Arthrography Spring 2009 Draft

Arthrography Used to obtain diagnostic information regarding the: Joint space Surrounding soft tissue Cartilage Lesions of the menisci Delineates the joint space and its surrounding structures Largely replaced by MRI

Joint Overview Broken down into 3 classifications Fibrous (slightly movable or immovable) Cartilaginous (slightly movable or immovable) Synovial (freely movable) For arthrography we are mainly interested in synovial joints

Synovial Joint Get their name from synovial fluid within joint space It is enclosed in a fibrous layer called the joint capsule These fibers are arranged irregularly Connects articulating bones just beyond joint space uniting the bones of the joint Further contains synovial membrane, hyaline cartilage, intra-articular joint structures and ligaments

Synovial Fluid Synovial fluid is clear viscous fluid that serves as a lubricant Fluid works with structures such as menisci, disks and fat pads to reduce friction Resembles the white of an egg in consistency Nourishes hyaline cartilage (lines articular surfaces) Is produced in the synovial membrane

Anatomy of a Synovial Joint Synovial membrane Hyaline articular cartilage Intra-articular JT structures Menisci, fat pads, and intra-articular disks Ligaments SYNOVIAL MEMBRANE: Inner surface of the JT capsule Is connective tissue Covers all structures within the JT except hyaline cartilage Produces synovial fluid HYALINE ARTICULAR CARTILAGE Is located on the bearing surfaces of the bones composing the JT Does not contain nerve endings or blood vessels INTRA-ARTICULAR JT STRUCTURES Aid in providing efficient lubrication of the articular surfaces LIGAMENTS Can be in the JT space as well as in the JT capsule Limits motion in undesirable directions and functions as sense organs of motion and position.

Most Common Areas of Examination Arthrography can be done on any encapsuled JT Knee is most common type of arthrogram performed Other joint spaces include: Wrist Shoulder TMJ Hip

Pneumoathrograms Air or gaseous medium is used 100-150 ml Produces painful distention of joint Possible air embolism Accuracy is considerably less than that when 2 contrast methods are used

Positive or Opaque Arthrography Water soluble iodinated contrast Ionic or non-ionic 30-100ml can be used Contrast is readily absorbed, tolerated and excreted Produces greater diagnostic accuracy Concentration should be no more than 30%

Double contrast Arthrography Both gaseous and water soluble contrast employed By using both contrasts less of each can be used. Reducing patient discomfort Decreasing chance of air embolism Highly accurate diagnostic study

Contrast Precautions Verify it is the correct contrast Ionic or Non-ionic iodinated contrast Omnipaque or Isovue (non-ionic) Correct concentration Check expiration date Keep contrast vial in room until procedure is complete

Indications and Contraindications for Arthrography 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

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

Risks It is an invasive procedure therefore there are certain risks to the patient Reaction to contrast media Vasovagal reaction Nausea, perspiration and pallor Allergy to anesthetic agent Inflammatory synovitis

Patient PREP Get thorough pt history PT comfort Reason for exam Allergies Ease patients anxieties Answer questions Explain procedure PT comfort Allow them to use restroom Get pt into gown Blankets Obtain informed consent Sometimes hospitals require doctor to do this

Procedural PREP Obtain Arthrogram tray Additional supplies needed Skin PREP Shave area if needed Betadine to clean area of interest in circular motion from inside to outside (often times DR prefers to do this)

Arthrogram Tray Syringes Needles Connector tube Sterile towels 5cc, 20 cc and 30cc luer lock Needles 25g, 20g, 18g Connector tube Sterile towels Sterile drape Gauze pads (4x4) Prep sponges Adhesive tape Anesthetic Sometimes DR draws this up and some do not have this on tray

Aseptic Technique Do not contaminate arthrogram tray Tray is sterile Do not contaminate area of interest after scrubbed

Additional Equipment & Supplies Shields Towels and blankets Contrast Sterile gloves Antiseptic solution Gauze Ace bandages (if needed) Fluoroscopy & radiographic capabilities Gown Extra syringes and needles Bandaids Forceps (if part of protocol) Gloves Specimen tubes (if needed)

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

Radiation Safety Have shields for PT’s, DR and yourself Question LMP and the possibility of being pregnant Use cardinal rules Time Distance Shielding ALARA Use pulse if possible Save the last image on screen when possible

General Guidelines Also refer to DEPT protocol Many hospitals have different protocols for different DR’s Make sure you have everything ready This makes the procedure go smoothly

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

Clinical Indications for Knee Arthrograms Pain, swelling and limited ROM Trauma or athletic injuries Suspected damage to menisci and capsule Rupture of articular ligaments Cartilaginous defects Arthritis

Knee Arthrogram: Vertical method Apply all principles from slides 15-21 Scout films: often AP, Lateral and oblique Check with DEPT protocol Anesthetic injected Contrast is injected (single contrast study) This widening or spreading of the joint space of the intrastructural spaces permits better spread of the contrast around the meniscus.

