Sheath Injection
(Left) Axial ultrasound of the
bicipital groove shows an
irregular contour of the biceps
tendon st. The surrounding
fluid is fairly echogenic ſt.
The subscapularis tendon ﬇ is
a useful landmark. (Right)
Axial ultrasound in the same
patient shows the needle ﬇
extending deep to the tendon.
Injectate st has flowed away
from the injection site along
the sheath.
17
 Ultrasound-Guided Joint and Bursa Injections

KEY FACTS
General Principles

PROCEDURE • Position, insert needle along long axis of probe at angle to

• Position patient so that operator can hold probe in
nondominant hand and needle in dominant hand while
viewing ultrasound monitor
• Determine optimal frequency ultrasound probe
○ High frequency unless target very deep
• Perform preliminary ultrasound
○ Identify landmarks, avoid blood vessels
○ Determine optimum entry site for needle and plan
needle trajectory
• Mark needle entry position and probe position on skin
○ For superficial structures, place needle entry close to
edge of probe
○ For deep structures, place needle entry site further from
probe to allow needle more horizontal course
• Cleanse skin, place probe in sterile cover and use sterile gel
• Probe should be perpendicular to skin
allow visualization
○ Look at needle during 1st cm of insertion, not at
ultrasound screen, to help place along axis of probe
• Visualize needle tip in joint or desired compartment
• Aspirate/inject; observe in real time to confirm change in
volume within compartment
• Fluoroscopic guidance for injection often easier for large
patients, deep sites
POST PROCEDURE
• Include in report
○ Effusion, synovitis
○ Appearance of fluid aspirated (clear, yellow, cloudy,
bloody, etc.)
○ Pain before and after procedure; 1-10 scale with 10
being most severe pain ever experienced

Arthrogram Tray US-Guided Shoulder Injection: Posterior

(Left) Clinical photograph
shows typical arthrogram tray
setup for ultrasound-guided
injection and aspiration.
(Right) Clinical photograph
shows posterior approach to
shoulder with patient in the
lateral decubitus position.
Sterile towels are placed to
accommodate transducer and
needle.

US-Guided Shoulder Injection: Anterior US-Guided Shoulder Injection: Upright

(Left) Clinical photograph
shows anterior approach to
shoulder. Needle ﬇ trajectory
is oriented along the long axis
of the probe ſt. A
disadvantage of this approach
is that the needle is within the
patient's line of vision, which
can increase anxiety. (Right)
Clinical photograph shows
posterior approach to shoulder
with patient seated, arm
resting on a small, adjustable
table. This approach is useful
in patients who have poor
mobility or difficulty breathing
and can be employed for
patients in wheelchairs.

18
 Ultrasound-Guided Joint and Bursa Injections
PREPROCEDURE
Indications
• Injection of contrast for MR or CT
• Aspiration of joints and periarticular collections
• Injection of anesthetic &/or steroid into joint or other
compartment (e.g., subacromial/subdeltoid bursa) for
diagnostic or therapeutic indications
Getting Started
• Medications
○ 1% lidocaine HCl for local anesthesia
○ Long-acting anesthetic &/or steroid for
diagnostic/therapeutic injection
• Equipment list
○ Arthrography tray
○ Sterile towels useful to drape larger area to
accommodate probe + needle
– Can also use aperture drape, especially with small
hockey-stick probe
○ Sterile probe cover and gel
○ Ultrasound probe of appropriate frequency
○ Needles
– 1.5" 25-g needle for anesthesia and checking needle
trajectory
– Longer needle for joint access if needed
– Visibility of needle not necessarily correlated to
needle gauge, experiment with different needles
available to you
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Position patient so that operator can hold probe in
nondominant hand and needle in dominant hand while
viewing ultrasound monitor
○ Preferable to place needle out of patient's direct line of
sight
Procedure Steps
• Determine optimal frequency ultrasound probe
○ High frequency unless target is very deep
○ Linear array best for tracking needle course
• Perform preliminary ultrasound
○ Identify landmarks, identify blood vessels, and plan
needle trajectory
○ Mark needle entry position and probe position on skin
– For superficial structures, place needle entry close to
edge of probe
– For deep structures, place needle entry site further
from probe to allow needle more horizontal course
• Cleanse skin
• Provide subcutaneous anesthetic
• Use sterile gel to assist sound transmission
• Place probe in sterile cover on skin, reproducing image
acquired during planning
• Probe should be perpendicular to skin
• Position, insert needle along long axis of probe at angle to
allow visualization
○ Look at needle during 1st cm of insertion, not at
ultrasound screen, to help place along axis of probe
General Principles
• Needle will be seen as bright, linear reflector; align with
probe so needle is in view
○ Occasionally only tip seen, especially with smaller gauge
needles and deeper locations
○ Can wiggle needle slightly and observe real-time to find
needle tip
○ Can wobble probe slowly back and forth to find needle
○ Injected anesthetic is visible and may also help locate
needle tip
• Visualize needle tip in joint or desired compartment
• Aspirate fluid if joint effusion present
○ If fluid clear yellow and no clinical suspicion of infection,
fluid usually discarded
• Aspirate/inject; observe in real time to confirm change in
volume within compartment
○ Injected fluid flowing freely into compartment confirms
correct placement
Findings and Reporting
• Joint effusion, synovitis
• Pain before and after procedure; 1-10 scale with 10 being
most severe pain ever experienced
Alternative Procedures/Therapies
• Radiologic
○ Fluoroscopic guidance for injection often easier for large
patients, deep sites
OUTCOMES
Problems
• Fluid cannot be withdrawn from joint
○ Inject small amount of normal saline under ultrasound
guidance
– Check that fluid flows freely away from needle into
joint
– If no free flow, needle probably not in fluid collection
Complications
• Most feared complication(s)
○ Septic arthritis
– Careful sterile technique must be used
– Never pass needle into joint through suspected soft
tissue infection
SELECTED REFERENCES
1. Kane D et al: Musculoskeletal interventional procedures: with or without
imaging guidance? Best Pract Res Clin Rheumatol. 30(4):736-750, 2016
2. Martínez-Martínez A et al: Comparison of ultrasound and fluoroscopic
guidance for injection in CT arthrography and MR arthrography of the hip.
Radiologia. 58(6):454-459, 2016
3. Ng AW et al: Comparison of ultrasound versus fluoroscopic guided rotator
cuff interval approach for MR arthrography. Clin Imaging. 37(3):548-53, 2013
4. Sofka CM et al: Ultrasound-guided adult hip injections. J Vasc Interv Radiol.
16(8):1121-3, 2005
5. Adler RS et al: Percutaneous ultrasound-guided injections in the
musculoskeletal system. Ultrasound Q. 19(1):3-12, 2003
6. Lin J et al: An illustrated tutorial of musculoskeletal sonography: part 4,
musculoskeletal masses, sonographically guided interventions, and
miscellaneous topics. AJR Am J Roentgenol. 175(6):1711-9, 2000
19
 Ultrasound-Guided Joint and Bursa Injections
General Principles

Needle and Transducer Placement US-Guided Hip Aspiration

(Left) Graphic shows
positioning of probe and
needle for ultrasound-guided
procedures. The needle should
be as horizontal in approach
as possible to improve US
visualization. The deeper the
structure to be accessed, the
further the needle should be
positioned from the probe.
(Right) Sagittal US shows
needle placement during
aspiration of hip joint effusion.
The needle trajectory is steep
ſt, and the distal portions are
difficult to see as a result, but
the tip st is visible in the joint
effusion ﬇, anterior to the
femoral neck ﬊.

