1. Arthrography
Spring 2009
Draft

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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%

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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)

17. 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

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

19. 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)

20. 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

21. 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

22. 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

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

24. 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

25. 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.

26. 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

27. 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

28. Vertical Knee Radiographs
Medial Meniscus Tear

29. 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

30. 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

31. 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

32. 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

33. Horizontal Knee Radiographs
Spot Films
Medial Meniscus AP
LAT

34. 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

35. 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

36. 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

37. 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 ml
Double 3-4 positive contrast and of air

38. 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

39. 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

40. 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

41. Rotator Cuff Tear

42. 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

43. MRI Arthrogram of Shoulder

44. 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

45. 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.

46. 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.

47. Children Hip Arthrography

49. 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

50. Wrist Arthrogram

51. Wrist Arthrogram
Rheumatoid Arthritis

52. 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.

53. 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