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ARTHROGRAMSRT 255

Radiography of a joint space or it’s surrounding structures with

injection of contrast media

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ARTHROGRAMS

–Injected into JOINT SPACES

“DOUBLE CONTRAST”–IODINE (positive contrast)

• WATER soluble –(Ionic or Non-Ionic)

–AIR (negaitve contrast)

3Arthrography is concerned

with synovial jointsMOSTLY REPLACED BY MRI – non invasive, good detail of soft tissue structuresCONTRAINDICATIONS TO MRI:• CLAUSTROPHOBIC• PT SIZE• Foreign Body (metal) • COST / INSURANCE REIMBURSEMENT

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Anatomy of a Synovial Joint

• Synovial membrane– Menisci, fat pads, and

intra-articular disks

• Ligaments

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INDICATIONS FOR EXAM

• This procedure is used to obtain diagnostic information regarding the joints and surrounding soft tissues or cartilage.

• ligament, meniscus (cartilage), bursa

Usually done for the knee

• shoulder, hip, wrist, TMJ

6Indications and Contraindications

for Arthrography• Indications:

– Suspected injury of meniscus (tears)– Suspected capsular damage– Rupture of articular ligaments– Cartilaginous defects– Arthritic deformities (specifically TMJ)– Congenital luxation ( dislocation) of hip– Extent of damage from trauma

• Contraindications:– Hypersensitivity to iodine

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Clinical Symptoms

• Pain

• Swelling

• Limited range of motion

• Recurrent instability (such as ankle)

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Contrast media

• Contrast INJECTED into joint space – capsular space – bursa (30 – 100 ml may be needed)

• CONTRAST – water based only – iodinated (ionic or nonionic)

• Negative , positive or both (Double Contrast)• Negative – room air, CO2 • Possible hazard of air is an air embolism• Water-soluble contrast agents – easily absorbed

9 Contrast Mediakeep bottle in room until end of study

have several syringes available

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PROCEDURE – PREP• Patient Prep – (none prior to exam)

– Pt comfort (gown, empty bladder)

• get history • check allergies

• SKIN PREP –

may need to shave area of injection

• betadine scrub – circular motions

11Sterile Procedure

GLOVES

GOWN (?)

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Sterile tray “arthrogram tray”

Aseptic technique for skin cleansing

–(betadine – check for allergy)

• Local anesthetic

• (usually on tray, put may have to draw up – sterile procedure)

• do not contaminate tray

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Aseptic Technique

betadine scrub

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ARTHROGRAM TRAY

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ARTHROGRAM TRAY

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SUPPLIES

Needles used –

• length and gauge depends on part being examined

• DR may aspirate joint prior to injection of contrast media

• (have large syringes available)

• Sterile gauze, towels, ace bandages

18 Needles

• Smaller gauge has a larger number• Larger gauge has a smaller number• Length and gauge of needle is usually part of protocol

– DR’s preference– Part being examined

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Supplies Needed

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23Aspiration

• Dr’s may aspirate fluids before injecting contrast media– If there is a joint

effusion especially

• Fluid is sent to lab in specimen vials

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28 Fluid from aspiration-

Sent to lab

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KNEE ARTHOGRAM Most common problem : • Pain and Swelling,

– Limited ROM (range of motion)

• athletic injuries• Knee support to stress knee• Contrast Injected – then part is

stressed or moved to work contrast into joint spaces –

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RADIOGRAPHY

• SCOUT FILMS

• AP

• LATERAL

• Other

• (CHECK WITH Radiologist)

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CONTRAST INJECTION

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34 KNEE ARTHROGRAM

(MOST COMMON)

Air and contrast material injected into the joint reveal the outlines of the joint space including the supra patellar pouch

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FILMING - KNEE

Filming done under fluoroscopy (Knee spot films may be done 9 on 1)Knee stressed to see medial and lateral

meniscus

• DOUBLE CONTRAST KNEE – FILMS TAKEN WITH HORIZONTAL BEAM =

• contrast moves down – air moves up – shows good delineation of tissues

36 For Cruciate ligamentspatient may sit on end of table with knee flexed 90 degrees –

•Then a cross table lateral taken

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38 8 on 1 spot filming

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Knee Arthrogram

• Place PT prone – Place PT in frame or stress

device to open JT space– Sometimes support is

placed under distal femur and small sandbag on ankle to widen JT space

• Part is manipulated to disperse contrast and often multiple spot films are taken under fluoroscopy

40 Knee stressed to see

medial and lateral meniscus

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Knee Arthrogram

• Overheads are done– AP, lateral, 20 degree right and left oblique– Sometimes Interconyloid fossa projections are required

• Single contrast study for a torn meniscus may fail to demonstrate the tear

• Usually single contrast studies are used to demonstrate loose particles of the JT

• Post procedure– PT may feel tightness – This should go away in 1-2 days– Can be treated with analgesics

42Meniscus Tears

• Symptoms may include: • "Popping" sound at the

time of the injury • Pain • Tightness • Swelling within the knee,

often called "water on the knee"