Bariatric Knee Needle Placement in Bariatric Knee

(Left) Axial PD FS MR of the
knee shows a large joint
effusion ſt, the target for
joint aspiration in this case.
Because of the patient's size,
US guidance was requested.
(Right) Axial US with a linear
array 9-3 MHz transducer
shows needle ſt placed into
suprapatellar recess ﬇. Fluid
contains low-level echoes due
primarily to its depth. It can be
difficult to tell deep fluid
collections from low-
echogenicity scar. Fluid was
freely aspirated in this case.

US-Guided Bursal Injection US-Guided Cyst Injection

(Left) Coronal US shows
therapeutic injection of
anesthetic and steroid into the
subacromial-subdeltoid bursa
of the shoulder. Note needle
ſt, rotator cuff tendon st,
and deltoid muscle ﬇. (Right)
Axial oblique US shows
decompression of a hip
paralabral cyst. Note needle
ſt entering cyst ﬇ adjacent
to cortex of femoral head st.

20
 Ultrasound-Guided Joint and Bursa Injections
Tibiotalar Joint Pre Injection
Posterior Approach Shoulder Injection
Greater Trochanteric Bursitis
General Principles
Tibiotalar Joint Post Injection
(Left) Sagittal US shows tibia
ſt and talar dome st prior to
injection for arthritis. There is
no visible joint effusion.
Osteophyte ﬇ is visible on
talus. (Right) Sagittal US
following injection in the same
patient shows injected fluid in
anterior joint recess ſt. Small,
echogenic focus ﬇ may
reflect injected steroid or air.
Posterior Approach Shoulder Injection
(Left) Axial US shows posterior
approach to shoulder. Needle
ſt enters the joint just lateral
to the labrum. Inadvertent air
bubbles st in the joint are
from incomplete clearing of
air from syringe. Landmarks
for position are the articular
surface of the humeral head
﬊, the glenoid ﬉, and the
deep surface of the
infraspinatus ﬈. (Right) Axial
US later in injection in the
same patient shows distention
of posterior joint recess st by
injectate. Injectate must
always flow freely away from
needle to confirm location.
Needle in Greater Trochanteric Bursa
(Left) Axial US shows fluid
collection st superficial to
gluteus medius insertion ſt on
greater trochanter ﬇. Fluid is
slightly anterior to the
trochanter, and US is useful to
target the collection, as
opposed to the commonly
performed injections without
guidance. (Right) Axial US
during injection shows needle
ſt in bursa, approaching from
the anterior margin of the
thigh. Injection needs to be
anterior to the greater
trochanter ﬇ in this case.
21
 Aspiration for Fluid Analysis

KEY FACTS
General Principles

PREPROCEDURE • Steps to follow

• Ultrasound, CT, or MR should be performed to confirm fluid ○ Find shortest approach to fluid collection that avoids
collection present broken skin, cellulitis, and blood vessels
• If fluid not visible on imaging, attempted aspiration almost ○ Mark entry site, perform sterile prep and drape
always negative ○ Advance needle under fluoroscopic or ultrasound
• Contraindication guidance
○ Cellulitis overlying approaches to joint ○ Confirm correct location either by direct visualization
under ultrasound, by aspiration of joint fluid, or by
PROCEDURE injection of air
• Fluoroscopic approach ○ Do not inject iodinated contrast, which is bacteriocidal
○ Easier in large patients and deep fluid collections ○ Remove stylet and aspirate fluid, starting with small
○ Advance until hit bone or metal (prosthetic joints) syringe
○ Often useful to slide needle to side of bone into deeper ○ If cannot obtain fluid, utilize squeeze maneuver or move
portion of joint needle
• Ultrasound approach ○ Aspirate as much fluid as possible, send all fluid to
○ Allows direct visualization of fluid collections, helps laboratory for analysis
direct needle ○ Replace stylet and remove needle
○ Have needle as parallel as possible to transducer to
improve visualization

MR of Infectious Tenosynovitis US of Infectious Tenosynovitis

(Left) Sagittal STIR MR of the
foot shows a large fluid
collection ſt surrounding the
anterior tibial tendon st. The
patient had diabetes and
sepsis not responsive to
antibiotics. Aspiration was
requested. Note amputation
at midfoot ﬊. (Right) Sagittal
US in the same patient shows
echogenic material ſt within
the sheath of the anterior
tibial tendon st. Color
Doppler (not shown)
confirmed that there was
surrounding hyperemia but no
blood flow within the
collection.

Fluid Aspiration Aspirated Fluid

(Left) Oblique US in the same
patient shows an 18-g
hypodermic needle ﬇ in place
within the fluid collection ſt.
Much of the fluid has already
been withdrawn. Anterior
tibial tendon is noted st.
(Right) Clinical photograph
shows that the fluid aspirated
from the tendon sheath of the
same patient is thick, dark,
and opaque. A sterile cap ﬉
has been placed and the fluid
is sent for culture in the
syringe, from which all air has
been expelled. Specimen grew
S. aureus.

