1 ARTHROGRAMS RT 255 Radiography of a joint

1 ARTHROGRAMS RT 255 Radiography of a joint space or it’s surrounding structures with injection of contrast media

2 ARTHROGRAMS –Injected into JOINT SPACES “DOUBLE CONTRAST” –IODINE (positive contrast) • WATER soluble – (Ionic or Non-Ionic) –AIR (negaitve contrast)

3 Arthrography is concerned with synovial joints MOSTLY REPLACED BY MRI – non invasive, good detail of soft tissue structures CONTRAINDICATIONS TO MRI: • CLAUSTROPHOBIC • PT SIZE • Foreign Body (metal) • COST / INSURANCE REIMBURSEMENT

4 Anatomy of a Synovial Joint • Synovial membrane – Menisci, fat pads, and intra-articular disks • Ligaments

5 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

6 Indications 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

7 Clinical Symptoms • Pain • Swelling • Limited range of motion • Recurrent instability (such as ankle)

8 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, CO 2 • Possible hazard of air is an air embolism • Water-soluble contrast agents – easily absorbed

9 Contrast Media keep bottle in room until end of study have several syringes available

10 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

11 Sterile Procedure GLOVES GOWN (? )

12 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

13 Aseptic Technique betadine scrub

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15 ARTHROGRAM TRAY

16 ARTHROGRAM TRAY

17 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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20 Supplies Needed

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23 Aspiration • 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

29 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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31 RADIOGRAPHY • SCOUT FILMS • AP • LATERAL • Other • (CHECK WITH Radiologist)

32 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

35 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 ligaments patient may sit on end of table • Then a cross table lateral with knee flexed 90 degrees – taken

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38 8 on 1 spot filming

39 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

41 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

42 Meniscus 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

44 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)

45 Horizontal Knee Radiographs Spot Films Medial Meniscus AP LAT

46 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

47 CT 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 • Gadolinium contrast is used • Contraindications include metal in body, claustrophobia, & PT size MRI Knee Arthrography

49 Ace Bandages Wrap joint after contrast injection

50 MEDIAL MENISCUS

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52 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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55 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

58 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.

59 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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71 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

72 Shoulder 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

73 SCOUT FILMS • AP – – INTERNAL & EXTERNAL ROTATION • GRASHEY (OBL FOR FOSSA) • AXILLARY (THUMB UP) FOR GROOVE • TRANSTHORACIC or Y -VIEW

74 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

75 Normal Shoulder Arthrograms Single Contrast Double Contrast

76 Shoulder Single and Double contrast Single contrast

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78 Rotator Cuff Tear

79 Shoulder Arthrogram • After double contrast shoulder arthrogram CT may be used in some patients – In 5 mm intervals through shoulder joint • CT scans have shown to be more sensitive and reliable in diagnosis Small chip on anterior surface on 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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88 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 -4 ml 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

92 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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96 Wrist Arthrogram

97 Wrist Arthrogram Rheumatoid Arthritis

98 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 Tomography MRI

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