• Locking up, catching, or giving way of the knee

• Tenderness in the joint

43 Knee Arthrogram

double contrast study

• smaller amounts of contrast can be used– Decreases discomfort to PT– Provides are more accurate study– Demonstrates menisci the best– Positive contrast coats menisci– Air rises

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Knee Arthrogram:

• Apply same principles Scout films: often AP, Lateral and oblique– Check with DEPT protocol

• Anesthetic injected• Contrast is injected

(double contrast study)• PT placed semiprone• Knee is manually

stressed while spot films are taken (medial & lateral meniscus)

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Horizontal Knee RadiographsSpot Films Medial Meniscus

AP

LAT

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For Cruciate Ligaments

• Double Contrast study• PT’ s sits with knee flexed 90 degrees

over the side of the table• Firm pillow placed under knee so that

forward pressure can be applied• PT holds IR with grid• Closely collimate • Tightly overexposed lateral projection is

made

47CT Knee Arthrography

• PT gets a regular arthrogram in radiology

• Then is taken to CT for imaging

• Can be single or double contrast (water soluble iodine)– Usually double

48 MRI Knee

Arthrography• Gadolinium contrast

is used

• Contraindications include metal in body, claustrophobia, & PT size

49 Ace Bandages

Wrap joint after contrast injection

50 MEDIAL MENISCUS

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MRI

53 BAKERS CYST

a collection of synovial fluid which has escaped from the knee joint or a bursa formed a new synovial-lined sac in the popliteal space

seen in degenerative or other joint diseases

                      

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HIP ARTHROGRAM

• Children - to check for congenital hip dislocation – before and after treatment

• Adults – to check position of hip prosthesis - subtraction gives better images

• Note: cement in the joint and contrast have the same density – see pg 567 Merrill’s

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57 C-ARM FOR NEEDLE LOC

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Hip Arthrogram

• Common puncture site– ¾ “ distal to the inguinal crease– ¾” lateral to the palpated femoral pulse

• Spinal needle is used due to how deep the hip joint is into the body.

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Children Hip Arthrography

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62 DEVELOPMENTAL DISPLASIA

OF THE HIP

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65 Hip Arthrogram &

Digital Subtraction

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SHOULDER ARTHROGRAM

• Done for evaluation of partial or complete tears of the ROTATOR CUFF

• Persistent Pain, Weakness and “Frozen Shoulder”

• May do single or double contrast - 10-12 ml of contrast

72Shoulder Arthrogram• The usual objection site is

approx ½ inch inferior & lateral to the coracoid process

• Usually spinal needle is used because the joint capsule is usually deep

• Scout films: AP (internal & external), 30 degree oblique, axillary, tangential– See Chapter 5 for PT and part

positioning

AP scout

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SCOUT FILMS

• AP –

–INTERNAL & EXTERNAL ROTATION

• GRASHEY (OBL FOR FOSSA)

• AXILLARY (THUMB UP) FOR GROOVE

• TRANSTHORACIC or Y -VIEW

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Shoulder Arthrogram

• Indications:– Partial or complete tears of rotator cuff– Tears of glenoid labrum– Persistent pain or weakness– Frozen shoulder

• Single or double contrast can be used– Single 10-12 ml– Double 3-4 positive contrast and 10-12 of air

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Normal Shoulder Arthrograms

Single Contrast Double Contrast

76 Shoulder Single and Double

contrast

Single contrastDouble contrast

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Rotator Cuff Tear

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Shoulder Arthrogram

• After double contrast shoulder arthrogram CT may be used in some patients– In 5mm intervals

through shoulder joint

• CT scans have shown to be more sensitive and reliable in diagnosis

Small chip on anterior surfaceon glenoid cavity

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82 Commonly people tear their cuff from falling on an

outstretched hand or throwing.

This is what a torn rotator cuff looks like.

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85 Single-contrast arthrogram showing rotator

cuff tear (arrow).

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MRI Arthrogram of Shoulder

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91 Wrist Arthrogram

• Indications: trauma, persistent pain, limited ROM.

• Contrast is injected through the dorsal wrist at the articulation of the radius, scaphoid and lunate– 1.5-4ml water soluble iodinated contrast

• After injection the wrist is carefully moved to spread contrast

• Under fluoro or tape recording the wrist is rotated for exact area of leakage

• AP, LAT and both obliques often taken (check DEPT protocols

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WRIST ARTHROGRAM

• Trauma, persistent pain, limited rom

• Wrist gently manipulated after contrast media injection

• 1.5 – 4 ml of contrast injected

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Wrist Arthrogram

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Wrist Arthrogram

Rheumatoid Arthritis

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OTHER JOINT SPACES

• ANKLE

• TMJ (USUALLY DONE IN CT)

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100 TMJ Arthrogram

• CT and MRI have largely replaced TMJ arthrography because they are noninvasive

• Useful in diagnosing– Abnormalities of the articular disk

• Indications: pain, clicking sound, lock jaw when chewing sticky candy– Starburst– Taffy

101 TMJ Arthrograms

MRI

Tomography

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