22
 Aspiration for Fluid Analysis
PREPROCEDURE
Indications
• Suspected joint or tendon sheath infection
• Evaluation of crystal-induced or inflammatory arthritis
Contraindications
• Never enter joint through cellulitis or broken skin
Preprocedure Imaging
• Ultrasound, CT, or MR should be performed to confirm fluid
collection present
○ If fluid not visible on imaging, attempted aspiration
almost always negative
• Purulent fluid may appear echogenic on ultrasound
• Granulation tissue may be low echogenicity on ultrasound
and mimic fluid
Getting Started
• Things to check
○ Anticoagulation medications should be noted
– Therapeutic range is not contraindication to aspiration
– Remember there are risks to stopping anticoagulation
– Apply pressure as needed after procedure
• Equipment list
○ Arthrogram tray or sterile towels plus syringes
○ 1% lidocaine for anesthesia
○ Nonbacteriostatic saline for lavage
○ 25-g needle for local anesthetic
○ 18-g needle for aspiration
– Purulent fluid thick and viscous, smaller gauge
needles often not successful for aspiration
– Use as short a needle as possible
– Aspiration more difficult through longer needles,
which increase resistance
○ Purple top (contains EDTA) tube for cell count
– Prevents clotting of bloody specimens, which
prevents cell count
○ Caps for syringes
– Send fluid for culture in syringes with air removed
○ Blood culture bottles if desired for culture
○ Send fluid to evaluate for crystals if differential
diagnostic consideration
PROCEDURE
Patient Position/Location
• Best procedure approach
○ Fluoroscopic approach
– Easier in large patients and deep fluid collections
– Fluoroscopic guidance used to advance needle to
bone (or metal prosthesis)
□ Correct location predicted based on knowledge of
joint anatomy
□ Can slide needle off bone/metal into more
dependent portion of joint
○ Ultrasound approach
– Allows direct visualization of fluid collections, helps
direct needle
– Have needle at shallow angle relative to transducer to
improve visualization
General Principles
– May require long needle, which makes aspiration
more difficult
○ Combined fluoroscopic and US approach
– Can localize pocket of fluid under US, then aspirate
under fluoroscopy
– May allow use of shorter needle, which improves yield
Procedure Steps
• Identify site for aspiration, usually best with ultrasound
• Mark entry site, perform sterile prep and drape
• Advance needle under fluoroscopic or ultrasound guidance
• Always keep stylet in needle to prevent clogging of needle
• Pseudocapsule around arthroplasty often dense and
resistant to needle advancement
○ Sharp, jabbing motion will advance needle through
pseudocapsule
• Pannus due to rheumatoid arthritis also difficult to
penetrate; use similar motion
• Confirm correct location either by direct visualization under
ultrasound, by aspiration of joint fluid, or by injection of air
○ Do not inject contrast, which is bacteriocidal
• Remove stylet and aspirate fluid, starting with small syringe
○ More difficult to aspirate using larger syringe
○ Change to larger syringe if large amount of fluid present
○ Aspirate as much fluid as possible, send all fluid to
laboratory for analysis
• Replace stylet and remove needle
• Provide skin pressure at site
If Unable to Aspirate Fluid
• Check to confirm needle truly intraarticular
○ Fluoroscopy: Inject air
– Confirms location and often mobilizes fluid
○ Ultrasound: Inject small amount of nonbacteriostatic
saline or air
– Observe in real time during injection
• Perform squeeze maneuver
○ Assistant with gloved hands "milks" joint from below
patient and drape
○ Maintain suction on syringe during this maneuver
• Change needle position to another portion of joint
○ 18-g needle has limited ability to steer, so withdraw
partially before repositioning
• Slide needle to side of bone (or prosthesis) into deeper
portion of joint
• Lavage with normal saline only if other maneuvers not
successful
○ Should be avoided if possible, because orthopedic
surgeons rely heavily on white blood cell count in fluid to
determine if infection present
○ Inject 5 cc quickly while assistant maintains squeeze
maneuver; aspirate quickly
SELECTED REFERENCES
1. Kane D et al: Musculoskeletal interventional procedures: with or without
imaging guidance? Best Pract Res Clin Rheumatol. 30(4):736-750, 2016
2. Hansford BG et al: Musculoskeletal aspiration procedures. Semin Intervent
Radiol. 29(4):270-85, 2012
23
 Aspiration for Fluid Analysis
General Principles

CT of Hip, Aspiration Requested US Aspiration After Girdlestone

(Left) Coronal CT shows
Girdlestone procedure
(excision of proximal femur
and debridement of
acetabulum). Aspiration was
requested to rule out
infection. (Right) Sagittal US in
the same patient shows the
empty acetabulum ſt after
Girdlestone. Low-level
echogenic material fills the
acetabulum, and fluid was
retrieved from the center
under US guidance. US
appearance is nonspecific and
could reflect fluid or
granulation tissue.

Aspiration of Dislocated Hip Air Injection at Prosthesis

(Left) AP fluoroscopic image in
a patient with dislocated hip
hemiarthroplasty shows
needle tip ſt placed into
acetabulum. After dislocation,
fluid often pools in
acetabulum. (Right) AP
fluoroscopic image shows air
ſt outlining the femoral
prosthesis. This is useful both
to confirm intraarticular
needle location and to
mobilize fluid within the joint.
Aspiration is often easier after
air injection. Note that needle
st has been advanced along
the lateral side of prosthesis in
order to access a deeper
portion of the joint.

Combined US and Fluoroscopic Guidance Combined US and Fluoroscopic Guidance

(Left) Sagittal US shows a very
small amount of fluid ſt
adjacent to prosthetic femoral
neck. The patient was quite
large. It was elected to
approach this under
fluoroscopy in order to use a
direct vertical approach, which
allowed use of a shorter
needle. Aspiration is more
difficult with longer needles
due to increased resistance.
(Right) AP fluoroscopic image
shows needle placed on
femoral neck, at site of fluid
seen on ultrasound ﬈. Fluid
was successfully withdrawn.

24
 Aspiration for Fluid Analysis

General Principles
Acute Gout US-Guided Aspiration of Acute Gout
(Left) PA radiograph in a 27-
year-old woman shows soft
tissue swelling surrounding
the 2nd PIP joint. There is a
small erosion ſt. Attempts to
aspirate the joint in clinic were
unsuccessful, and patient was
sent for US-guided aspiration.
(Right) Sagittal US in the same
patient shows a 22-g
hypodermic needle ﬇
inserted into PIP joint of hand.
A joint effusion ſt is present,
containing echogenic debris,
which is nonspecific but in this
case represented gout
crystals.

Seronegative Arthritis Seronegative Arthritis

(Left) Sagittal STIR MR shows
a large joint effusion ſt and
thickened, heterogeneous
synovium ﬇ indicating
synovitis in a 21-year-old
woman with pain and elevated
inflammatory markers.
Differential diagnosis for this
monoarticular arthritis
includes infection and
inflammatory arthritis, and
aspiration under ultrasound
was requested. (Right) Sagittal
US with color Doppler shows
joint effusion and synovitis
deep to the triceps tendon ſt.
Aspirated fluid was bloody
with elevated WBC. Cultures
were negative.

Echogenic Fluid, Rheumatoid Arthritis Air Injection Into Joint

(Left) Sagittal US of ankle with
color Doppler shows large
joint effusion ſt containing
low-level echoes, and
hyperemia of the joint capsule
st. Patient had several
months of morning pain,
stiffness, and equivocal lab
values for rheumatoid
arthritis. Aspiration was
requested. (Right) Sagittal US
of same patient shows
echogenic air ſt within the
joint effusion. The joint fluid
was thick and difficult to
aspirate even through 18
gauge needle. Air confirms
correct needle placement, and
helps mobilize fluid.