Knee Arthrogram: Vertical Method 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

Knee Arthrogram: Vertical Method 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

Vertical Knee Radiographs Medial Meniscus Tear

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

Knee Arthrogram: Horizontal Method Usually a double contrast study With this type 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

Knee Arthrogram: Horizontal Method Apply all principles from slides 15-21 Scout films: often AP, Lateral and oblique Check with DEPT protocol Anesthetic injected Contrast is injected (double contrast study) PT placed semiprone

Knee Arthrogram: Horizontal Method Knee is manually stressed while spot films are taken (medial & lateral meniscus) Draw a line on medial or lateral side of knee and then direct CR to the meniscus Rotate knee toward the supine position Turn 30 degrees for each of the projections

Horizontal Knee Radiographs Spot Films Medial Meniscus AP LAT

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

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

MRI Knee Arthrography Gadolinium contrast is used Side effects can be: It is a clear substance that when injected into a vein accumulates in abnormal tissue Side effects can be: Mild headache, nausea, local pain, low blood pressure, allergic reaction, urticaria and SOB. Contraindications include metal in body, claustrophobia, & PT size MRI Knee Arthrography

Shoulder Arthrogram Indications: Single or double contrast can be used 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

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

Normal Shoulder Arthrograms SINGLE CONTRAST: Normal AP, with contrast media surrounding the biceps tendon sleeve and lying in the intertubercular (bicipital) groove (arrows). The axillary recess is filled has a normal medial filling defect (arrowheads) created by the glenoid labrum. DOUBLE CONTRAST: Normal AP double contrast shoulder arthrogram. Single Contrast Double Contrast

Shoulder Single and Double contrast Normal axillary double contrast shoulder with PT in supine position. (O) opaque medium (A) air created density SINGLE CONTRAST Normal axillary single contrast shoulder arthrogram. Single contrast Double contrast

Rotator Cuff Tear

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 CT shoulder arthrogram. The radiographic arthro in this patient was normal However, the CT shoulder arthro shows a small chip fx (arrow) on the ant surface of glenoid cavity. Head of humerus (H), air surrounding biceps tendon(arrowheads), air contrast medium (A), opaque contrast medium (O), and glenoid portion of scapula(G) are evident. Small chip on anterior surface on glenoid cavity

MRI Arthrogram of Shoulder

Hip Arthrogram Performed most often on children for congenital dislocation pre and post treatment Performed on adults to detect loose prosthetics or confirm presence of an infection Cement & barium are added to hold prostheses and to be able to check it radiographically BA and cement have approx same Z# making evaluation of JT by arthrography Digital subtraction is used to overcome this problem

Hip Arthrogram & Digital Subtraction Digital subtraction of the same image as the left image. Contrast medium (black) shows better demonstration of the JT. Contrast around the prosthesis in the proximal and lateral femoral shaft (arrows) indicates a loose prosthesis. Lindes of the medial and lateral aspect of the femur (arrowheads) are subtraction registration artifact caused by slight PT movement during the injection of contrast medium.

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.

Children Hip Arthrography

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

Wrist Arthrogram

Wrist Arthrogram Rheumatoid Arthritis

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 Useful in diagnosing abnormalities of the articular disk, the small oval, fibrocarilaginous or fibrous tissue plate located between the condyle of the mandible and mandibular fossa. Disk damage can be a result of trauma or a stretched or loose posterior ligament that allows the disk to be anteriorly displaced causing pain.

TMJ Arthrograms Tomography MRI Often tomo and standard x-rays are taken as scouts. Then under fluoro the contrast media is injected and spot images are taken to evaluate mandibular motion. Both open and closed mouth radiographs, tomo and fluoro spots are indicated. Tomography MRI