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

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

3. 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. 4 Anatomy of a Synovial Joint Synovial membrane –Menisci, fat pads, and intra-articular disks Ligaments

5. 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. 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. 7 Clinical Symptoms Pain Swelling Limited range of motion Recurrent instability (such as ankle)

8. 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, CO2 Possible hazard of air is an air embolism Water-soluble contrast agents – easily absorbed

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

10. 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. 11 Sterile Procedure GLOVES GOWN (?)

12. 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. 13 Aseptic Technique betadine scrub

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15. 15 ARTHROGRAM TRAY

16. 16 ARTHROGRAM TRAY

17. 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. 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. 20 Supplies Needed

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23. 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. 28 Fluid from aspiration- Sent to lab

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

32. 32 CONTRAST INJECTION

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34. 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. 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. 36 For Cruciate ligaments patient may sit on end of table with knee flexed 90 degrees – Then a cross table lateral taken

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38. 38 8 on 1 spot filming

39. 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. 40 Knee stressed to see medial and lateral meniscus

41. 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. 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. 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. 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. 45 Horizontal Knee Radiographs Spot Films Medial Meniscus AP LAT

46. 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. 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. 48 MRI Knee Arthrography Gadolinium contrast is used Contraindications include metal in body, claustrophobia, & PT size

49. 49 Ace Bandages Wrap joint after contrast injection

50. 50 MEDIAL MENISCUS

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52. 52 MRI

53. 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. 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. 57 C-ARM FOR NEEDLE LOC

58. 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. 59 Children Hip Arthrography

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62. 62 DEVELOPMENTAL DISPLASIA OF THE HIP

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65. 65 Hip Arthrogram & Digital Subtraction

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71. 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. 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. 73 SCOUT FILMS AP – –INTERNAL & EXTERNAL ROTATION GRASHEY (OBL FOR FOSSA) AXILLARY (THUMB UP) FOR GROOVE TRANSTHORACIC or Y -VIEW

74. 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. 75 Normal Shoulder Arthrograms Single Contrast Double Contrast

76. 76 Shoulder Single and Double contrast Single contrast Double contrast

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78. 78 Rotator Cuff Tear

79. 79 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 surface on glenoid cavity

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82. 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. 85 Single-contrast arthrogram showing rotator cuff tear (arrow).

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88. 88 MRI Arthrogram of Shoulder

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91. 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

92. 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. 96 Wrist Arthrogram

97. 97 Wrist Arthrogram Rheumatoid Arthritis

98. 98 OTHER JOINT SPACES ANKLE TMJ (USUALLY DONE IN CT)

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100. 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. 101 TMJ Arthrograms MRI Tomography

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