25
 Therapeutic Injections

KEY FACTS
General Principles

TERMINOLOGY ○ Aspiration of synovial fluid

• Injection of anesthetic, corticosteroid, HA, or PRP for ○ Injection of air or iodinated contrast (fluoroscopy)
treatment of joint pain ○ Injection of anesthetic under direct visualization
(ultrasound)
PREPROCEDURE ○ Aspirate joint effusion if present
• Imaging guidance has been shown to improve efficacy of • Injectate should flow easily, without resistance
therapeutic injections • Apply pressure quickly when needle withdrawn to prevent
• Multiple conditions treated by therapeutic injections: agent from backflow at needle site
Arthritis, adhesive capsulitis, bursitis, tenosynovitis, tendon
partial tear (PRP only) OUTCOMES
• Absolute contraindications • No injected agent has long-term benefit for osteoarthritis
○ Active joint infection or bacteremia • Length of pain relief quite variable
○ Cellulitis overlying injection site • PRP may promote tendon healing
○ Allergy • Complications
○ Joint instability ○ Hyperglycemia in diabetic patients (with corticosteroids)
○ Intraarticular fracture ○ Allergic reaction (uncommon)
• Standard sterile technique, guidance with ultrasound or ○ Depigmentation: Subcutaneous injection of
fluoroscopy corticosteroid may cause local skin depigmentation
• Confirm location

Intrasubstance Tear of Supraspinatus PRP Injection Into Intrasubstance Tear

(Left) Coronal T2 FS MR shows
fluid ſt in the center of the
supraspinatus tendon. It does
not extend to either the
articular or bursal surface,
consistent with intrasubstance
tear. (Right) Coronal US shows
a 22-g needle st in the
supraspinatus tendon. PRP
injectate ſt is hyperechoic
and flows away from the
needle tip into the
intrasubstance tear. Greater
tuberosity ﬇ and superficial
margin of supraspinatus ﬊
are noted.

Painful Synovial Cyst Ultrasound-Guided Cyst Injection

(Left) Coronal PD FS MR shows
a synovial cyst ſt at the
medial head of the
gastrocnemius muscle. This is
a common incidental finding,
but in this case, the patient
had posterior knee pain with
pinpoint tenderness over the
cyst, and imaging-guided
corticosteroid injection was
requested. (Right) Sagittal US
shows a 22-g spinal needle ſt
with its tip in the synovial cyst
st, which is adjacent to the
medial femoral condyle ﬇.
Patient had excellent pain
relief after injection of 20 mg
of Kenalog.

26
 Therapeutic Injections

General Principles
– Hip, shoulder, knee: 6-8 cc bupivacaine, less if
TERMINOLOGY combining with viscosupplement
Abbreviations – Hindfoot: 3-5 cc bupivacaine, less if combining with
• Hyaluronic acid (HA) viscosupplement
• Platelet-rich plasma (PRP) – Tarsometatarsal, MTP joints: 1 cc bupivacaine
• Corticosteroids
Definitions ○ Onset and duration of action of corticosteroid varies by
• Injection of anesthetic, corticosteroid, HA, or PRP for type
treatment of joint pain – Onset generally 2-5 days, duration 4-12 weeks
○ Frequency of corticosteroid injections controversial due
PREPROCEDURE to concern regarding soft tissue/chondrocyte injury
Indications ○ Generally not recommended > 3-4x per year
• Imaging guidance has been shown to improve efficacy of – Weigh benefit of injection with risk of potential
therapeutic injections damage
• Multiple conditions treated by therapeutic injections ○ 2 main types of corticosteroids: Phosphate and acetate
○ Arthritis: Degenerative, inflammatory or crystal- – Phosphate type more soluble than acetate type
associated arthritis □ Used more commonly in acute conditions (e.g.,
○ Bursitis and tenosynovitis bursitis)
○ Adhesive capsulitis ○ Acetate-type corticosteroids used more commonly in
○ Tendinosis and partial tendon tear (PRP) chronic conditions (e.g., arthritis)
○ Labral tear (symptomatic relief) ○ Some corticosteroid preparations are fluorinated; these
may be more deleterious to soft tissues
Contraindications – Use of fluorinated compounds should be reserved for
• Absolute contraindications intraarticular injections
○ Active joint infection or bacteremia • Hyaluronic acid preparations: Basic principles
○ Cellulitis overlying injection site ○ Articular cartilage has no blood supply
○ Allergy to steroid (for steroid injections) – All nutritional support delivered via fluid that moves
○ For HA: Allergy to avian products as joint moves
○ Joint instability ○ Role of HA in synovial fluid is to maintain viscoelastic
○ Intraarticular fracture structural and functional properties of articular matrix
• Relative contraindications ○ Normal, healthy synovial fluid is high in concentration of
○ Anticoagulation therapy HA
○ Indwelling hardware – In osteoarthritic joints, concentration is reduced
○ Some recent articles suggest timing of intraarticular hip ○ Proposed mechanisms of action of exogenous HA
injection within 2 months of total hip arthroplasty (THA) – Antiinflammatory, nociceptive, &/or stimulation of in-
may increase infection risk, but more research is vivo HA synthesis
necessary ○ Multiple injections needed (3-5 depending on product)
except for Synvisc-1
Getting Started • Commercially available HA products in USA
• Things to check ○ Sodium hyaluronate (Hyalgan)
○ Patient allergy list ○ Highly purified hyaluronan (Euflexxa)
• Equipment list ○ High molecular weight hyaluronan (Orthovisc)
○ Skin disinfectant [povidone-iodine (Betadine) or ○ Sodium hyaluronate (Supartz)
alternative] ○ Hylan GF-20 (Synvisc)
○ Sterile drapes • Differences between HAs
○ Marking pen ○ Commercially available HAs have various molecular
○ Needles weight, viscosity, resident time in joint, etc.
– Local anesthetic: 25-g, 1.5" ○ No literature to date supports substantial clinical
– Large joints: 20- to 22-g spinal needle differences based on these distinctions
– Small joints: 22- to 25-g, 1.5" ○ Literature supports pain relief best at 5-13 weeks
○ Fluoroscopy or ultrasound to guide needle placement ○ Some pain and functional improvements to 26-52 weeks
• Local anesthetics • Comparison of HAs with corticosteroids
○ Lidocaine 1% ○ HAs more expensive than corticosteroids
– Onset seconds to minutes, duration 60-120 minutes ○ HA onset of action much slower than corticosteroid
– 1% lidocaine recommended for local anesthetic, 1-3 cc ○ HA not shown to have long-term advantages over
for ankle, 3-5 cc shoulder, 5-8 cc hip corticosteroids
○ Bupivacaine 0.25% or 0.5% ○ HAs may cause inflammatory response, especially with
– Onset 2-10 minutes, duration 180-360 minutes inadvertent extraarticular injection
○ Recommended intraarticular dose (not including steroid) • Indications for HAs
○ Approved by FDA only for osteoarthritis of knee

27
 Therapeutic Injections
General Principles
○ All other joints considered off-label
• PRP
○ Centrifuged autologous blood yields PRP
○ May be injected into tendons, bursae, or joints
– Some studies show improved tendon healing with
PRP
– Early studies showed reduced pain in grade 1-2
osteoarthritis of knee
– More recent data show no significant difference in
knee osteoarthritis pain 6 months after treatment
with HA or PRP
○ Preparation may be leucocyte-rich or leucocyte-poor
– Leucocyte-poor PRP increasingly preferred, but there
is ongoing debate
• Procedure steps
○ Choose location to avoid neurovascular structures
○ Do not go through skin affected by cellulitis or rash
○ Standard sterile technique, guidance with ultrasound or
fluoroscopy
○ Confirm location by aspiration of synovial fluid, injection
of air or iodinated contrast (fluoroscopy) or injection of
anesthetic under direct visualization (ultrasound)
○ Aspirate joint effusion if present
○ Injectate should flow easily, without resistance
– Reposition and recheck if meet resistance
○ Apply pressure quickly when needle withdrawn to
prevent agent from backflow at needle site
POST PROCEDURE
Expected Outcome
• Initial symptomatic relief from local anesthetic (several
hours)
• Variable onset of response to steroid preparation (typically
2-5 days)
• Variable duration of response to corticosteroid (typically 2-3
months)
• Variable onset of response to HA (typically 2-3 weeks)
• Variable duration of response to hyaluronic acid (typically 3-
4 months)
OUTCOMES
Problems
• Hyperglycemia in diabetic patients with corticosteroid
intraarticular injections
○ Advise patient to monitor glucose level frequently for 72
hours following procedure
• Facial flushing with corticosteroid injections
• Small risk of inflammatory response with hyaluronic acid
preparations (2-3%)
• Allergic reaction (uncommon)
○ Probable cause of joint pain, increased effusion 1-2 days
after injection
○ Treat with diphenhydramine hydrochloride (Benadryl),
25-50 mg orally
• Depigmentation: Subcutaneous injection of corticosteroid
may cause local skin depigmentation
○ Ensure that injection is only into contained space (joint,
bursa, or tendon sheath)
○ Apply pressure to site to prevent leaking of steroid from
injection site
28
Complications
• Most feared complication(s)
○ Infection (1:30,000)
○ Bleeding
• Other complications
○ Temporary paresthesias or muscle weakness due to local
anesthetic
– Caution patients, help off table to prevent falls
Efficacy of Injected Agents
• No injected agent has long-term benefit for osteoarthritis
• Length of pain relief is quite variable
• PRP may improve tendon healing
SELECTED REFERENCES
1. Bowden DJ et al: Injectable viscoelastic supplements: a review for
radiologists. AJR Am J Roentgenol. 209(4):883-888, 2017
2. Cole BJ et al: Hyaluronic acid versus platelet-rich plasma: a prospective,
double-blind randomized controlled trial comparing clinical outcomes and
effects on intra-articular biology for the treatment of knee osteoarthritis.
Am J Sports Med. 45(2):339-346, 2017
3. Dai WL et al: Efficacy of platelet-rich plasma in the treatment of knee
osteoarthritis: a meta-analysis of randomized controlled trials. Arthroscopy.
33(3):659-670.e1, 2017
4. Trigkilidas D et al: The effectiveness of hyaluronic acid intra-articular
injections in managing osteoarthritic knee pain. Ann R Coll Surg Engl.
95(8):545-51, 2013
5. McCarrel TM et al: Optimization of leukocyte concentration in platelet-rich
plasma for the treatment of tendinopathy. J Bone Joint Surg Am.
94(19):e143(1-8), 2012
6. Tveitå EK et al: Hydrodilatation, corticosteroids and adhesive capsulitis: a
randomized controlled trial. BMC Musculoskelet Disord. 9:53, 2008
7. Lambert RG et al: Steroid injection for osteoarthritis of the hip: a
randomized, double-blind, placebo-controlled trial. Arthritis Rheum.
56(7):2278-87, 2007
8. Robinson P et al: Clinical effectiveness and dose response of image-guided
intra-articular corticosteroid injection for hip osteoarthritis. Rheumatology
(Oxford). 46(2):285-91, 2007
9. Ozturk C et al: The safety and efficacy of intraarticular hyaluronan
with/without corticosteroid in knee osteoarthritis: 1-year, single-blind,
randomized study. Rheumatol Int. 26(4):314-9, 2006
10. Qvistgaard E et al: Intra-articular treatment of hip osteoarthritis: a
randomized trial of hyaluronic acid, corticosteroid, and isotonic saline.
Osteoarthritis Cartilage. 14(2):163-70, 2006
11. Tehranzadeh J et al: Therapeutic arthrography and bursography. Orthop
Clin North Am. 37(3):393-408, vii, 2006
12. Tehranzadeh J et al: Cartilage metabolism in osteoarthritis and the influence
of viscosupplementation and steroid: a review. Acta Radiol. 46(3):288-96,
2005
13. Kullenberg B et al: Intraarticular corticosteroid injection: pain relief in
osteoarthritis of the hip? J Rheumatol. 31(11):2265-8, 2004
14. Eustace JA et al: Comparison of the accuracy of steroid placement with
clinical outcome in patients with shoulder symptoms. Ann Rheum Dis.
56(1):59-63, 1997
15. Plant MJ et al: Radiographic patterns and response to corticosteroid hip
injection. Ann Rheum Dis. 56(8):476-80, 1997
Another random document with
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[17] Pronounced cree-cree.
 LESSON XX.
A QUEER CRICKET.
When you are out in the woods, you may find a very small, brown
cricket, in the moist places at the roots of trees. That is the wood
cricket.
The most curious of all the crickets is the mole cricket. The mole
cricket is the stoutest and largest of all the cricket family. He takes
his name from the little furry, mouse-like animal that burrows in the
ground,—the mole.
The mole cricket is something like the mole in shape, and in the
shape of its front feet. It is very like the mole in its ways.
Mole crickets in the larva and pupa state are like their parents in
looks and habits. They lack only the wings. The wings of mole
crickets are short. They open and close them at each stroke when
they fly. This makes them fly with a wave-like motion. Now they go
up, now they drop down.
 A HAPPY FAMILY.
The mole cricket sings only at night. It does not make such loud
music as the field cricket.
The most curious thing about the mole cricket is its front feet. They
are broad and short, and have toes. They look like a mole’s front
feet. They also look like the glove, or hand part, of a little suit of
armor.
These hands are made for digging. The mole cricket burrows along
under the ground as a mole does. Have you seen the long, low ridge
of earth the mole makes in field or garden? The mole cricket’s furrow
is like that, only much smaller.
The mole cricket eats the roots of vegetables, as he goes along
under ground. He is fond of peas, beans, and beets. He will eat the
roots of flowers, also. He is a plague in a garden. He likes, also, to
live near a stream or canal. He is very fond of damp places.
The mole cricket neither flies nor sings by day. If dug out of his
burrow, he seems very stupid and helpless. At evening, he tries to
comfort himself by a low, jarring song.
The mole cricket has a hard, shell-like body. Its legs also are horny.
For this reason, one of its names is the “earth crab.” It is of a lighter
color than the other crickets.
Mrs. Mole Cricket makes a very pretty nest. It is the size and shape
of half an egg, cut lengthwise. It is put very near the surface of the
ground. Then the rays of the sun can warm the eggs.
Mrs. Cricket makes her nest soft and smooth. Then she puts into it
about one hundred eggs. The eggs are in a tough skin, not a shell.
They are of a gray-yellow color. The earth above the nest often looks
like an ant-hill.
Mrs. Cricket does not cease her care for her eggs, when they are put
into the nest. There are some kinds of beetles that eat these eggs.
Mrs. Cricket digs round and round her nest a network of halls. She
hopes the beetle will get lost when he comes to look for her eggs.
After the eggs are laid, and the halls are all made, what do you think
Mrs. Cricket does? She sits in one of her halls. She listens for Mr.
Beetle or any other enemy. When he comes, she runs out to attack
him. She fights so bravely that she drives him away.
At night, when the mole cricket is flying about, its body sometimes
shines like fire. You know the firefly shines. But the firefly gives forth
its light in flashes. The glow-worm has a steady light.
The mole cricket does not always shine. But some have been found
to do so. People who have seen these big, bright things flying in the
dark, have been so foolish as to get frightened.
I hope if you think of being afraid at any time, you will first make sure
what it is that you are afraid of. The mole cricket is nothing to fear,
even when he shines.
I think the reason that his body has been found to shine sometimes
is this. He spends his time digging among dead wood and leaves.
Sometimes he digs about dead animals.
Now, no doubt, there are times when in this work his body gets
covered with a fire-shining stuff,[18] that comes among dead things.
Then when he comes, fresh from his work, his body glows, and he
shines as he flies. After a little, the shining matter wears off, and he
shines no more.

FOOTNOTES:
[18] The teacher might give examples of phosphorescent light.
 LESSON XXI.
OTHER HOPPERS.
One day, when I was a child, I went to play in a field, with my brother.
I saw that many blades of grass had little balls of foam on them. My
brother said, “The horses have been eating here; this froth is from
their mouths.”
But when I had looked a little longer, I said, “There are no horses in
this pasture. This grass has not been bitten.”
A man who came by, said, “Ah, that is cuckoo spit. The cuckoos
dropped it from their mouths.” When the man had gone, I said, “Our
father told me we had no cuckoos near here. And birds do not drop
froth from their bills.”
A little French boy, who had followed the man, said, “How silly that
man is! That is frog spit! Frogs make it, not cuckoos.” I told him,
“There are no frogs in this field. I do not see one. But the froth is all
over the grass.”
“Since no one can suit you,” said my brother, “you had better find out
for yourself.”
Then I took a leaf and laid on it some grass blades with the foam
balls on them. And I gently opened the balls with a grass stem.
Oh here was a queer sight! Here was a little, live, pale, green thing.
It had two tiny, black eyes, two little feelers, a body shaped like a
three-cornered wedge.
“See, see!” I cried. “These balls are cradles! The grasshopper has
made these beds for her babies. Here is a wee grasshopper in each
one.”
But it is very easy to be mistaken. I was wrong, too. For these little
things were not grasshoppers, and they had made their foam balls
for themselves.
Looking closer, we saw that the little green thing held fast by its head
to the grass stem.
Then we saw that the foam ball being made of bubbles, changed
and broke. You know bubbles do not last long. These tiny bubbles
slowly broke, and a clear drop of water ran to the bottom of the ball.
When the drop grew large, it fell off. Then another formed in its
place.
We did not need to think long to be sure that the little hopper sucked
sap, or juice, from the grass. This sap not only fed it, but ran through
its body, and made its foam cloak, or bed. This kept it safe and
warm.
When we learned more of these things, we found that these were not
grasshoppers. They belong to another order of insects. I tell you
about them now, lest you make the mistake that I did.
These insects are hoppers. Frog-hoppers some call them. Their hind
legs are very strong. They make great leaps for their size.
There are a number of odd insects in this order.[19] They are very
unlike each other, except in the wings. It is called the order of the
same-wings, because the upper and under wings are alike. Only the
upper ones are longer.
In this order you will find some of the fireflies. You know them. They
fly about over the grass on summer nights. They make pretty little
fireworks for you, before you go to bed.
The little aphis, which spoils the roses, is of this order. You know the
ants keep the aphis for their cow, and eat the sweet juice it makes.
[20]

We will look at only two of this family. We want to know a little about
this wee frog-hopper. And we will learn a little about his biggest
cousin, the cicada, or “the singer.”
The hoppers have, also, a queer little cousin, the scale bug. The
hopper draws out the plant sap, and covers its body with water. The
scale bug turns the same sap into white dust. It covers its funny little
body all over with flour!
Frog-hoppers are small insects. They have long feelers. They have
only two joints in their feet. The frog-hopper has a big eye on each
side of its head. It has, also, three simple eyes set on the top of its
head, like this ⛬
All the hoppers live on plant juice. The little ones are very greedy.
The mother lays her tiny eggs in the plant. When the larvæ come out
they fasten their mouths on the skin of the plant, and begin to suck
sap.
This bite of the hopper often makes ugly brown holes, or ridges,
come on plants. Often the plants become sickly, and die, from loss of
sap. The hoppers are not good friends of the plants, as the bees,
ants, wasps, and birds are.
The largest of the same-wing order is the cicada. Did you ever hear
him sing? Mrs. Cicada is quiet. Her mate sings all day. The hotter it
is, and the drier, the more he sings. In all lands he is named from his
noise, “the singer,” “the screamer,” “the squealer.”
The cicada is a dry, horny insect. He will keep well in a cabinet. He
lives in trees. Mrs. Cicada has no music, but she has a sharp knife.
How does she use that?
We might as well call her knife an awl, or a gimlet, for it is like all
three. It is used to cut, or bore, a hole in the tree. Into the hole she
puts her eggs.
This tool which Mrs. Cicada carries has three blades. The outer ones
are rough on the edges. They can cut into very hard wood. Mrs.
Cicada takes hold of the tree bark with her front feet. Then she cuts
away with her knife, until she has made a neat little furrow.
She chooses a dead branch for this. The sap in a live branch would
harm her eggs.
When the larvæ come out of the eggs, they at once leave the hole,
and drop to the ground. There they dig a little house for a home.
Their fore feet are well made for digging.
Underground they feed on roots. They change from larvæ to pupæ.
Next summer they come up, full-grown. Then Mr. Cicada begins his
song. Mrs. Cicada at once goes to work to cut holes for her eggs.
When, in mid-summer, the shrill song of the cicada is heard, people
say: “Ah, now it will be hot and dry!” The poets have always loved
the cicada, and made many pretty songs and stories about him.

FOOTNOTES:
[19] Animals and plants are divided into Classes, Orders, and
Families, that we may arrange and study them more readily. A
Class contains many objects with some great points of
resemblance—as the Class of Insects. The Orders bring those
together which have yet more points of resemblance—as the
Order of the Same-Wings. Families contain those yet more
closely related—as the Aphis Family, the Frog-hopper Family. The
Classes, Orders, and Families have Latin or Greek names, of
which in this book we give only the meaning.
[20] Nature Reader, No. 2, “Lessons on Ants,” p. 29.
 LESSON XXII.
REAL LIVE FAIRY.
One September morning I took Hermie, and went over the hill, to the
windmill. The hillside was covered with wild carrot, golden-rod,
asters, white, purple, and pink. Near the windmill was a late wild-
rose, in full bloom.
Right in the golden centre of the rose, on the stamens and pistils, I
saw what might be two fine jewels, and the coiled-up spring of a fairy
watch. On the ground, among the rose-leaves, lay four lovely fans, in
black and gold. They looked as if the fairy-queen and her court
ladies might have dropped them, as they came home late from a
ball.
I put all these things on a piece of white paper. Then I sat on a stone,
took out my microscope, and said to Hermie, “Look here!”
“O!” cried Hermie, “these are the head and wings of a poor butterfly!
But where is his body gone?”
“A bird has eaten it,” I said; “see, the bird’s bill has taken in the body
and clipped off the wings, and just missed the head, which has
dropped off. These are not the relics of a fairy ball, but of a cruel
murder.”
“I do not see,” said Hermie, “how a butterfly, which flits so fast, could
be picked up so.”
We looked about the leaves of a wild-carrot, and, on the under side
of two or three, safe from the wet, we found a cluster of pale
greenish eggs. “See,” I said, “the bird dipped down, and picked up
the butterfly, while it was clinging to the leaf, laying its eggs.
“Or, perhaps the eggs were all laid, and the butterfly was resting on
the bush. Many of these insects die, soon after the eggs are laid.
When the eggs are safely
placed, the insect seems to feel
tired and dull.”
Then we looked at the black and
yellow wings through the
microscope. “See all these little
scales and plumes!” said
Hermie. “They lie thick as a
bird’s feathers! Once I put a
butterfly in a box. When I let him
out, the box was all dusted over
with gold dust. But the butterfly
did not look bare. He seemed as
well dressed as ever.”
Then we looked at the head.
“What big eyes!” said Hermie,
“and that curled-up thing is his
mouth. I have seen him drinking
with it out of flowers. I do think
butterflies are the prettiest things
that are made!”
Many persons think the
butterflies are the most beautiful
of all the insects. Next to the
beetles they are the most
numerous order. They have,
also, been the most studied. Let
us look at them a little.
The butterflies belong to the
great order of the scale-wings.
To this order belong two groups
of very beautiful insects. We will THE LIGHT BRIGADE.
look at them. They are the
butterflies and the moths.
The butterflies are insects of the day. The moths are generally
insects of the night. Even when the moths fly by day they can be
easily known from the butterflies. The butterfly always has a knob or
a point on the end of his horns. The ends of the moth’s horns are
pointed.
When the butterfly is at rest, his wings are held up and laid flat
against each other. Thus the top sides are hidden, and the under
sides show. His wings are called vans.
The moth rests with his wings folded along his body or laid out flat.
They cling close to what he rests upon. If they bend at all, they bend
downward, not upward. The body of the moth is shorter and thicker,
more wedge-shaped, than that of the butterfly.
Now, for a look at our butterfly. The head is small and moves freely. It
is not set in a socket to the body, but held by a little neck. On each
side of the head is a great, bright eye with many thousand facets, or
surfaces.
At the back of the head of a butterfly are generally two small, simple
eyes. These are usually hidden under long hairs. Do you see the soft
hairs which clothe all the butterfly’s body? For you must notice that
the butterfly wears an elegant, soft, velvet coat of fine hairs. This
coat is usually black or brown. But it has often stripes or spots of a
lighter color.
On the top of the head the butterfly carries a pair of many-jointed
horns. As I told you, the ends of these are little knobs.
The chief part of the mouth of the butterfly is a tube, called a trunk.
Did you ever notice the big trunk of an elephant? The butterfly’s
trunk is small. It is coiled up like a watch-spring when it is not in use.
The butterfly can unroll it. It is so slim he can thrust it into the longest
and narrowest flower cups.
Really this trunk is made of two pieces with little points upon them.
These two parts lie together and seem one. Between them the
honey is drawn up. You must know that butterflies live chiefly on
honey. It is not likely that they take much other kind of food, but they
are fond of water. Have you seen them in damp places?
When the fine trunk of the butterfly is curled up it is kept safe by two
hairy pieces which grow on the front of the head.
The butterfly has six legs that grow from the chest part of its body.
But the butterfly is not a walking insect. Bees, wasps, ants, and
beetles, you know, walk a great deal. Butterflies rarely use their legs
for anything but standing when they eat or rest. They move only by
flying.
The wings are made of two thin skin-pieces laid upon a framework of
nerves or veins. They are covered with a double layer of scales. The
edge scales are long and fringe-like. The upper and under sides of
the wings differ in color.
The upper wings are widest. They have smooth edges, and are of a
triangle-shape. The lower wings are rounded. They have waved or
pointed edges. Sometimes they have two long points like tails.
The body of the butterfly is made in rings, but they are soft, not horny
like those of a dragon-fly. The body is slender and has no weapon. It
has no sting to fight, and no saw to cut wood to make a place for its
eggs.
 LESSON XXIII.
THE CHILD OF THE DAY.
The butterfly is the chief partner of the flowers. Its long, slim drinking
tube helps it to dip far into a flower’s throat. As it reaches in, it gets
the stamen pollen well upon it. Then, since the butterfly rarely walks
about, as the beetles do, it is not likely to waste the pollen by rubbing
it off where it is not wanted.
Not only is the butterfly the flower’s best partner, but it wears the gay
colors of the flowers. Once I was walking in a garden with a very little
boy. A flight of yellow butterflies came over a tulip bed. “See! see!”
cried the child, “the flowers are loose, and are flying away!” Poets, as
well as children, have called the butterflies “flying flowers.”
In very early times, people began to study butterflies. It was not only
their number or their beauty which made people notice them. It was
the wonder of their changes, from egg to full-grown insect.
Who would think that this splendid thing, which scorns to use its feet,
and lives on the wing in the clear air, was once a worm, crawling on
many legs, among the grasses and leaves?
Who would think that this dainty creature, which drinks dew and
honey, once spent all its days, chewing and gnawing leaves as the
earthworm does?
Who would think that these bright wings, which are so crisp and stiff
that they never bend or wrinkle even by a single fold, were once like
little flat buds, inside a crawling caterpillar, or bound up in the tight,
horny pupa case?
Let us follow the journey of these little greenish eggs, stuck on the
under side of a carrot leaf. Let us follow them up their curious way,
until we see them sitting on the heart of a rose, as on a throne of
gold, and then suddenly sailing off among the sunbeams!
 Each kind of butterfly prefers some
especial plant, on which the
caterpillar feeds. On this plant the
eggs are laid. Some butterflies like
oaks best; some cabbage; some
choose plants of the carrot family for
a home.
The butterfly which we will now hear
about is the “swallow-tail.” It is one
which likes fennel and wild carrot. It
lays its eggs on the under side of the
leaf of one of these plants. The eggs
are placed in little patches. They are
of a greenish color, and nearly
round. The eggs of some other
butterflies are of very odd shapes.
The first eggs of the swallow-tail
butterfly are laid in May. In eight or
ten days the eggs turn nearly black.
Then out comes the little caterpillar.
The first thing he does is to turn
around and eat up his shell! Next he
begins to eat carrot leaf. He grows,
and in a few days casts his skin.
The caterpillar keeps on growing. To
get more room he sheds his skin. He
eats the cast-off skin each time. He
is a very pretty caterpillar. His color
is bright green. On each of his twelve
rings he has a black band. On each
black band there are gay, yellow
THE LITTLE PRISON. spots. He is about an inch and a half
long when full grown.
There is a queer thing about this caterpillar. If you touch him, while
he eats, he runs out a little forked horn from behind his head. He
seems to want to frighten you! When you let him alone he draws in
his horns. These horns can emit a strong smell.
His feet are made with rings and hairs, so that he can creep safely
along the plants where he feeds. His mouth is weak, so he can eat
only soft leaves. In about two weeks he has eaten all that he needs.
Then he creeps up a plant stem and spins a strong silk rope. He
binds this rope about his body and the plant stem. That ties him fast.
The caterpillars of several kinds, which tie themselves in this way for
the pupa state, are called girdle caterpillars, or belted caterpillars. He
is also held fast by the tail as well as by this body belt. When he is
tied, his body shortens and thickens. His caterpillar skin bursts, and
drops off.
He is now a pupa. The pupa skin hardens into a little case. Now he
neither moves nor eats.
How long is he a pupa? That depends upon the time of year. In
spring, two weeks are enough for the change. In hot summer, nine
days or a week will do. If it is cold autumn weather, the pupa will not
change to a full-grown insect until the next spring.
If in the winter you find a pupa tied to a weed, and bring it into a hot-
house, or a warm room, in a few days you will have a fine butterfly
out. A wise man, who studied butterflies, put some pupæ in a very
cold place, and they did not change for two or three years!
When it is time for the insect to come out of the pupa case, some
motions like deep breathing are made. These crack open the hard
skin. Then the insect pulls itself out. It is moist and weak. Its wings
droop a little.
The new butterfly breathes hard, many times. At each breath air
rushes through its body, and through the tubes of its wings. The
frame of its wings stiffens and fills out. The body and legs grow dry
and firm.[21]
Then the new-made butterfly rests a little,—perhaps for several
hours. After that it seems to feel fine. It can move its wide wings! It
can fly! It sails away!
Now it lights on a great white head of wild carrot, or on a rose. Let us
look at it. Its wings are black and yellow. The black is in bands and
streaks. It has six bluish spots on each lower wing, and one large red
and blue spot. Its body is like black velvet. Each lower wing has a
long, beautiful, curved tail.
The butterfly is an insect with far more beauty than sense. We may
say it is an insect with very little brains. It has none of the wise ways
of the ant, wasp, bee or spider; it only flies and eats, and lays eggs.
It builds no house, stores no food, takes no care of its young.
The butterfly can see. It has wonderful eyes. It can hear. It can smell.
It can taste. Its flower partners spread out for it their finest colors,
perfumes, and honey drops.

FOOTNOTES:
[21] See Nature Reader, No. 2, Lesson 45.
 LESSON XXIV.
LIFE AMONG SNOW AND ROSES.
I told you that the butterfly did no work, built no house, and showed
very little sense. That is true of the full-grown butterfly. He seems so
pleased with his wings that he does nothing but enjoy them.
But you must know that the caterpillar is only one state of the
butterfly, and there are caterpillars which build for themselves very
curious houses.
There are caterpillars which leave the egg in the autumn. They live
as caterpillars all winter, and enter the pupa state in the spring. Let
us watch them, as they live with the snow-flakes flying about them.
Then we will watch them to the time of roses.
Many butterflies lay their eggs singly. They put one egg alone, on the
tip of a willow, hazel, poplar, or oak leaf. Other butterflies put their
eggs in small clusters on the underside of carrot, nettle, or
blackberry leaves. Some put eggs in a ring, around an elm or birch
twig.
Now and then you find the eggs in a chain or pyramid, hanging upon
a leaf. There are, also, some butterflies which drop their eggs on the
ground among the grasses, or on the lower parts of grass blades.
In all cases the caterpillar feeds on the plant on which he is hatched
from the egg. When he is ready to come out of the egg all he has to
do is to bite a hole in his shell and crawl forth. Then, at once, he
begins to eat.
He may begin at the tip of the leaf, and eat up to the mid-vein on
both sides. He is careful not to bite the mid-vein. When he has had a
full meal, he goes and lies along the mid-vein to rest. Then, when
rested, he eats again. Many do this, but not all.
 When one leaf is finished, he takes
the next one on the twig. After the
first leaf he is not so careful to begin
at the tip. He just bites out pieces
anywhere, but he does not bite the
big vein. Perhaps it is too hard.
Perhaps he knows he must have it
for a roadway.
Do you remember what you read in
the First Nature Reader about the
spider, which has in her body little
knobs for spinning silk?[22] The
caterpillar has a silk-spinner. It is in
the underside of his head. It is a little
tube in the shape of a cone.
Did you ever notice the queer way a
caterpillar has of wagging his head
from side to side? He acts as if in
great pain. But he is not in pain. He is
only laying down a silk web with that
motion.
It is by means of this silk that the
caterpillar makes his home. Let us
look at him while he works. He
fastens his line to the edge of a leaf.
Then he carries it to the other edge,
or to the next leaf. Then another line,
and so on. Each line is a little shorter
than the one before. This bends the
leaf. At last it is bent into a tube, or
box, or several leaves are bound into
A FROSTY MORNING. a bower.
The caterpillar bites a notch, or line,
in the tip of the leaf to make it bend over for a roof. Is not that
cunning? Think how strange it is, that a tiny thing, just out of the egg,
away up alone on a tree, should know how to build this pretty house!
The caterpillar of the swallow-tail chooses a leaf for a home, weaves
a silk carpet over it, and lies along the mid-vein. What do you think
he does on rainy days, when the water begins to take his bent leaf
for a spout or gutter?
He builds a second floor of silk, a little higher up, between the edges
of the leaf. That makes a nice, dry, silk hammock. There he lies,
while the water ripples along the mid-vein below him. I suppose the
sound of the water sings him to sleep.
A caterpillar which makes a bag of a nettle leaf, for a nest, lies in it
so snug that he is too lazy to go out for food. So he eats up his roof
for his dinner! Another caterpillar draws a leaf together into a pretty
little pocket. He weaves silk over it, outside and in, and then,—he
eats up this dear little home, and has to make another!
These caterpillars make their homes for summer. There are some
which need winter homes. The caterpillar of the Viceroy butterfly is
only half-grown when winter comes. He lives in a willow-tree. He
makes his warm winter house of a willow leaf.
How does he do it? He eats part of the leaf away to the mid-vein.
Then he bends the lower part together, with silk. He fastens the
edges tight and lines the inside with silk. Then he covers the outside
with silk, and binds the nest to the twig with a silk thread, by crawling
around and around, drawing the silk with him.
The fierce winter storms will not tear off this house, which he has
bound to the tree. The silk he uses is of a brown, dry-leaf color.
When the house is made, he crawls in, head first. The knobbed hind
end of his body fills up the open part of the nest. Did you ever hear
of caterpillars called “woolly-bears,” because of their furry bodies?
This caterpillar has a little cousin, who makes his winter home of a
bent birch leaf. The color of his silk, and the knobbed end of his
body, are just the gray-purple of young birch buds. So, in the spring,
no bird notices him. Thus, while the snow flies, these caterpillars lie
safe in their warm homes. They are torpid.